According to AMA medical decision making is measured by - correct answer 1’
number of dx or management options
2’ amount and complexity of data review
3’ risk of complications
CPT Assistant - correct answer provides official guidance in CPT coding
published by the AMA
A barrier to wide spread use of automated code assignments is - correct answer
poor quality of documentation
When should coders assign codes from lab reports alone - correct answer Never’
If findings are out of normal range and the physician has ordered additional
testing or treatment; consult with the physician as to whether the Dx should be
added or if an abnormal finding should be listed’
4 cooperating parties of ICD-9 and responsibilities of each - correct answer NCHS
(national center for health statistics): maintaines dx classifications in Vol 1&2
CMS: maintains procedural classification in Vol 3
AHIMA & AHA: give advice & assistance on coding guidelines in conjunction with
health information management practitioners, physicians, & other users of ICD-9
When can code 99291 (E/M critical care) be used in place of a medical visit or ER
code - correct answer When the patient meets the definition of critical care and
receives outpatient care on the same day
,limiting charge - correct answer this is the amount a NON PAR Medicare provider
can collect from a patient in excess of 15% over the NON PAR Medicare approved
amount’
When does CMS send the payment directly to the patient - correct answer when a
NON PAR provider does not accept assignment
hard coding - correct answer refers to CPT/HCPCS codes that appear in the
hospitals chargemaster and will be included automatically on the patient's bill’
CAC- computer assisted coding - correct answer AHIMA defines as the use of
computer software that automatically generates a set of medical codes for review
, validation, and use based upon the documentation provided by the various
providers of healthcare’
modifier: A1-principle physical of record - correct answer required for patients
covered by Medicare when reporting Initial Hospital Service codes
POMR- PROBLEM ORIENTED MEDICAL RECORD - correct answer Organized by
problem number
Database: history and physical
Problem List: titles, numbers, dates of problems’’’"Table of Contents" of the
record
Initial Plan: describes diagnostic, therapeutic, and patient education plans
Progress Note: documents the progress of a patient throughout the episode of
care
, Discharge Note/ Transfer Note: summarizes episode of care and current status of
patient
Cost Sharing Provision of Health Ins’ - correct answer formulary for drugs
co-pay
benefit limitations
Common Complication of Labor and Delivery - correct answer forceps or vacuum
extractor delivery without mention of indication
renal sphincter tear, not associated with 3rd degree peritoneal laceration
trauma to perineum and vulva during delivery
HIPAA law in regards to children under 18 - correct answer defers to state law on
matters that concern minors
disease index - correct answer list diagnostic codes in order
physician index - correct answer lists cases in order by physician name or
number
master patient index - correct answer cross reference patient name and medical
record number
operation index - correct answer list medical records by operative procedures
Point of Care Service - correct answer when clinical documentation is entered in
computer at the same time and location of service
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