Uhdds inpatient coding Study guides, Class notes & Summaries

During an audit of health records, the HIM director finds that transcribed reports are being changed by the author up to a week after initial transcription. The director is concerned that changes occurring this long after transcription jeopardize the legal principle that documentation must occur near the time of the event. To remedy this situation, the HIM director should recommend which of the following? - Develop a facility policy that defines the acceptable period of time allowed for a transc...

CCA Exam Preparation All Domains Actual Questions and Answers During an audit of health records, the HIM director finds that transcribed reports are being changed by the author up to a week after initial transcription. The director is concerned that changes occurring this long after transcription jeopardize the legal principle that documentation must occur near the time of the event. To remedy this situation, the HIM director should recommend which of the following? - Correct Answer-Develo...

CCS Exam Prep 2024 Latest Update7 yo pt admitted to ED for tx of shortness of breath and given epinephrine and nebulizer tx. Shortness of breath and wheezing are unabated following tx, so what dx should be suspected? - ANSWER Asthma with status asthmaticus Pt admitted with high temp, lethargy, hypotension, tachycardia, oliguria, elevated WBC, and has more than 100K organisms of E. coli per cc of urine. Attending phys documents "urosepsis", so what is the next step for the coder? - ANSWER Si...

7 yo pt admitted to ED for tx of shortness of breath and given epinephrine and nebulizer tx. Shortness of breath and wheezing are unabated following tx, so what dx should be suspected? - ANSWER-Asthma with status asthmaticus Pt admitted with high temp, lethargy, hypotension, tachycardia, oliguria, elevated WBC, and has more than 100K organisms of E. coli per cc of urine. Attending phys documents "urosepsis", so what is the next step for the coder? - ANSWER-Since PD is a nonspecific term and...

coding 2A Staghorn calculus of the left renal pelvis was treated earlier in the week by lithotripsy and is now removed via a percutaneous nephrostomy tube. What is the root operation performed for this procedure? a. Destruction b. Extirpation c. Extraction d. Fragmentation - correct answer Correct Answer: B The root operation extirpation is defined as taking or cutting out solid material from a body part. The matter may have been broken into pieces during the lithotripsy previous to this e...

Your organization is sending confidential patient information across the Internet using technology that will transform the original data into unintelligible code that can be re-created by authorized users. This technique is called a. firewall c. a call-back process b. validity processing d. data encryption d. data encryption As part of a concurrent record review, you need to locate the initial plan of action based on the attending physician's initial assessment of the patient. You c...

CCA EXAM PRACTICE TEST QUESTIONS AND ANSWERS 100% PASS The concept of "minimum necessary" included in the HIPAA means that healthcare providers must Limit use, access, and disclosure to the minimum necessary to accomplish the intended purpose Code assignment for stage three decubitis ulcers of the hip and heel require how many codes? 2 The diagnostic statement indicates the patient has metastatic carcinoma to the bone. This site is considered to be Osseous Origin A revenue code is A four d...

CDIP LATEST 2023 GRADED A+ eMAR Electronic medication administration record PACS Picture archive and communication system CPOE Computerized provider/practitioner/physician order entry CAMP Coaching, asking, mastering, peer learning ICEHR Integrated care EHR HCO Health care organization HIM Health Information Management Stage 0 EHR implementation Lowest level of transformation Stage 1 EHR implementation Electronic capture of health info is in standardized format, track key clinical condit...

Uniform Hospital Discharge Data Set (UHDDS) Chap.4 Study Guide with Complete Solutions Uniform Hospital Discharge Data Set (UHDDS) - Answer️️ -Used for reporting inpatient data in *acute care, short-term care, and long-term care hospitals.* Minimum set of items based on standard definitions to provide consistent data for multiple users. Required for reporting Medicare and Medicaid patients. Many other health care payers use UHDDS for the uniform billing system. UHDDS requiered da...

RHIA AHIMA practice Test 108 Questions with Verified Answers Processing - CORRECT ANSWER Domain 2 Classifying, sorting, storing and retrieving data are all characteristics of which system component? 1. Output 2. Feedback 3.Processing 4.Input K81.2, OFT40ZZ, OFJ44ZZ - CORRECT ANSWER Domain 1 The patient is taken to the OR for a laparoscopic gallbladder removal secondary to acute and chronic cholecystitis. The surgeon encounters difficulty secondary to the patients body habitus and co...