Exam 9: Auditing

If a patient states that the present illness started 3 days ago, the element he or she would be describing is the:

If documentation in the patient chart supports a higher level of service than that coded, the error would be called:

A prepayment audit would verify:

An internal audit can be conducted:

HPI types include:

Match the following -The type of ROS that inquires about the system directly related to the problem identified in the HPI.

Medicare can deny or downcode an E/M service if it feels that the service provided exceeds the patient's documented needs.

For a presenting problem without an established diagnosis, the clinical impression may be stated as a "possible" or "rule-out" diagnosis.

Match the following -The type of audit conducted by an insurance carrier to make sure a practice is compliant.

An extended HPI will include one to three documented HPI elements.

An inventory of body systems obtained by asking the patient a series of questions is called a(n) ________.

A multisystem evaluation that includes at least six organ systems or body areas, and for each system/area selected, performance and documentation of at least two elements would be considered a(n):

Documentation of a review of systems (ROS) is required in all types of histories EXCEPT:

If a patient presents with an acute or chronic illness that poses a threat to life or body function and requires emergency surgery, the level of risk involved with the medical decision making would be considered:

An internal audit may be performed by a:

A prospective audit would typically be done on claims that require an attachment or more information.

Explain the difference between upcoding and downcoding.

Name an audit tool used for billing Medicare Part B?

If a patient states that the pain he or she is experiencing is burning, the element he or she would be describing is the:

The key elements in determining the level of E/M services include the extent of the history, physical exam, and medical decision making.