Chapter 10 Review

Front 1

How does the MAA prove medical necessity?

Back 1

"Link" the diagnosis codes with the procedure/service codes

Front 2

When is it recommended the MAA create an authentication legend?

Back 2

When the procedure is completed

Front 3

What are LDCs and what do they do?

Back 3

Local Coverage Determinations specify under what clinical circumstances a service is covered and list the covered and non-covered codes

Front 4

What does VistA stand for?

Back 4

Veteran's Health Information System and Technology Architecture

Front 5

Who developed the VistA health record?

Back 5

The U.S. Department of Veterans Affairs

Front 6

Provide other names for medically managed diagnoses:

Back 6

Secondary diagnoses or coexisting diagnoses

Front 7

How many diagnoses can be reported on the CMS-1500 claim form?

Back 7

Up to four

Front 8

What information is needed by hospitals and ambulatory surgical centers to compile their operative reports? (1)

Back 8

Date of surgery, patient I.D., Pre and post-op disgnosis

Front 9

What information is needed by hospitals and ambulatory surgical centers to compile their operative reports? (2)

Back 9

List of procedures performed, names of primary/ secondary surgeon(s), and positioning and draping of the patient surgery

Front 10

What information is needed by hospitals and ambulatory surgical centers to compile their operative reports? (3)

Back 10

Achievement of anesthesia, closure of the surgical site, and signature of the surgeon

Front 11

What is required by Medicare for all outpatient and physician office procedures not covered by Medicare (ABN)?

Back 11

A waiver

Front 12

What does ABN stand for and what is it used for?

Back 12

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

Front 13

What is the primary purpose of the patient record?

Back 13

To provide continuity of care

Front 14

Why is the patient record important to the health care facility?

Back 14

It contains documentation of all health care services provided to the patient and supports the diagnosis, justifies treatment, and records treatment results

Front 15

What does the auditing process involve?

Back 15

Reviewing patient records and CMS-1500 or UB-04 claims to process coding accuracy and completeness of documentation

Front 16

What should you not use when marking on original documents to ensure accuracy when coding case reports?

Back 16

Highlighters or other markers

Front 17

What are operative reports?

Back 17

Short narrative descriptions or formal dictated reports

Front 18

What are chargemasters used for?

Back 18

To select procedures, services and supplies provided to hospital emergency department patients and outpatients

Front 19

What is OCE?

Back 19

A software used to edit outpatient claims submitted by hospitals

Front 20

What form are SOAP notes written in?

Back 20

Outline form

Front 21

Which block on the claim form is the first-listed diagnosis?

Back 21

Reported on Block 21

Front 22

Which form are narrative clinic notes written in?

Back 22

Paragraph form

Front 23

When do health insurance specialists review the patient record?

Back 23

When assigning codes to diagnoses, procedures, and services

Front 24

What does the patient record serve as?

Back 24

The business record for a patient encounter and is maintained in a paper or automated format

Front 25

Which two major formats for documenting clinic notes do health care providers use?

Back 25

Paragraph form and outline form

Front 26

What does the "subjective" part of the SOAP notes refer to?

Back 26

The patient's CC/ how the patient feels

Front 27

What does the "objective" part of the SOAP notes refer to?

Back 27

Contains to documentation of measureable or objective observations made during the physical exam and diagnostic testing

Front 28

What does the "assessment" part of the SOAP notes refer to?

Back 28

Usually includes the physician's rationale for the diagnosis

Front 29

What does the "plan" part of the SOAP notes refer to?

Back 29

The statement of the physician's intended medical management of the case (how they plan to treat the condition)

Front 30

What is the CMS-1500 form?

Back 30

The outpatient claim form

Front 31

Diagnostic test results are documented in how many locations?

Back 31

Two

Front 32

Medically managed diagnoses ___ or _____ receive treatment during an encounter.

Back 32

May or May not

Front 33

What does global surgery period include?

Back 33

The preoperative assessment, surgery and postoperative care

Front 34

What is the auditing process?

Back 34

Review patient records, CMS-1500, UB04 claims for accuracy