Clinical - History and Coding

Question 1

Irj

Answer 1

Egyptian doctor

Question 2

Microscopes led to

Answer 2

discovery of bacteria

Question 3

1896

Answer 3

Year X-Rays were discovered

Question 4

DRG’s

Answer 4

Diagnostic Related Groups: Describes the case mix of an institution

Question 5

Case Mix

Answer 5

Description of the types of patients a hospital treats

Question 6

The development of DRG’s….

Answer 6

Was initially a method to monitor the utilization and quality of care

Question 7

DRG’s (1983)

Answer 7

How Medicare evaluated and calculated reimbursement to facilities

Question 8

The ICD-9 library was developed in

Answer 8

1979

Question 9

Bill of Patient’s Rights was established by the

Answer 9

AHA (American Hospital Association)

Question 10

OSHA

Answer 10

Occupational Health and Safety Admin - Requires annual safety and fire training

Question 11

res ipsa loquitur

Answer 11

let the facts speak for themselves - said of medical documentation

Question 12

respoondeat superior

Answer 12

Let the superior answer - a facility is responsible for the actions of the employees

Question 13

Galen

Answer 13

Greek physician - Roman Empire’s greatest physician. Made great strides in foundations of pathology and physiology. Miasma theory

Question 14

Hippocrates

Answer 14

Father of modern medicine

Question 15

Shamanism

Answer 15

One of the oldest healing traditions

Question 16

Louis Pasteur

Answer 16

Key figure in germ theory

Question 17

ALARA

Answer 17

As low as reasonably achievable

Question 18

HIPAA

Answer 18

Health Insurance Portability and Accountability Act. Enforced by the Department of Health and Human Services (HHS).

Question 19

________ should be complete, objective, legible and accurate

Answer 19

Medical Record

Question 20

Good Patient Care Practice

Answer 20

labeling of images
correct patient positioning
performing correct exam
identification

Question 21

Common Imaging Record Keeping Mistakes

Answer 21

mis-marked images 
mis-identified images 
errors in PT info 
lost images 
improper image release 
release of images to wrong person

Question 22

Common Clinical Errors

Answer 22

incorrect shielding 
labeling of images 
positioning 
exam 
patient identification 
unsecured patient 
improper protocol 
incorrect information on patient records

Question 23

Unstructured Data

Answer 23

information that requires human interaction to observe, read and interact. Scanned documents, pictures, annotations on image, written report, comments, notes, etc.

Question 24

Structured Data

Answer 24

Can be processed and interpreted by a computer

Question 25

NLP

Answer 25

Natural Language Processing. Software application able to take unstructured data and create structured data

Question 26

Semantic Interoperability

Answer 26

the ability of computer systems to interchange data and to interpret and use the data according to it’s meaning, not just the literal text.

Question 27

Data Models

Answer 27

Documentation and organization of structured data for communication between different systems and entities

Question 28

UMLS

Answer 28

Unified Medical Language System - Developed by the National Library of Medicine. Facilitates retrieval and integration of info from multiple sources. Combines over 100 controlled vocabularies.

Question 29

Codes

Answer 29

Sequence of symbols, usually digits or letters, designating an object or concept.

Represent terms used in healthcare

Structed according to logic based representations of meanings. Typically hierarchical.

Question 30

Classification

Answer 30

Grouping of systematic placement of things or concepts into categories or classes which share a common attribute.

Question 31

Coding Scheme

Answer 31

Set of concept codes, uniquely identified in a scheme using certain classification rules.

Question 32

Concept

Answer 32

An idea which has a meaning, each concept is identified by a concept code. Eg: Orientation, Extremities.

Question 33

Relationships

Answer 33

Defined between concepts.

Question 34

Display term (code meaning)

Answer 34

Human readable term

Question 35

Value set

Answer 35

set of values allowed for a particular data item, defined by data dictionary

Question 36

Data dictionary

Answer 36

vocabulary

Question 37

SNOWMED

Answer 37

Systemized Nomenclature of Medicine. Originally developed by the College of American Pathologists.

Question 38

SNOWMED CT

Answer 38

SNOWMED Clinical Terms - comprehensive clinical terminology that assists in capturing detailed clinical information. Maintained and distributed by IHTSCO

Question 39

LOINC

Answer 39

Laboratory subset widely used for lab data originating from lab tests.

Question 40

National Committee on Vital and Health Statistics

Answer 40

NCVHS - Recommends a core set of terminologies for use in EHR.

PCDS (Patient Care Data Set)

Question 41

OASIS

Answer 41

Outcomes and Assessment Information Set, established by HHS for home health data reporting

Question 42

PCDS

Answer 42

each component contains the terms according to the three axes - Problems, Goals and Orders.

Question 43

HEDIS

Answer 43

Health Plan Employer Data and Information Set (National Committee for QA) to accredit managed care

Question 44

UHDDS

Answer 44

Uniform Hospital Discharge Data Set by Natl Center for Health Statistics of the Centers for Disease Control and Prevention) - monitors 34 states.

Question 45

ACS X12N

Answer 45

Accredited Standards Committee - Required exchange for Electronic Data Exchange (EDI). Many insurance related exchanges.

Question 46

ICD

Answer 46

International Statistic Classification of Diseases and Health Related Problems. 1850s. Initiated by the WHO.

ICD-10-CM (clinical modification)
ICD-10-PCD (Procedures)

Question 47

CPT Codes

Answer 47

Current Procedural Terminology Codes - Established by the Health Care Financial Administration (now the CMS Centers for Medicare and Medicaid Services). Determined reimbursement rates.

Question 48

Clinical Modifiers

Answer 48

Allows modification of procedure codes to provide more granular representation of services rendered.

Question 49

RUC

Answer 49

Relative Update Committee - recommends reimbursement values to HCFA based on data collected by medical societies on the going rate of services.

Question 50

HCPCS

Answer 50

Healthcare Common Procedure Coding System - Set of codes used to describe specific items and services part of healthcare. Extension to CPT.

Level 1: CPT and is numeric value
Level 2: alphanumeric and includes codes not covered by the CPT and is predominantly used by non-physician services like ambulances, medical devices, etc..

Question 51

CDT

Answer 51

Current Dental Terminology

Question 52

NDC

Answer 52

National Drug Codes