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EXAM:TAUC PRE-SCRIBE U( 6-DIFFERENT SETS COMBINED TOGETHER)

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EXAM:TAUC PRE-SCRIBE U( 6-DIFFERENT SETS COMBINED TOGETHER) What should be consistently documented in the Procedures section for billing purposes? Correct-Prescription medication discussions Review of outside diagnostic results Discussions with external professionals Independent historian...

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  • September 5, 2024
  • 194
  • 2024/2025
  • Exam (elaborations)
  • Questions & answers
  • TAUC PF
  • TAUC PF
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EXAM:TAUC PRE-SCRIBE U( 6-DIFFERENT SETS
COMBINED TOGETHER)
What should be consistently documented in the Procedures section for billing purposes?

Correct-Prescription medication discussions


Review of outside diagnostic results


Discussions with external professionals


Independent historians needed




What is included in the prescription medication discussions? Correct-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? Correct-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?

Correct-Document any conversations you have with external sources such as:

, EXAM:TAUC PRE-SCRIBE U( 6-DIFFERENT SETS
COMBINED TOGETHER)
-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? Correct-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? Correct-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? Correct-Choose the numbered

choices from the bottom section (top 4)


-Acute


-Chronic

, EXAM:TAUC PRE-SCRIBE U( 6-DIFFERENT SETS
COMBINED TOGETHER)
-Incidental lesion/mass


Bottoms 6 are additions to top 4




What should all fractures be referred to as? Correct-Clinical not possible and you must

include an associated fracture dx




Should you document any refused procedures in the procedure note? Correct-yes




Can diagnosis modifiers be modified at a later time? Correct-Yes in the diagnosis screen by

clicking on "dx mod" button




Are charts coded by providers? Correct-No




What do you do if the common diagnosis list does not contain the diagnosis you need?

Correct-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


-Select a second more accurate diagnosis on the second screen

, EXAM:TAUC PRE-SCRIBE U( 6-DIFFERENT SETS
COMBINED TOGETHER)

After you select the diagnosis, what must you specify in the next screen? Correct-

Laterality, visit number, further specification of anatomy




What can you do if you are unable to locate the exact diagnosis? Correct-Rename the

diagnosis by typing in the rename bar




A plan is not created for every diagnosis... T/F Correct-FALSE




What does a plan contain? Correct-Advice


Referral options


Discharge instructions


RX




Every plan should include how many items/topics that are chosen under the advice?

Correct-3

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