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EHR Certified Exam study guide Flashcards | StudBud
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EHR Certified Exam study guide
EHR Certified Exam study guide
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1
The common abbreviation for Chest X-Ray is..
CPR
CXR
XRC
PMHX
2
A lab report cannot be used for coding purposes because...
They are not reviewed by the Nurse Practitioner before inclusion record
They are not reviewed by a doctor before inclusion in the record
It is not the protocol set forth by HIPPA
It is considered liability
3
Blood pressure: 130/85 mmHg, with a physical exam of clear lungs bilaterally, no wheezes or crackles. This is example of
objective
Assesment
Subjective
Plan
4
Often doctor's do not have the expertise to treat a specific patient's condition. A doctor will then do what?
Send them to a ER
Tell the patient to call their insurance
Tell them to take more vitamins
Give a Referral
5
Why should closed patient records be purged and placed in electronic storage?
Liability reasons in the event of medical malpractice.
To ensure compliance with patient preferences for record retention.
To save space.
To reduce the risk of data breaches
6
The best definition for a company that processes health information and executes electronic transactions is:
health care plans
Health care providers
clean houses
Clearing House
7
what is essential to proper E/M code assignment?
Documentation
Writing legibly
Assigning different medical codes
Assigning the codes only
8
the HCPCS codes are maintained by which of the following?
The center for Medical Codes and the FBI and CIA
The centers for Medicare and Medicaid Services
The center for Medicaid and Medical standards
all of these
9
The ability of separate EHR systems to share info in compatible formats is called?
Interoperability
Compatible info systems management
Transferance
Audit
10
The process of moving a patient from appointment making through checkout is called?
Patient exchange
Patient movement
Patient Portal
Patient flow
11
When is the secondary insurance plan billed?
After the patients visit
After the Primary
Before the Primary
After the Secondary
12
Providers who have not adopted an EHR system by 2014 are subject to:
The medical office gets shut down
Financial penalties
They will catch hands from the government
Subject to have their rights stripped as heathcare providers
13
The biggest advantage of voice recognition software over manual transcription is.
faster billing
speed of documentation
physicians dont have to write anymore
none of these
14
When you report a procedure in addition to the primary procedure, this term is known as a Add-On code?
True
False
15
_____ are used to report encounters for circumstances other than disease or injury in ICD-10-CM
Alphanumeric Codes
Z codes
Alpha codes
Numeric Codes
16
An ONC meaningful use criteria mandates that a certified EHR program must be able to record the patient's?
Bowel Movements
An assessment
Social media habits
Height, weight, blood pressure, BMI
17
What is the Birthday Rule?
parents birthday falls first in a calendar year is primary coverage
parents who is oldest is primary coverage over the child
18
If a patient has had a malignancy removed and no further treatment is needed it is coded as:
A success
History
Code 50-678-12342
A failure
19
If a patient is injured in an automobile accident, what type of insurance is applicable?
Individual Health Plans
Liability copayment
Liability Insurance
Health insurance
20
The UB-04 is used to submit..
ICD-10-CM codes
Doctors Orders
Hospital Claims
Patient Prescriptions
21
The first three factors a coder must consider when coding is the patient status, place of service and:
Have they been to outer space
Where they got their shoes
Type of doctor
Type of service
22
for a specialist to document in a rapid and efficient way, EHR companies provide
Free consultation to EHR companies
Secure patient messaging system for follow-up communication
Pre-built visits, physicians order and letter templates for each specialty
Voice recognition for transcription and auto-completion of patient data
23
Which code indicates the type of visit code?
Code 200
ICD-10 codes
Type of Visit Code (TOV)
The code you need to get through any door in the millennium falcon.
24
What is meant by "code top the highest level of specificity"?
Writing code that addresses the broadest concepts and general functions
use all codes related
using the most specific code possible
Writing code that is modular and reusable for multiple tasks
25
In using an EHR, the word "cloning" refers to:
None of the above
moving one part of the SOAP to the next
Making duplicates only
Copying and pasting notes from the patient's previous visit
26
Is an Emancipated minor billed for medical treatment
False
True
27
Codes that identify the procedures performed for a patient are called?
CPB
Unified Medical Language System
HIPAA
Current Procedural Terminology
28
Individuals receiving Temporary Assistance for Needy Families payments are limited to a ____ year benefit period?
