Query the physician - Study guides, Class notes & Summaries

As the corporate director of HIM Services and enterprise privacy officer, you are asked to review a patient's health record in preparation for a legal proceeding for a malpractice case. The lawsuit was brought by the patient 72 days after the procedure. Health information contains a summary of two procedures that were dictated 95 days after the procedure. The physician in question has a longstanding history of being lackadaisical with record completion practices. Previous concerns regarding thi...

The Medical Record Committee is assessing various strategies to improve documentation in the health record. Concerns have been raised that current documentation practices may be insufficient to support diagnoses or reflect the progress and clinical findings in patient care. Which of the following would be the best first step to help improve physician documentation? (Ans- Determine the type and volume of documentation problems This type of healthcare organization review is conducted at the r...

The American Hospital Association (AHA), the American Health Information Management Association (AHIMA), Center for Medicare and Medicaid Services (CMS), and National Center for Healthcare Statistics (NCHS) are all a.Cooperating parties b.Governing bodies c.Coding associations d.Work independently to develop coding guidelines - Answer- a The American Hospital Association (AHA), the American Health Information Management Association (AHIMA), Center for Medicare and Medicaid Services (CMS), an...

A patient is admitted to the hospital with shortness of breath and congestive heart failure. The patient undergoes intubation with mechanical ventilation. The final diagnoses documented by the attending physician are: Congestive heart failure, mechanical ventilation, and intubation. Which of the following actions should the coder take in this case? a. Code congestive heart failure, respiratory failure, mechanical ventilation, and intubation b. Query the attending physician as to the reaso...

A 23-year-old female is admitted for vaginal bleeding following a miscarriage two weeks prior to this admission. She is afebrile at this time and is treated with an aspiration dilation and curettage. Products of conception are found. Which one of the following should be the principal diagnosis? - Answer-O03.1, Delayed or excessive hemorrhage following incomplete spontaneous abortion A psychiatrist documents that a patient has wide mood swings from excessive happiness to loss energy and crying...

RHIT EXAM PREP PRACTICE QUESTIONS AND ANSWERS (Coding) 2024 (VERIFIED ANSWERS). (113) If a patient has an excision of a malignant lesion of the skin, the CPT code is determined by the body area from which the excision occurs and which of the following? A) Length of the lesion as described in the pathology report B) Dimension of the specimen submitted as described in the pathology report C) Width times the length of the lesion as described in the operative report D) Diameter of the lesion a...

RHIA 2024 Test Questions with Revised Answers When is a physician query not appropriate - Answer-a query may not be appropriate when the clinical information or clinical picture does not appear to support the documentation of a condition or procedure. in situations in which healthcare entity's policies can provide guidance on a process for addressing the issue without querying the attending physician. What is clustering - Answer-practice of coding or charging one or two middle levels of ser...

A 23 year old female is admitted for vaginal bleeding following a miscarriage two weeks prior to this admission. She afebrile at this time and is treated with an aspiration dilation and curettage. Products of conception are found. Which of the following should be the principle diagnosis? a. O03.1, Delayed or excessive hemorrhage following incomplete spontaneous abortion b. O08.1, Delayed or excessive hemorrhage following ectopic and molar pregnancy c. R57.9, Shock, unspecified d. T81.10XA, P...

CCA #1 & #2 Questions And Verified Correct Answers | Updated A 7-year-old patient was admitted in the emergency department for treatment of shortness of breath. The patient is given epinephrine and nebulizer treatments. The shortness of breath and wheezing are unabated following treatment. What diagnosis should be suspected? - ANSWER : Asthma with status asthmaticus A patient is admitted with a high temperature, lethargy, hypotension, tachycardia, oliguria, and elevated WBC. Th...

Genetic Counseling Board Review Questions You are meeting with a 25 year old woman and her parents in the cardio genetics clinic. The patient was seen at an outside institute and had genetic testing related to hypertrophic cardiomyopathy. Unfortunately, genetic testing did not find the cause of her heart condition. Now, the family is coming to you to discuss enrolling in a cardiovascular genetics research study that aims to find new genes for HCM. During the course of the session, you begin to ...