Podcast
Questions and Answers
Which of the following is necessary for computer systems to exchange information?
Which of the following is necessary for computer systems to exchange information?
- Compatibility
- Integration
- Interconnectivity
- Interoperability (correct)
Where can an EHR specialist find documentation to verify the time of a medication administration?
Where can an EHR specialist find documentation to verify the time of a medication administration?
MAR
Before a surgical procedure, an EHR specialist should obtain what to ensure payment of the claim by the third party payer?
Before a surgical procedure, an EHR specialist should obtain what to ensure payment of the claim by the third party payer?
Preauthorization
Anyone who thinks a healthcare provider has violated HIPAA privacy regulations can file a written complaint within how many days to the Office for Civil Rights (OCR)?
Anyone who thinks a healthcare provider has violated HIPAA privacy regulations can file a written complaint within how many days to the Office for Civil Rights (OCR)?
What is a threat to the security of information in an EHR system?
What is a threat to the security of information in an EHR system?
Who analyzes medical codes for patient encounters and reports any errors?
Who analyzes medical codes for patient encounters and reports any errors?
In what area of a patient's EHR will the EHR specialist find the necessary documentation to substantiate a short-term disability claim for a woman on maternity leave?
In what area of a patient's EHR will the EHR specialist find the necessary documentation to substantiate a short-term disability claim for a woman on maternity leave?
What is a benefit of documenting a patient encounter at the point of care?
What is a benefit of documenting a patient encounter at the point of care?
What is a feature of a patient portal within an EHR system?
What is a feature of a patient portal within an EHR system?
A patient presents to a provider's office with a third degree burn on his hand from cooking oil. What should an EHR specialist code first?
A patient presents to a provider's office with a third degree burn on his hand from cooking oil. What should an EHR specialist code first?
For what reasons should an EHR specialist run a statistical report containing information about patients' colonoscopies and fecal occult blood tests?
For what reasons should an EHR specialist run a statistical report containing information about patients' colonoscopies and fecal occult blood tests?
What refers to a provider's liability for the wrongful acts of his employees?
What refers to a provider's liability for the wrongful acts of his employees?
What can be integrated with an EHR system to automatically generate ICD and CPT information directly from clinical documentation?
What can be integrated with an EHR system to automatically generate ICD and CPT information directly from clinical documentation?
What safeguard includes authentication controls for a patient's PHI?
What safeguard includes authentication controls for a patient's PHI?
What is a feature of clinical decision support?
What is a feature of clinical decision support?
What should an EHR specialist look for as part of a routine chart audit?
What should an EHR specialist look for as part of a routine chart audit?
What is the first step of the scanning process?
What is the first step of the scanning process?
A provider's office is using coding software with the ability to receive updates twice a year. What code follows this updating schedule?
A provider's office is using coding software with the ability to receive updates twice a year. What code follows this updating schedule?
If a patient has insurance that requires a co-payment, what is needed to accurately collect and post the patient's payment?
If a patient has insurance that requires a co-payment, what is needed to accurately collect and post the patient's payment?
What describes the reference used to enter diagnosis codes in a hospital setting?
What describes the reference used to enter diagnosis codes in a hospital setting?
An EHR specialist enters a patient's insurance information into the EHR system. How long does it take for this information to post to the patient's chart?
An EHR specialist enters a patient's insurance information into the EHR system. How long does it take for this information to post to the patient's chart?
What is the coding system used to convert written diagnoses into numeric form?
What is the coding system used to convert written diagnoses into numeric form?
What is a function of the Drug Utilization Review (DUR) feature in an EHR system?
What is a function of the Drug Utilization Review (DUR) feature in an EHR system?
What report indicates the status of a claim since submission?
What report indicates the status of a claim since submission?
From what part of a SOAP note should an EHR specialist abstract a diagnosis?
From what part of a SOAP note should an EHR specialist abstract a diagnosis?
What computerized documents would an EHR specialist generate to obtain a patient-specific list of procedures, services, and supplies with associated costs?
What computerized documents would an EHR specialist generate to obtain a patient-specific list of procedures, services, and supplies with associated costs?
Storing backup data or media in an off-site location is an example of what?
Storing backup data or media in an off-site location is an example of what?
Hospital A was recognized for its employee safety record, and hospital B has set a goal to achieve similar results. This is an example of what?
