Exam 4: Medical Documentation and the Electronic Health Record

Your physician has been to the hospital providing constant bedside attention and treating a patient in respiratory failure. These services are considered

Match these types of physicians with the description of the services each provides. -Provider who sends the patient for tests or treatment.

The term ____________________ refers to a disease that persists over a long time.

When each entry in the medical record is worded similar to the previous entries, this is considered

The key to substantiating procedure and diagnostic code selections for appropriate reimbursement is a supporting electronic health record.

When a discussion takes place with a patient concerning the risks and benefits of treatment options, it is considered

Preservation of health records is governed by

When documenting a case for billing, a level must be determined from one of ____________________ types of medical decision making.

A new patient is one who

Parts of the small and large intestines, right ovary, right uterine tube, appendix, and right ureter are found in the

An advantage of electronic medical records is

Levels of evaluation and management services are based on type(s) of physical examination that may be

Match each of these terms, as they are used in a medical office, with the correct definition. -How long the symptom/pain has been present and how long it lasts when the patient has it.

Under the Medicare incentive program for implementation of EHR, eligible providers will

How should an entry in a patient's electronic medical record be corrected?

Match each of these terms, as they are used in a medical office, with the correct definition. -Degree of symptom and/or pain on a scale from 1 to 10.

Private insurance carriers have the right to claim refunds in the event of accidental miscoding.

A review of patient records done before billing is submitted is called

An established patient is one who

Review of medical events in the patient's family, including diseases that may be hereditary, is known as a/an ____________________.