TAUC Pre-scribeU Tested And Graded A+
What should be consistently documented in the Procedures section for billing purposes?
️Prescription medication discussions
Review of outside diagnostic results
Discussions with external professionals
Independent historians needed
What is included...
TAUC Pre-scribeU Tested And Graded A+
What should be consistently documented in the Procedures section for billing purposes?
✔️Prescription medication discussions
Review of outside diagnostic results
Discussions with external professionals
Independent historians needed
What is included in the prescription medication discussions? ✔️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? ✔️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? ✔️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? ✔️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? ✔️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? ✔️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? ✔️Clinical not possible and you must include an associated
fracture dx
Should you document any refused procedures in the procedure note? ✔️yes
Can diagnosis modifiers be modified at a later time? ✔️Yes in the diagnosis screen by clicking on "dx
mod" button
Are charts coded by providers? ✔️No
What do you do if the common diagnosis list does not contain the diagnosis you need? ✔️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
After you select the diagnosis, what must you specify in the next screen? ✔️Laterality, visit number,
further specification of anatomy
What can you do if you are unable to locate the exact diagnosis? ✔️Rename the diagnosis by typing in
the rename bar
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