Exam 4: Medical Documentation and the Electronic Health Record

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During an audit, points are awarded when documentation is present.

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A disease that runs a short but relatively severe course is referred to as ____________________.

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acute

Once an individual has been found guilty of committing a Medicare or Medicaid program-related crime,

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A

The key to substantiating procedure and diagnostic code selections for proper reimbursement is

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An eponym should not be used when a comparable anatomic term can be used in its place.

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PFSH is the abbreviation for ___________________________________.

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An established patient is anyone who has previously received professional services from the physician or another physician of the same specialty who belongs to the group practice.

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WNL is the abbreviation for _________________________.

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It is the responsibility of the ____________________ to handwrite or dictate the documentation for medical transcription.

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Match each of these types of medical services to the correct definition. -Services rendered by a physician whose opinion is requested by another physician for evaluating a patient's illness.

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What does comorbidity mean?

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A referral is the same as a consultation.

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A diseased condition or state is known as

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An edit check is a good audit prevention measure to have in place.

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The upper middle region above the stomach is known as the ____________________ region.

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If a professional liability claim is filed by a patient, good ____________________ helps establish a strong defense.

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An internal review known as a ______________________________ is done after billing insurance carriers.

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A problem-focused examination is more complex than a detailed examination.

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The section of Current Procedural Terminology (CPT) codes which are used to report office and other types of visits with health care professionals is referred to as _________________.

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At least _______ elements of the HPI or the status of at least three chronic conditions is required for the extended level of HPI.

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