10
5
3
1
29
The ICD-10-PCS includes procedure codes for which of the following:
Procedure Codes for the inor
Procedures codes for the patient
Procedure codes for the alliance
Procedure codes for the doctor
30
The ICD-10-CM is comprised of which of the following?
Medical terminology
Diagnoses
anatomy and physiology
Lab Reports
31
To help guard against security breaches, emails containing protected health information should be:
Never be sent in the 1st place
Monitored by your DON
Encrypted
unencrypted
32
the use of E prescribing is part of the requirement for (HITECH)
False
True
33
The format for Level II codes in the HCPCS is a letter followed by ____ numbers
nine
two
four
six
34
Currently, participation in the Physician Quality Reporting Initiative is:
Mandatory
Voluntary
Both of these depending on the practice
Not optional
35
There must be a _______ to perform any test of treatments:
order by the president of health and human services
order by the HCP
order by the coder
order by the billing specialist
36
a small business with fewer than 15 employees carries what type of primary insurance?
Standard plan
Employer Group Plan
Tell them they don't deserve insurance
None required
37
Multigravida is a term associated with
Brain
Heart
Pregnancy
Liver
38
What is an adjustment?
all of the above
Insurance liability
Fixing the crease in your shoes
The amount an insurance company may say is not allowed
39
When you electronically archive patient records, where do they go?
The Doctors Personal Computer
The Pentagon
CD or Hard Drive
Library of Congress
40
The anesthesia section in the E/M codes is used for the follow types: Local, Regional,General and International
False
True
41
What type of statement needs to appear on a fax cover sheet when transmitting PHI?
Notice of privacy
Non disclosure
Confidentiality Statement
Nothing. Its safe as is.....
42
A log that contains information about the administration of the medication to the patient is called?
sig
Medication list
RXHX
Medication Adminstration Record
43
Only services deemed medically _________ can be billed to insurance
unnecessary
Necessary
none of the above
fraudulent
44
Health Level 7 (HL7) standards Allows different software to interface with each other
False
True
45
What do the letters NOS indicate?
Not otherwise specified/ Equals unspecified
NONE
National Operating System
Necessary Office Space
46
Who manges a personal Health Record(PHR)
The individual
Staff
Your Mommy
Physcians
47
a legal doctrine that says services rendered must be reasonable and necessary to generally accepted clinical standards?
Demographics
Clincal ethicality
Medical Necessity
Legal Medical Practice
48
Lack of documentation during a patient visit could result in:
Improved patient satisfaction
Enhanced continuity of their care
Decreased reimbursement
Deceased patient
49
What could be considered a contributing factor to medical errors?
Use of advanced medical technologies
Illegible or incorrectly interpreted handwritten orders
Effective communication between healthcare providers
Writing the wrong prescription
50
When working under a managed care plan, doctors agree to...
Accept whatever fee you as the patient gives them?
Follow the rules of The engagement act of 1996?
Take chickens as a form of payment just like boomers did.
Accept fees that are predetermined by the plan
51
Which acronym was one of the first terms used in the idea of storing medical information electronically?
EMR
EHR
HER
CCFCCP
52
Which of the following is not a safety screening performed by e-prescribing module within the EHR?
allergies
Drug - Tolerance
patient medications
health conditions
53
What type of insurance covers employees that are injured on the job?
Worker's Compensation
The employee standard plan
None
Storm Troopers basic plan
54
The format for the ICD-10-PCS is: A 7 digit code with a combination of numbers and letters
False
True
55
Physicians establish a list of their usual fees for...
For patient who want to self pay
The procedures and services they frequently perform
The procedures and services they don’t perform
The offices of Medicare and Medicaid
56
Does medical identity theft include Health Insurance ID?
False
True
57
Notes about a prescription getting ordered for an pt. would appear in what part of the SOAP note?
assessment
Objective
Plan
Subjective
58
An EHR function that allows a doctor or prescriber to order meds and tests using an automated format is called...
An email
E-prescriber
KASPER
Computerized physician order entry
59
What are demographics?
Items on a map
Identifying information that makes all pts. the same
Graphics
Identifying info that differentiates one patient from another
60
This type technology translates what a provider is saying and types those words into text
none of these
both of these
Voice dictation
Voice Recognition
61
Patient's complaint
: "I've been feeling really tired for the past two weeks and getting headaches every day" Example of?
