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Scribe america > Course 6: Billing & Disposition > Flashcards

Course 6: Billing & Disposition Flashcards

1
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5
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6
Q

Disposition (3)

A

pt’s destination after leaving the ED…

  1. Discharged
  2. Admitted
  3. Transferred
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7
Q

Hospitalist

A

Physician that cares for a hospitalized patient

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8
Q

E&M Levels

A

set of criteria that determine how a physician can be paid for their services

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9
Q

Level 5

A

highest level of billing

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10
Q

down-coded

A

when a physician can only be reimbursed for a lower level of care due to inadequate documentaiton

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11
Q

Caveat Statement

A
  • a disclaimer—»evaluation may be limited secondary to:
    • respiratory distress
    • unresponsiveness
    • clinical condition
    • dementia
    • AMS
    • limited cognitive ability
  • Document “Unable to obtain a complete ___ due to ___” in each section independently:
    • the HPI, ROS, Past History, and Physical Exam.
    • Otherwise the chart will be down coded due to the missing information.
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12
Q

Quality Measure

A

a national standard among ED physicians that dictates the care and documntation requried for each diagnosis or complaint

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13
Q

DC’D

[what to document] (5)

A
  • Discharged Home—»remember to document…
  1. Follow-Up—» told who to follow-up with (PCP, local clinic, specialist)
  2. Time period in which to follow up—» # days until pt follow-up
  3. specific conditions for return to the ED—» specfic sx that if expereinced the pt should return to ED
  4. Condition: “stable for discharge”—» documented on every chart being discharged “stable for DC”
  5. Time of disposition—» document the time of the discharge and of the re-evaluation
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14
Q

Hospitalized

[what to document] - (5)

A
  • Admitted (usually to hospitalist/internist)
  1. admitting physician:
  2. time of consult w/admitting physician—»time stamp of when physician speaks w/the consulting dr (what was discussed and who agreed to admit the pt)
  3. patient condition: clinical condition of pt —»provided by dr. as…
    1. Good,
    2. Fair,
    3. Serious,
    4. Critical
  4. Admission Locaiton: area of hospital (ICU, Tele, OR, etc)
  5. Admission Time: time of admission
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15
Q

Transferred

[what to document] (4)

A
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16
Q

Documenting an AMA Note

(7)

A
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17
Q

How to code Level 5 for the…

HPI

A
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18
Q

How to code Level 5 for the…

ROS

A
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19
Q

How to code Level 5 for the…

PMHx

A
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20
Q

How to code Level 5 for the…

PE

A
21
Q

CODING LEVEL 5 SUMMARY

[KNOW THIS SLIDE]

A
22
Q

Level 5 Medical Decision Making (MDM)

(11)

A
23
Q

Additional Documentation For Reimbursment (5)

A
24
Q

What are the 5 Vital Signs?

A
25
Q

Heart Rate (HR)

[normal vs. abnormal ranges]

A
26
Q

Blood Pressure (BP)

[normal vs. abnormal ranges]

A
27
Q

Oxygen Saturation (SaO2)

[normal vs. abnormal ranges]

A
28
Q

Temperature (T)

[normal vs. abnormal ranges]

A
29
Q

Common Oxygen Routes

RA

A
30
Q

Common Oxygen Routes

NC

A
31
Q

Common Oxygen Routes

FM

A
32
Q

Common Oxygen Routes

NRB

A
33
Q

Critical Care Oxygen Routes

CPAP

A
34
Q

Critical Care Oxygen Routes

BiPAP

A
35
Q

Critical Care Oxygen Routes

BVM

A
36
Q

Critical Care Oxygen Routes

ETT

A
37
Q

What are the 4 Critical Care Oxygen Routes?

A
38
Q

What are the 4 Common Oxygen Routes?

A
39
Q

HIPAA topic: Is it acceptable to use the physician’s charting account to enter the EKG interpretation once the physician provided approval?

A

No, all chart done by a scribe must be completed in the scribe’s charting account.

40
Q

Does the following Past Hx meet level V billing requirements:

HTN, previous CVA in 2008 with residual LLE weakness, DM diagnosed at age 47, CABG x2 in 2011, and Tonsillectomy.

A

No. This is only medical and surgical history which are considered ONE element.

41
Q

HIPAA topic: Give 5 examples if PHI.

A
  1. Patient’s Name,
  2. DOB,
  3. SSN,
  4. address,
  5. email,
  6. insurance information,
  7. phone number.
42
Q

How many elements are required for a level V ROS with and without the “All Systems Negative” phrase?

A

2 with, 10 without.

43
Q

True or false: The “All systems negative” phrase is used for all chart.

A

False.

Including the phrase is the physician’s preference AND also never used on patient’s unable to complete the interview (advanced dementia, AMS, unresponsive, etc.)

44
Q

Name 4 common events that are time stamped in the chart.

A
  1. The moment the provider walks into the patient’s room for the initial evaluation,
  2. medication orders,
  3. consults,
  4. procedure start/end times,
  5. disposition times.
45
Q

Describe a scenario where the R/B/A discussion would very commonly occur.

A

Before higher risk procedure such as the lumbar puncture, conscious sedation, cardioversion, receiving tPA, starting/stopping blood thinners, CT’s for children.

46
Q

List 2 examples of a “unique exam identifier”.

A
  1. Scars,
  2. tattoos,
  3. amputations,
  4. G-tubes,
  5. trach scars,
  6. “zipper” sternotomy scar,
  7. birthmarks.
47
Q

How many elements are included in this HPI:

Ariana Venti is a 24 y/o female presenting to the ED with sharp chest pain onset suddenly 4 hours ago. The pain is located over the central chest and worse when leaning forward.

A
  • 4 total = billing at level 5!
  1. Sharp- quality
  2. 4 hours ago, sudden- onset
  3. Central- location
  4. Leaning forward- modifying factor (worsening factor)
48
Q

R/B/A

A
  1. Risk benefits analysis
  2. treatment plan, potential risks, alternatives

Scribe america (8 decks)

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