TAUC Pre-Scribe U
What should be consistently documented in the Procedures section for billing purposes? - Answer -
Prescription medication discussions
Review of outside diagnostic results
Discussions with external professionals
Independent historians needed
What is included in the prescription medication discussions? - Answer -Document ll discussions regarding any prescription medicine that the patient is already taking whenever it is relevant to the current condition
- Ex. BP meds for pt who is hypertensive
Document when a pt refuses a prescription medicine recommended
What is included in review of outside diagnostic results? - Answer -Whenever a patient shows you outside labs or radiology results and asks you questions about them... Document: outside lab results reviewed and showed (insert interpretation)
When documenting discussions with external professionals what must you include? - Answer -Document
any conversations you have with external sources such as:
-ER triage nurse
-Urgent specialist
-External provider involved w/ pts care -Non-healthcare professionals involved in pts management
What do you document when independent historians are needed? - Answer -When a pt is unable to provide a complete or reliable hx document discussions with another historian
When selecting a dx modifier what should you not do? - Answer -Do not select any of the three choices in the top under "uses for coding" -uncomplicated -systemic symptoms
-poses a threat to life or bodily functions
What do you select instead when selecting a dx modifier? - Answer -Choose the numbered choices from the bottom section (top 4)
-Acute
-Chronic
-Incidental lesion/mass
Bottoms 6 are additions to top 4
What should all fractures be referred to as? - Answer -Clinical not possible and you must include an associated fracture dx
Should you document any refused procedures in the procedure note? - Answer -yes
Can diagnosis modifiers be modified at a later time? - Answer -Yes in the diagnosis screen by clicking on "dx mod" button
Are charts coded by providers? - Answer -No
What do you do if the common diagnosis list does not contain the diagnosis you need? - Answer -You can use the ICD-10 search function
-Type the diagnosis you are searching for, select from list, this will take you to the next screen
What should be consistently documented in the Procedures section for billing purposes? - Answer -
Prescription medication discussions
Review of outside diagnostic results
Discussions with external professionals
Independent historians needed
What is included in the prescription medication discussions? - Answer -Document ll discussions regarding any prescription medicine that the patient is already taking whenever it is relevant to the current condition
- Ex. BP meds for pt who is hypertensive
Document when a pt refuses a prescription medicine recommended
What is included in review of outside diagnostic results? - Answer -Whenever a patient shows you outside labs or radiology results and asks you questions about them... Document: outside lab results reviewed and showed (insert interpretation)
When documenting discussions with external professionals what must you include? - Answer -Document
any conversations you have with external sources such as:
-ER triage nurse
-Urgent specialist
-External provider involved w/ pts care -Non-healthcare professionals involved in pts management
What do you document when independent historians are needed? - Answer -When a pt is unable to provide a complete or reliable hx document discussions with another historian
When selecting a dx modifier what should you not do? - Answer -Do not select any of the three choices in the top under "uses for coding" -uncomplicated -systemic symptoms
-poses a threat to life or bodily functions
What do you select instead when selecting a dx modifier? - Answer -Choose the numbered choices from the bottom section (top 4)
-Acute
-Chronic
-Incidental lesion/mass
Bottoms 6 are additions to top 4
What should all fractures be referred to as? - Answer -Clinical not possible and you must include an associated fracture dx
Should you document any refused procedures in the procedure note? - Answer -yes
Can diagnosis modifiers be modified at a later time? - Answer -Yes in the diagnosis screen by clicking on "dx mod" button
Are charts coded by providers? - Answer -No
What do you do if the common diagnosis list does not contain the diagnosis you need? - Answer -You can use the ICD-10 search function
-Type the diagnosis you are searching for, select from list, this will take you to the next screen
