Deck 6: Financial Management: Insurance and Billing Functions

Question 1

A. How does a user re-save an OV note so that it is stored under a customized category in the care tree rather than the Encounters category?
B. What are the two places where the patient's face sheet can be edited?
C. Why is it important to see a history of a patient's lab results from several different dates?

Answer 1

(A)A user re-saves an OV note so that it is stored under a customized category in the care tree rather than in the Encounters category by highlighting the entry in the care tree and selecting the Edit button. After that then the user selects Tools and the Chart Tab submenu and then Save As.
(B)The two places where the patient's face sheet can be edited are within the OV note and by accessing the Office Visit screen and choosing Edit.
(C)It is important to see the history of a patient's lab results from several different dates. The reason is is because the doctor can then see a pattern and view a trend for the same lab type over a period of time from within the OV note.

Question 2

Use your critical-thinking skills to answer the following questions.
Why is it beneficial to the provider that the Chief Complaint, Present Illness, Review of Systems, Examination, Procedure, Other Treatment , and Follow-up/Reminder areas of the OV screen display additional notes from previous encounters with the patient?

Answer 2

It is beneficial to the provider that the Chief Complaint, Present illness, Review of Systems, Examination, Procedure, Other Treatment and Follow-up/Reminder areas of the OV screen display additional notes from previous encounters with the patient. The provider can highlight and copy any previous notes and copy it to the present note. This allows the clinicians to refresh their memory regarding past visits.

Question 3

A. Why does an insurance company require codes rather than free text when a medical clinic documents procedures and diagnoses?
B. What five criteria are used by the E M Coder to determine the appropriate E M code for a routing slip?
C. What are the two means by which a E M code can be chosen?

Answer 3

(A)An insurance company requires codes rather than free text when a medical clinic documents procedures and diagnoses because it helps with the privacy of the patient. Plus, using the codes helps the insurance company determine the validity of the medical visit. This in turn, also determines whether or not the insurance will cover the visit and pay for the visit to the doctor.
(B)The five criteria used by the E M Coder to determine the appropriate E M code for a routing slip are:
• Patient type (whether they are new or consulting or established)• How complex the problem presented is.
• Level of history reviewed.
• Extent of the exam and review of systems.
• Level of medical decision making.
These codes can be medically overridden to change the location and possibly the time spent on the office visit.
(C)The two means that an E M code can be chosen are the office visit note and time frame. This is based on the time factor of the patient encounter.

Question 4

Use your critical-thinking skills to answer the following questions.
If a user accidentally saved an OV note under the wrong category in the care tree of the patient's chart, how would the user get the document under the correct category?

Question 5

A. Office visit notes that have been permanently signed and locked cannot be edited. However, what can be added to a locked OV note?
B. What is automatically added to an addendum when one is saved?
C. How would a user distinguish between locked and unlocked office visit notes in the patient's care tree?

Question 6

A. If tests have been ordered in the office visit and the results have been entered into the pending tests and saved into a patient's chart, the results will appear along with the ordered tests in what two reports?
B. The H P contains information from the patient's current exam. What other types of information from the patient's chart does the H P contain?
C. Which report enables the user to select different items from the OV note to be included in the customized report?

Question 7

OV notes that have been permanently signed and locked cannot be:

A) Opened
B) Edited
C) Moved to another location in the care tree
D) Deleted

Question 8

All the text chosen throughout the OV note will be automatically placed in what format by the EHR program.

A) HIPAA
B) ONC
C) ANSI
D) SOAP

Question 9

A clinician can edit the patient's face sheet and immunization Record in what two screens?

A) Patient chart; office visit note
B) Patient chart; To Do List
C) Office visit note; routing slip
D) Office visit note; Messages center

Question 10

What items does the routing slip contain?

A) Only the diagnosis and procedure codes
B) The E M codes
C) All the billable items and codes
D) The physician notes

Question 11

The purpose of the office visit template report is to:

A) Create an office visit note that can be used for other patients.
B) Have a standard report to send to hospitals when the patient is admitted.
C) Provide patients with a copy of their recent examination report, required by the ONC.
D) Create customized reports of specific elements from the office visit note.

