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EHR Study Guide
How many types of payers are there?
What is a ledger report?
EHR Study Guide
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1
What is a ledger report?
CPT codes
Patient emergencies
Payments adjustments and responsibility of patient
Method of reimbursement for patients
2
How many types of payers are there?
7
2
1
5
3
What is a day sheet?
Payments are posted in the morning before seeing patients
Payments are posted on Friday’s
Payments are posted electronically only
Payments are posted at the end of the day
4
What is upcoding?
Assigning higher level service or procedures to increase reimbursement
Releasing patient information
Information shared between computer systems
Health care level 7
5
What is a breach of confidentiality?
Realizing information without proper authorization
Documenting telephone calls
Retrieving educational information
Health insurance claim
6
What is the first step in an office/facility obtaining their own EHRS?
Help ensure documents are completed
None of the above
Establish guidelines for research
Selecting a committee to guide process of implants and training
7
What does HIPAA regulate ?
All the above
Protecting patients while being seen by physicians
Set standards while also ensuring privacy& security of electronic health
Health insurance claims
8
What does HL7 do?
None of the above
Retrieve educational information
Health care level 7 Establish guidelines for research
Health documentation
9
Can you use the body of an operative report to confirm the procedure and diagnosis?
Most of the time
Yes
No
Sometimes
10
What is a provider database?
Includes referral information
Patient records
CPT manual
Electronic data interchange
11
What does interface mean?
Patients negative lab results
Out patient hospital care
Documents used in medical offices
Computer system/component to accept or send data to other systems
12
What is benchmarking?
Payment adjustments
Real time documentation
Releasing information with proper authorization
Research that gives an idea of what is happening
13
Who receives the EOB?
Physician
The patient
Parent/guardian
The provider
14
What is interoperability?
Info that can be shared w/computer systems or written applications
Impatient care
Medical officials
Computer systems
15
Example of auditing is conducting a financial exam of an individual or organizations account?
True
False
16
What is data integrity?
All the above
Proper authorization
Most common procedures
Maintain accuracy and consistency of data
17
What does the LOINC do?
Exchange & pulling of results such as lab results,vital signs& research
Provide query about blurt vision
Remind patient about test & screening
None of the above
18
Which goes first on a CMS-1500 claim form ?
HL7
CPT code
ICD-10-CM
None of the above
19
Which of the following features of CDSS notifies providers that medication they prescribed is not covered by insurance?
Formulary alert
eMAR
Clinical decision support
MAR
20
What needs to be checked to file for reimbursement?
Medicare
Accuracy & completeness
All of the above
Procedures and screenings
21
How do using templates specific to a physician or facility help?
Retrieve educational materials and information
Submit insurance claims
Translating health documentation
Help ensure complete documentation which helps claims not be denied
22
OIG means office of inspector general?
True
False
23
What is HPI? (History of present illness)
Patients description of current illness
Patients writing down their pain level
Templates served as structured data
Subjective notes
24
What does a medical record include?
Maintaining accuracy & consistency of data
Medical/Surgical interventions observations & treatment outcomes
Diagnosis
Treatments
25
Mar=electronic eMAR=paper
False
True
26
What is the “do not use” list ?
Retrieve educational info
Referral to a specialist
Any reason a pt is being seen but in their own words
MS04- a list of abbreviations that can be confused . Cannot be documented
27
How often is it recommended to update your procedure codes?
Every 3 months
Twice a year
Annually/Yearly
Every month
28
What is an example of objective data ?
Patient has an amputation of left leg
If a patient walks with an unsteady gait
Vital signs
Patient complains of headache
29
Is cloning copying&pasting health information?
False
True
30
What is a payer portal?
None of the above
Place to pay online
Checking medical bills
Paying light bill
31
What is e-scribing ?
Surgical interventions
All the above
Prescribing medications electronically
Health insurance claim
32
What is MAR/eMAR?
Used to track medications from order to administrative
Outpatient hospital care
All the above
Documents
33
What is a CPOE?
Prevents duplication of orders
Duplication/prevents duplication of orders
Documents used for medical offices
Previous illnesses
34
What is continuity of care?
Establishing guidelines for research
Transferring patient record to consulting provider
All the above
Helps claims not be denied
35
What does part B of Medicare cover ?
Outpatient hospital care durable medial equipment and provider services
None of the above
Component to accept or send data to another system with out loss of meaning
Relationship between procedures and diagnosis
36
What are accounts receivable?
Medical accounts
Money owed to company by its debtors
Family/social history
37
Where is the patient education located within the EHR software?
CDS of patients education
Health insurance claim form
bill services supplies and products
All the above
38
What is encryption ?
None of the above
Establishing guidelines for research
Claims being denied
Type of security that scramble words&can be seen by receiving computer
39
What is a PPS?
Comprehensive record of pt complaints/conditions
Medical/surgical interventions
Symptoms explained in pt own words
Method of reimbursement in Medicare payment based on predetermined amount
40
Explain of chief complaint?
Documents used in medical offices
Any reason a patient is being seen in their own words
All the above
Provider query about blurry vision
41
Who/What is the primary government payer in the U.S?