Hospital A was recognized for its employee safety record, and hospital B has set a goal to achieve similar results. This is an example of what?
Billed procedures and services should be supported by what?
Billed procedures and services should be supported by what?
What is included in an implant registry?
What is included in an implant registry?
An EHR specialist is accessing her facility's provider database. What is she looking for?
An EHR specialist is accessing her facility's provider database. What is she looking for?
What is a comprehensive clinical vocabulary designed to encompass all terms used in healthcare?
What is a comprehensive clinical vocabulary designed to encompass all terms used in healthcare?
What represents PHI?
What represents PHI?
What is an advantage of using clinical templates to record patient encounters?
What is an advantage of using clinical templates to record patient encounters?
Prior to transmitting claims, an EHR specialist is reviewing provider documentation on each claim being billed. What must be documented in the patient chart for each encounter?
Prior to transmitting claims, an EHR specialist is reviewing provider documentation on each claim being billed. What must be documented in the patient chart for each encounter?
A provider performs a chest x-ray before and after the placement of a chest tube. This repeat procedure should be coded with what?
A provider performs a chest x-ray before and after the placement of a chest tube. This repeat procedure should be coded with what?
During an office visit, a provider examines a 9-month-old patient for a diaper rash. What type of code should the EHR specialist use to define this type of visit?
During an office visit, a provider examines a 9-month-old patient for a diaper rash. What type of code should the EHR specialist use to define this type of visit?
What is the most important reason to maintain an inventory of software used in an office?
What is the most important reason to maintain an inventory of software used in an office?
A patient who has Medicare coverage opts to have a procedure performed that is not covered. What form is the patient required to sign?
A patient who has Medicare coverage opts to have a procedure performed that is not covered. What form is the patient required to sign?
Which part of the financial information system would be used to manage aging reports by guarantor or carrier?
Which part of the financial information system would be used to manage aging reports by guarantor or carrier?
An EHR specialist is coding a claim for a patient who fell off a chair and broke an arm. What coding tool is necessary to explain the patient's condition in full?
An EHR specialist is coding a claim for a patient who fell off a chair and broke an arm. What coding tool is necessary to explain the patient's condition in full?
An EHR specialist is monitoring changes to CPT codes for his facility. These code changes are managed and updated by who?
An EHR specialist is monitoring changes to CPT codes for his facility. These code changes are managed and updated by who?
When purging inactive health records, what piece of information must an EHR specialist retain?
When purging inactive health records, what piece of information must an EHR specialist retain?
What demonstrates the use of an aging report?
What demonstrates the use of an aging report?
What federal act mandates physical, technical, and administrative safeguards?
What federal act mandates physical, technical, and administrative safeguards?
A clinician is recording patient information. What information should a clinician document as subjective?
A clinician is recording patient information. What information should a clinician document as subjective?
What is an automated benefit of using an EHR system at the time of service?
What is an automated benefit of using an EHR system at the time of service?
A patient is being seen in a clinic for a follow-up visit. The medical assistant has gathered the patient's vital signs. Where should this information be entered?
A patient is being seen in a clinic for a follow-up visit. The medical assistant has gathered the patient's vital signs. Where should this information be entered?
What is the most important reason that the provider should include comprehensive documentation in the patient record?
What is the most important reason that the provider should include comprehensive documentation in the patient record?
What should an EHR specialist do after entering diagnosis and procedural codes in an office using an EHR system?
What should an EHR specialist do after entering diagnosis and procedural codes in an office using an EHR system?
Health Level 7 (HL7) is used to...?
Health Level 7 (HL7) is used to...?
The scheduling template within an EHR system can be used for...?
The scheduling template within an EHR system can be used for...?
What is included on a face sheet?
What is included on a face sheet?
What should a provider's office document to demonstrate it is HIPAA compliant?
What should a provider's office document to demonstrate it is HIPAA compliant?
An EHR specialist is coding for the reimbursement of durable medical equipment. What code set should she use?
An EHR specialist is coding for the reimbursement of durable medical equipment. What code set should she use?
What is the maximum number of days a provider's office has to notify patients when there is a breach to medical record security?
What is the maximum number of days a provider's office has to notify patients when there is a breach to medical record security?
What does the Office of Inspector General recommend as part of a facility's compliance plan?
What does the Office of Inspector General recommend as part of a facility's compliance plan?
An EHR-based provider's office is expanding from two employees to five. What action is the most important to maintain security of protected health information?