Question 12

The Lab submenu under the Actions menu in the OV screen enables the provider to:

A) Order new labs for the patient.
B) View previous labs for the patient.
C) Connect to SureScripts across the Internet to send the patient's labs.
D) Access the patient's pending labs.

Question 13

The electronic routing slip is displayed for the provider:

A) Only when the user selects the Save and Edit Routing Slip option
B) Every time the OV note is saved
C) By accessing the Tools menu in the OV screen
D) In the PMS program

Question 14

The patient's name is always automatically defaulted into the excuse note because:

A) Patients' names are often difficult to spell.
B) It saves the provider time in not having to type the name.
C) It is created within the patient's chart screen or the patient's OV note screen.
D) The checkout desk needs to know which patient the excuse note is for.

Question 15

The OV note report that provides information on just the physical examination and test results for the patient is called:

A) History Physical
B) OV note report
C) OV note template report
D) Examination Report to patient

Question 16

A. Provide a brief description for each of the components of the SOAP format.
Subjective:
Objective:
Assessment:
Plan:
B. What panel is seen on the left side of the OV screen when first entering the window?
C. What screen must be opened first before the OV screen can be opened?

Question 17

When a provider signs and permanently locks an OV note:

A) Only that provider can enter data into the OV note.
B) No one can enter data into the OV note, not even the provider.
C) Only that provider can unlock the OV note.
D) A new OV note will have to be started to include addenda.

Question 18

Match the terms with the definitions to be listed below.
_____ 1. SOAP format
_____ 2. BMI
_____ 3. Other Tx
_____ 4. ROS
_____ 5. PI
_____ 6. E M Coder
_____ 7. Proc
_____ 8. CC
_____ 9. History physical report
_____ 10. Template
_____ 11. Addendum
_____ 12. Office visit
_____ 13. Coordination of care
_____ 14. E M code
A. A model document predesigned with a set format and structure.
B. A structured questionnaire used by providers to gather healthcare history covering the organ systems from a patient.
C. A medical note added subsequent to the original note.
D. The documentation of the patient's medical history combined with the physical exam.
E. An encounter with a medical provider whereby the patient's chief complaints are reviewed and the patient examined.
F. A convenient way for healthcare providers to lay out the documentation of an office visit exam.
G. History of the patient's present illness.
H. The measurement of choice for studying obesity.
I. A sophisticated algorithm that determines the appropriate E M codes.
J. The presenting patient's chief healthcare complaints.
K. Section of the SOAP note that contains the performed procedure and procedure documentation.
L. An area of the SOAP note for documenting counseling and coordination of care items.
M. Resources to ensure that healthcare providers have access to all required information on a patient's conditions and treatments and to ensure the patient receives appropriate healthcare services.
N. A five-digit number used by a physician to report evaluation and management services provided to a patient.

Question 19

The H P report:

A) Stands for History Problems
B) Enables the user to create customized reports from the OV note
C) Combines information on the patient's healthcare history and current examination
D) Is received from the hospital when the patient comes for follow-up work

Question 20

A. When certain navigation tabs are selected in the Office Visit screen, (for example, CC, PI, ROS, and Exam), what will appear on the bottom right side of the screen?
B. What does the Copy Highlighted Text to Note icon in the OV window enable a clinician to do?
C. Along with 9 basic vitals, how many additional custom vitals can be added to the SpringCharts EHR program?
D. Rather than free text (pop-up text), what do the diagnosis [Dx], prescription [Rx], tests [Test], and procedures [Proc] navigation buttons allow the user to access?

Question 21

Use your critical-thinking skills to answer the following questions.
Group the following eight activities that occur in a typical OV by the provider responsible for each activity, either clinician or physician:
Completing routing slip; Ordering a test; Record ing chief complaints and vital signs; Documenting ROS and exam; Documenting the administration of an injection; Reviewing face sheet information; Assigning diagnosis and medication; Entering in-house test results.