Plan
Objective
Subjective
The assessment
62
Who should be billed for the treatment of an emancipated minor?
The minor
The parents
The grandparents
None of the above
63
Most individuals receiving TANF payments are limited to a ______ year benefit period
Five
One
90876556777
Three
64
Software that is used in a medical office is called Practice management software
False
True
65
What Software is used to access current information about a disease or condition used by physicians.
Customer support software CSS
No software is needed
all the above
Decision Support Software (DSS)
66
Using a ________ will ensure each member of the staff has defined the data element correctly
CPT
Data Dictionary
Interoperability
a book of spells
67
What is the purpose of a billing audit?
To identify correct coding
To identify poor Penmanship
To identify poor coding
To provide specific codes
68
pt presents with symptoms consistent with acute bronchitis, including a productive cough, low-grade fever, example of?
Subjective
Assessment
Plan
Objective
69
The best definition for structured progress noted that the physicians use to document patient encounters in an EHR is:
Clinical templates
SOAP templates
a superbill form
ledger
70
Data may be structured or unstructured. Identify an example of unstructured data
Reports by the Alliance
Dictated Report
Customer database with name, address, and phone number
A spreadsheet of sales figures
71
If a patient is admitted to the hospital 4x in one year how many times are they entered into the patient master index?
One
Four
Zero
Two
72
A Thesaurus database of medical terms is called
Health Information Exchange
Unified Medical Language System
UMLC
Medical Dictionary
73
The acronym HIE stands for
Health Interoperability E-Mail
Health Information Exchange
Hypoxic ischemic encephalopathy
Health Information Expense
74
What is a private, secure electronic file that is created, maintained and owned by the patient called?
Personal Health Record
Pertinent Health Record
Patient Health Record
Present Health Record
75
A list of medical procedures and their respective allowed amounts is known as...
Fee schedule
Medically necessary expenditures
None
Program fees
76
If a Fracture is not documented as closed or open it is always coded as?
open
closed
neither
If a Fracture is not documented we do not code it
77
Evaluation and Management Codes (E/M Codes) are based on three factors...
Place of Service
Types of service
All the above
Patient Status
78
What is the abbreviation for a patients expressed concern?
E/C
C/O
E/o
F/O
79
PMHX is an abbreviation for the:
a planet in another galaxy overrun by the empire
Past moms history
Patient's Past Medical History
Parents past medical history
80
What is easily obtained when using an EHR system?
Interoperability
Faster shooting from a star ship
Ease of use
CPOE
81
What is the proper action to take when a very ill patient enters the office?
Assist the patient straight to the exam room
Yell STAT to the doctor because it's an emergency.
Use PPE, Call 911 and tell the doctor ASAP
Wait a long as possible and hope they simply get mad and leave
82
How is payment received in electronic office?
Cash
Paypal
Cash App
Electronic deposit is made into an online office account
83
A code that reports more than one diagnoses with one code is a _______________ Code
PCP
Combination
CPT
Z Code
84
On a prescription, the "SIG" is which part of the script?
signature
the Doctors notes
Instructions on taking the medication
nothing
85
The process of entering fees for services on a patient account is referred to as:
reconciliation
Procedure Posting
charges
superbilling
86
Consultation letters are different from referral letters. They are different why?
Who cares?
They are the same
A consultation is when a doc requests the opinion of another doctor.
referral letters are not from the HCP's
87
The Letters "qhs" means
In the Morning
Before 1500
As needed
Every bedtime
88
In documenting patient history, the letters PFSH stands for:
Physical Fit and strength health
Past history, family history and social history
Past happiness, family happiness and social happiness
Patient file and summary
89
The gatekeeper for some types of managed care plans is also referred to as the...
Internists
Nurse coordinator
Primary care Physician
King of Omashu
90
When thinking of an electronic Health Record, EHR, The word AUDIT means?
A review of patient Financial Records
A review of employee activity with in the EHR system
91
What is the most common encounter with patients in an ambulatory setting?
hospital visit and have to be admitted
The ER
Surgery
Office Visit
92
An active patient is defined as..
One who saw the provider within the last 5 years
One who saw the provider within the last 2 years
One who saw the provider within the last 3 years
One who saw the provider within the last 10 years
