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Exam 4: Medical Documentation and the Electronic Health Record

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Question 31

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Identify three ways that a physician may withdraw formally from further provision of care to a patient when the patient is noncompliant.

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(1) Send a letter of withdrawal by certi...

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Question 32

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Under the Federal False Claims Act, records that should be retained indefinitely include

A) payroll records and invoice and billing records.
B) appointment sheets and postal and meter records.
C) x-ray films, laboratory reports, and pathologic specimens.
D) accounts receivable ledgers, deceased patients' medical records, and petty cash vouchers.

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Question 33

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The code for repair of a superficial laceration is found in the CPT Integumentary/Surgery section under the heading

An expanded problem-focused examination is a/an

Match each of these terms, as they are used in a medical office, with the correct definition. -Things done to make the symptom/pain worse or better.

____________________ is a term used to define those providers or hospitals that have the capabilities and processes in place to actively use certified electronic health record technology.

Match each of these types of medical services to the correct definition. -Providing similar services to the same patient by more than one physician on the same day.

The documentation of the patient's previous experiences with illnesses, operations, injuries, and treatments is known as the ____________________.

As a health insurance claims professional, you may be required to _______ information from a medical record to justify a Health Insurance Claim Form after professional services are rendered.

The chronologic recording of pertinent facts and observations about the patient's health is known as

When the physician provides critical care in the hospital emergency department, it is billed as emergency care.

A consultation may take place in a home, office, hospital, or extended care facility.

Match each of these types of medical services to the correct definition. -Discussion with a patient, family, or both about diagnostic results and instructions for treatment.

An electronic medical report is a

Match each of these types of medical services to the correct definition. -Intensive care provided during an acute life-threatening condition that requires constant bedside attention by the physician.

Match each of these terms, as they are used in a medical office, with the correct definition. -Character of the symptom/pain (burning, gnawing) .

The acceptance of a subpoena by an authorized person is the equivalent of a subpoena being served personally.

An age-appropriate review of past and current activities of the patient (e.g., smoking or use of alcohol) is known as a/an ____________________.

The abbreviation HPI stands for ______________________________.

Skin repairs are coded according to the sum of the length of the repairs in centimeters.