Clinical encoder program - Study guides, Class notes & Summaries

CCA Exam Prep - Information Technology, Questions with accurate answers, Verified. This system will require the author to sign onto the system using a user ID and password to complete the entries made. a. Digital dictation b. Electronic signature authentication c. Single sign on technology d. Clinical data repository - b. Electronic signature authentication The protection measures and tools for safeguarding information and information systems is a definition of ________. a. Confiden...

RHIA Exam 267 Questions with Verified Answers A method of documenting nurses' progress notes by recording only abnormal or unusual findings or deviations from the prescribed plan of care is called: - CORRECT ANSWER Charting by exception The discharge summary must be completed within _________ after discharge for most patients but within ________ for patients transferred to other facilities. Discharge summaries are not always required for patients who were hospitalized for fewer than _____...

RHIA Exam 393 Questions with Verified Answers Where can you find guidelines for the retention and destruction of healthcare information? a. Institute of Medicine b. Municipal regulations c. HIPAA d. Accreditation standards - CORRECT ANSWER d. Accreditation standards This functionality can result in confusion from incessant repetition of irrelevant clinical data. a. Change b. Amendment c. Copy and paste d. Deletion - CORRECT ANSWER c. Copy and paste Which of the following ind...

Encoder - ANSWERComputer software that helps the coding professional to assign codes. This software now includes assistance with other coding systems Computer Assisted Coding - ANSWERUtilizes natural language processing (NLP) and algorithmic software to electronically analyze entire medical charts to pre-code with both CPT procedure and ICD10 diagnostic nomenclatures Natural language processing - ANSWERConsidered a special form of data entry, it is the capability of a computer to apply ver...

c. Edit checks Edit checks help ensure data integrity by allowing only reasonable and predetermined values to be entered into the computer (Rinehart-Thompson 2016a, 265). - Answer A coding analyst consistently enters the wrong code for patient gender in the electronic billing system. What data quality or data integrity measures should be in place to ensure that only allowable code numbers are entered? a. Access controls b. Audit trail c. Edit checks d. Password controls b. Delinquent r...

According to CPT, a repair of a laceration that includes retention sutures would be considered what type of closure? a. complex b. intermediate c. not specified d. simple - Answer a. Complex A skin lesion is removed from a patient's cheek in the dermatologist's office. The dermatologist documents "skin lesion" in the health record. Prior to billing the pathology report returns with a diagnosis of basal cell carcinoma. Which of the following actions should the coding professional do fo...

EPIC - Frequently Heard Terms Questions and Answers 2023 Account Maintenance A module that allows billers to see financial activity for a guarantor account or hospital account. Activity The main place where users or administrators enter and view data in Hyperspace. ADT / Prelude Improves bed utilization and gives users the tools to manage hospital stays from pre-admission through discharge. Allows clinicians to access a census workplace that allows them to view and update curre...

Correct!! software to electronically analyze entire medical charts to pre-code with both CPT procedure and ICD10 diagnostic nomenclatures Natural language processing - ANSWERConsidered a special form of data entry, it is Encoder - ANSWERComputer software that helps the coding professional to assign codes. This software now includes assistance with other coding systems Computer Assisted Coding - ANSWERUtilizes natural language processing (NLP) and algorithmic the capability of a computer...

Application service provider - answer-A third-party entity that manages and distributes software-based services and solutions to customers across a wide area network (WAN) from a central data center. Assessment (A) - answer-Judgement, opinion, or evaluation made by a healthcare provider; considered part of the problem-oriented record (POR) SOAP note. Assumption coding - answer-inappropriate assignment of codes based on assuming, from a review of clinical evidence in the patient's record, ...

Epic Terms Questions and Answers 2023 Account Maintenance (Revenue Cycle) A module that allows billers to see financial activity for a guarantor account (Professional Billing) or hospital account (Hospital Billing, Home Health Billing, and Coding and Abstracting). Activity (All Applications) The main place where users or administrators enter and view data in Hyperspace. For example, the Order History activity is used to view information for an order and the Medications activity is used...