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34 Cards in this Set
- Front
- Back
How does the MAA prove medical necessity?
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When is it recommended the MAA create an authentication legend?
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When the procedure is completed |
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What are LDCs and what do they do?
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Local Coverage Determinations specify under what clinical circumstances a service is covered and list the covered and non-covered codes |
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What does VistA stand for?
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Veteran's Health Information System and Technology Architecture |
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Who developed the VistA health record?
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The U.S. Department of Veterans Affairs |
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Provide other names for medically managed diagnoses:
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Secondary diagnoses or coexisting diagnoses |
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How many diagnoses can be reported on the CMS-1500 claim form?
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Up to four |
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What information is needed by hospitals and ambulatory surgical centers to compile their operative reports? (1)
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Date of surgery, patient I.D., Pre and post-op disgnosis
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What information is needed by hospitals and ambulatory surgical centers to compile their operative reports? (2)
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List of procedures performed, names of primary/ secondary surgeon(s), and positioning and draping of the patient surgery
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What information is needed by hospitals and ambulatory surgical centers to compile their operative reports? (3) |
Achievement of anesthesia, closure of the surgical site, and signature of the surgeon |
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What is required by Medicare for all outpatient and physician office procedures not covered by Medicare (ABN)?
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A waiver
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What does ABN stand for and what is it used for?
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Advanced Beneficiary Notices are what patients need to sign when it is felt Medicare may not pay for the services and the patient would be responsible for the bill |
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What is the primary purpose of the patient record? |
To provide continuity of care |
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Why is the patient record important to the health care facility? |
It contains documentation of all health care services provided to the patient and supports the diagnosis, justifies treatment, and records treatment results
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What does the auditing process involve?
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Reviewing patient records and CMS-1500 or UB-04 claims to process coding accuracy and completeness of documentation |
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What should you not use when marking on original documents to ensure accuracy when coding case reports?
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Highlighters or other markers |
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What are operative reports?
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Short narrative descriptions or formal dictated reports |
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What are chargemasters used for?
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To select procedures, services and supplies provided to hospital emergency department patients and outpatients |
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What is OCE?
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A software used to edit outpatient claims submitted by hospitals |
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What form are SOAP notes written in?
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Outline form |
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Which block on the claim form is the first-listed diagnosis?
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Reported on Block 21 |
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Which form are narrative clinic notes written in?
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Paragraph form |
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When do health insurance specialists review the patient record?
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When assigning codes to diagnoses, procedures, and services |
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What does the patient record serve as?
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The business record for a patient encounter and is maintained in a paper or automated format |
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Which two major formats for documenting clinic notes do health care providers use?
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Paragraph form and outline form |
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What does the "subjective" part of the SOAP notes refer to?
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The patient's CC/ how the patient feels |
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What does the "objective" part of the SOAP notes refer to?
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What does the "assessment" part of the SOAP notes refer to?
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Usually includes the physician's rationale for the diagnosis |
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What does the "plan" part of the SOAP notes refer to?
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The statement of the physician's intended medical management of the case (how they plan to treat the condition) |
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What is the CMS-1500 form?
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The outpatient claim form |
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Diagnostic test results are documented in how many locations?
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Two |
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Medically managed diagnoses ___ or _____ receive treatment during an encounter.
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May or May not |
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What does global surgery period include?
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The preoperative assessment, surgery and postoperative care |
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What is the auditing process?
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Review patient records, CMS-1500, UB04 claims for accuracy |