An EHR-based provider's office is expanding from two employees to five. What action is the most important to maintain security of protected health information?
According to HIPAA, the use of CPT and ICD-9-CM code sets is required for...?
According to HIPAA, the use of CPT and ICD-9-CM code sets is required for...?
What patient's right does HIPAA regulations address?
What patient's right does HIPAA regulations address?
Proper documentation to support reimbursement of services is the responsibility of what member of the healthcare team?
Proper documentation to support reimbursement of services is the responsibility of what member of the healthcare team?
What allows for entering and retrieving data, and is a special programming language for databases?
What allows for entering and retrieving data, and is a special programming language for databases?
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Study Notes
Electronic Health Records (EHR) Key Concepts
- Interoperability is essential for computer systems to exchange health information effectively.
- MAR (Medication Administration Record) contains documentation verifying the timing of medication administration.
- Preauthorization is required before surgical procedures to ensure third-party payer claims are accepted.
- Complaints regarding suspected HIPAA violations can be submitted to the Office for Civil Rights (OCR) within 180 days.
- Environmental factors pose threats to the security of information within EHR systems.
- Claim scrubbers analyze medical codes linked to patient encounters and report errors to improve accuracy.
- The discharge summary in a patient’s EHR provides information needed for short-term disability claims related to maternity leave.
- Documenting patient encounters at the point of care results in improved patient outcomes.
- A patient portal feature allows patients to update their health status between appointments.
- When coding a third-degree burn from cooking oil, classification coding should be prioritized.
Quality Measures and Reporting
- Running statistical reports on colonoscopies and fecal occult blood tests supports performance-based pay initiatives.
- Respondeat Superior outlines a provider's liability for the wrongful acts of employees.
- Computer-assisted coding can integrate with EHR systems to generate ICD and CPT codes from clinical documentation.
- Technical safeguards encompass controls such as authentication to protect patient Health Information (PHI).
- Clinical decision support features help tailor patient care to align with published guidelines.
Documentation and Compliance
- Routine chart audits should check for an Assignment of Benefits form.
- The first step of scanning documents into an EHR is document preparation.
- Coding updates for the ICD-9-CM occur twice a year as part of the coding software.
- An encounter form is required to accurately collect patient payments when a co-payment is necessary.
- The ICD-9-CM coding system serves as the reference for entering diagnosis codes in hospital settings.
Insurance and Claims Management
- Patient insurance information is posted in the EHR as soon as it is entered.
- The ICD coding system converts written diagnoses into numeric formats for uniformity.
- The Drug Utilization Review (DUR) functionality flags potential medication interactions to promote patient safety.
- An aging report monitors the status of claims after submission.
- Diagnoses should be abstracted from the Assessment section of a SOAP note (Subjective, Objective, Assessment, Plan).
Best Practices and Security
- Charge description master documents include specific details about procedures, services, and prices.
- Storing backup data off-site serves as a physical safeguard for data security.
- Benchmarking involves comparing safety records or performance metrics against other organizations.
- Medical records must support all billed procedures and services for claims to be valid.
- An implant registry tracks details such as the manufacturer's information.
Clinical and Administrative Functions
- Accessing the provider database in an EHR system helps locate specialty referrals.
- SNOMED-CT is a comprehensive clinical vocabulary encompassing all healthcare terms.
- The chief complaint is documented as subjective information in patient records.
- Adding comprehensive documentation in medical records is crucial for establishing medical necessity and adherence to payment guidelines.
- Claims for durable medical equipment should utilize the HCPCS code set.
Regulatory Compliance and Roles
- HIPAA Title II mandates the implementation of physical, technical, and administrative safeguards to protect patient information.
- Clinicians are responsible for ensuring proper documentation that supports reimbursement of healthcare services.
- EHR systems need role-based access controls for enhanced security, particularly in settings experiencing staff increases.
- Electronic Data Interchange (EDI) requires the usage of CPT and ICD-9-CM code sets under HIPAA requirements.
- Patients have the right to access their personal diagnosis history as outlined by HIPAA regulations.
Technical Aspects of EHR Management
- An SQL programming language facilitates data entry and retrieval within database systems.
- Compliance plans should include conducting chart reviews to measure billing accuracy as recommended by the Office of Inspector General.
- Following a security breach in medical records, the maximum notification period for affected patients is 60 days.
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