BCBS
Medicare
State Farm
All the above
42
What is EDI?
Outlining circumstances in PHI being disclosed
Patient prescription
A type of security measure
Computer to computer exchange of business documentation
43
Example of Plan of Care?
Patient care
A referral to a specialist
Insurance claims
Patient records
44
What services are examples of EHR meeting clinical quality measures?
Office staff doc pt phone calls,MA recording vital signs & pt history etc.
Both red and yellow
None of the above
Physicians speaking to patients about symptoms
45
What is a clinical decision support?
Retrieve educational material and information
All the above
Copying and pasting information
Prevents duplication of orders
46
What is the HIPAA privacy act ?
Outline circumstances in which PHI must be disclosed
Submit insurance claims
Advance beneficiary notice
Assisting HL7
47
Who can a provider disclose PHI without a patients permission?
In an emergency
Only in Outpatient hospital care
Only to another provider
In a Medical offices
48
Example of Review Of Systems? (ROS)
Health documents
Medicare
A provider query about blurred vision
A patient walks with a unsteady gait
49
An intake form is a form patient fills out upon intake ?
True
False
50
What is an encounter form?
Patient description of current illness
Prescribing medication electronically
Info shared between computer systems
Docs used to capture diagnosis/services, the CMS-1500 billing completed
51
What is international classification of diseases 10th revision clinical modification?
Patient education
Electronic data interchange
Provider database include referral information
ICD-10-CM convert narrative diagnosis into alphanumeric codes in all areas
52
What is production by procedure report ?
Letters, numbers and special characters
Used to bill services supplies and products
Form a patient can sign
Most common procedures completed by providers
53
What does a CPT manual do?
All the above
Comprehensive record
Procedures and services found here
Patient walking with unsteady gait
54
What is an aging report ?
Identifying past due patient or insurance amount balances
None of the above
Information shared between computer systems
Copying information
55
What is an audit trail?
Report that shows accessed by the user to each function of software
Documentation
Patient describing current illnesses
Copying/pasting information
56
What is an explanation of benefit?
Real time
Documents of patients procedures
How services provided were processed by insurance carrier
Checking for accuracy and completeness
57
What is an ABN & when is it used?
Available Benefits Nationally, assisting benefits to patients
Both red and blue
None of the above
Advanced beneficiary notice. When Medicare does not cover services provided
58
Example of a diagnosis
COVID
Stage 4 Cancer
HIV/AIDS
Vertigo
59
What is auditing?
Checking for accuracy and completeness
All the above
Prescribing medication electronically
Info shared between computer systems
60
What is ROBAC’s?
Restrict access to area of pt record for info based on job title
Method of reimbursement in which Medicare payment is paid
An emergency
None of the above
61
EDI stands for Electronic Data Interchange?
True
False
62
What is Medical Coding?
documentation of pt encounters into a series of numeric&alphanumeric codes
None of the above
PHI must be disclosed
Immediate real time documentation of pt procedures
63
What is code linkage ?
None of the above
Comprehensive records
procedure and diagnosis to demonstrate medical necessity
A referral to a specialist
64
What is point of care ? (POC)
Real time documentation of patient procedures
Assisting patients to bathroom
Real time of patients lab results
Managing patients wait time in the lobby
65
What is a chief complaint?
The main reason for the visit as stated by patient
Period
You know the answer
Don’t play with me
66
What is real time data ?
POC or subjective documentation
Health insurance act
Objective patient care
Assisting patients in their chief complaints
67
What does the parties medical history include?
Parents background
Diagnosis, viruses, treatments
Family , social and past medical history
All the above
68
What is an advanced directive?
A form a pt can sign to let someone make decisions if they’re unable to
Releasing information without proper authorization
A type of security measure
Copying & pasting information
69
What are incomplete records?
Patient description of current illness
Records that are missing information
Consistency of data
None of the above
70
What is a billing/payment status report ?
Method of reimbursement
Templates served as structured data
Transferring patient records to consulting providers
Claims waiting to be changed
71
What is a problem list ?
None of the above
A patients complaint
A comprehensive record of patients complaints and conditions
Report that shows access by user to each function software
72
The chief complaint goes where in a SOAP note ?
Objective
Health assessment
All the above
Subjective
73
What should a password contain?
Different numbers and lower case letters
Capital letters and different numbers
A combination of letters,numbers and special characters
All of the above
74
What is syndromic surveillance?
A type of security measure
Report that shows access by users
Auditing checking for accuracy and completeness
Providing info to local health depts or agencies
75
What/Who handles fraudulent billine?
Medicaid
Plan of care
OIG
HL7
76
What is structured date?
Medical coding
Review of systems
Feature of EHR system
Templates serve as structured data
77
What does the alert features do in the EHR systems ?
The main reason for the visit as stated by patient
The ability to work with other systems
Reminds about patient test procedures and screening
Observation and treatment outcomes
78
What is a CMS-1500?
Provider database
An emergency
Bill services
Insurance claim form used to submit insurance claims
