CCS EXAM PREP DOMAIN 5/14
QUESTIONS WITH ANSWERS
Cloud based EHR - -Data is stored and accessed online
-CMS defines an Electronic Health Record (EHR) as - -"an electronic version
of a patients medical history, that is maintained by the provider over time,
and may include all of the key administrative clinical data relevant to that
persons care under a particular provider, including demographics, progress
notes, problems, medications, vital signs, past medical history,
immunizations, laboratory data and radiology reports".
-Computer‐Assisted Coding (CAC) Software definition and objective - -A tool
that uses natural language processing (NLP) and machine learning to analyze
clinical documentation and suggest appropriate medical codes for patient
records
CAC objectives are to improve coding accuracy, efficiency, and productivity
while reducing the potential for human error.
-Encoder software - -used for assigning appropriate codes to diagnoses
(ICD‐10‐CM) and procedures (ICD‐10‐PCS and CPT).
It can
-provide suggestions
-instructional notes
-guidelines
-edits
-Examples of grouper software - -MS-DRG and APR-DRG
-Grouper software - -used in revenue cycle management to assign DRG's for
billing and reimbursement.
-Grouper software Algorithms are designed for - -compliance with
regulatory guidelines and coding standard
-Grouper software Grouping is based on - -clinical conditions and any
procedures performed
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