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Scribe > Course 6: Dispositions/Billing > Flashcards

Course 6: Dispositions/Billing Flashcards

1
Q

Dispositions

A
  1. Discharged (DC’d)
  2. Admitted
  3. Transferred
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2
Q

DC’d document:

A
  1. Follow-Up
  2. Time period in which to follow-up
  3. Specific conditions for return to the ED
  4. Condition: “Stable for discharge”
  5. Time of disposition
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3
Q

Hospitalized (admitted) document:

A
  1. Admitting physician
  2. Time of consult with admitting physician
  3. Patient Condition (good, fair, serious, critical)
  4. Admission location
  5. Admission time
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4
Q

Transferred document:

A
  1. “Patient stable for transfer”
  2. Time of consult with accepting facility
  3. “ED records accompanying patient”
  4. “Appropriate mode of transfer arranged”
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5
Q

Levels of reimbursement

A

Evaluation and Management Levels (E&M)

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6
Q

Your goal as a scribe

A

Eliminate ALL down coded charts

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7
Q

Elements for level 5 billing

A
  • HPI-4
  • ROS-10 or 2 “All systems negative”
  • PHM/SH/FH-2
  • Physican exam-8
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8
Q

Elements for coding Level 5 for the HPI

A
  • Location
  • Quality
  • Timing
  • Severity
  • Duration
  • Associated Sx
  • Modifying factors
  • Context
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9
Q

Elements for coding Level 5 for the ROS

A
  • Constitutional
  • Eyes
  • E/N/T
  • Cardiovascular
  • Respiratory
  • GI
  • GU
  • Musculoskeletal
  • Neurological
  • Integumentary
  • Hematological
  • Lymphatic
  • Immunological
  • Psychological
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10
Q

Elements for coding Level 5 for the PMHx

A
  • PMHx/PSHx
  • SHx
  • FHx
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11
Q

Elements for coding Level 5 for the Physical Exam

A
  • Constitutional
  • Eyes
  • E/N/T
  • Cardiovascular
  • Respiratory
  • GI
  • GU
  • Musculoskeletal
  • Neurological
  • Integumentary
  • Hematological
  • Lymphatic
  • Immunological
  • Psychological
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12
Q

Unable to get information

A

“Unable to obtain a complete… due to…” in each section

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13
Q

Level 5 MDM

A
  • Old records ordered and results
  • Lab and radiology orders and results
  • Consultations
  • Discussion with pt/family
  • Multiple differential Dx
  • References to Lab/Rad results
  • Medications and treatments in the ED
  • Multiple Re-Evaluations
  • Arranging Follow-up
  • Discussion of specific risks
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14
Q

Critical Care Time documentation:

A

Minimum of 30 minutes

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15
Q

Pulse Ox Interpretation documentation:

A

Normal or Hypoxic

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16
Q

Xray Interpretation documentation:

A

Always record the number of views, as well as “Interpreted by EP”. Include three findings minimum

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17
Q

EKG Interpretation

A

Must have the rate, rhythm, and at least two other findings

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18
Q

ED procedures

A

Commonly missed procedures are Splint applications, Laceration repairs, Bedside US, and Foreign body removals.

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19
Q

One of the most important ways to help your doctor is:

A

Ask if they would like Critical Care for pt’s that may qualify

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20
Q

Vital signs

A
  • Heart rate
  • Blood pressure
  • Oxygen saturation
  • Temperature
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21
Q

Oxygen routes

A
  • Room Air
  • Nasal Cannula
  • Facial Mask
  • Non-Rebreather Mask
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22
Q

RA

A

Room Air

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23
Q

NC

A

Nasal Cannula

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24
Q

FM

A

Facial Mask

25
Q

NRB

A

Non-Rebreather Mask

26
Q

Critical Care Oxygen Routes

A
  • Continuous Positive Airway Pressure
  • Biphasic Positive Airway Pressure
  • Bag-Valve-Mask
  • Endotracheal Tube
27
Q

CPAP

A

Continuous Positive Airway Pressure

28
Q

BiPAP

A

Biphasic Positive Airway Pressure

29
Q

BVM

A

Bag-Valve-Mask

30
Q

ETT

A

Endotracheal Tube

31
Q

ED Core Measures

A
  • Acute MI
  • CP
  • Syncope
  • Ischemic CVA
  • PNA
  • PE
  • Otitis Externa
  • Female Abd pain
  • Pregnant Abd pain
  • Pregnant Vaginal Bleeding
  • Pregnant Rh Negative
  • Central Line Placement
  • Long Bone Fx
  • Hospital-Acquired Conditions
32
Q

Acute MI document:

A

ASA 324 mg given at arrival

33
Q

CP (Non-Traumatic) document:

A

12-Lead EKG performed in ED

34
Q

Syncope document:

A

12-Lead EKG performed in ED

35
Q

Ischemic CVA document:

A
  • Document :last known well” date and time

- Document tPA eligibility (within three hours of onset)

36
Q

PNA document:

A
  • Vital signs, O2 saturation, mental status
  • Abx Selection and Timing
  • Blood Cultures
37
Q

Acute PE document:

A

Anticoagulation (Heparin) ordered

38
Q

Acute Otitis Externa (Outer Ear Infection) document:

A
  • Topical therapy
  • Pain assessment
  • Avoidance of PO (systemic) abx
39
Q

Abd pain- female pt document:

A

Pregnancy test (uHCG) was ordered

40
Q

Pregnant abd pain document:

A

US was ordered to determine the location of the pregnancy (r/o ectopic)

41
Q

Pregnant and Rh Negative document:

A

Rhogam was ordered

42
Q

Central Line Placement document:

A

Sterile technique: cap, mask, sterile gown, sterile gloves, sterile sheet, hand hygiene, 2% chlorohexidine

43
Q

Consent document:

A

“Consent obtained”

“Consent precluded by clinical urgency”

44
Q

Unique physical identifiers document:

A

Any unique physical identifier in the physical exam portion of the record. Old scars, tattoos, old amputations, or obvious surgical implants.

45
Q

Times document:

A

ALWAYS remember to document the time for everything. Initial contact, medications, consults, and the time the pt is dispositioned

46
Q

HIPAA

A

Health Insurance Portability and Accountability Act:

Laws that protect the private health information of pt’s across the country

47
Q

PHI

A

Protected Health Information:

Any type of information that can be directly or indirectly tied to a particular pt or visit

48
Q

HITECH

A

Health Information Technology for Economic and Clinical Health Act:
PHI may not be transferred electronically, copied, emailed, stored on external devices, or sent without special security known as encryption.

49
Q

Rules and regulations:

A
  1. Scribes cannot touch pt’s
  2. Beware of provider entrapment.
  3. Remove yourself from unprofessional situations/conversations
  4. Follow the dress code
  5. You cannot enter the facility unless you have your badge and your own EHR login.
  6. No cell phones at work
  7. Do not access family, friend, VIP’s or your own medical records.
  8. Never share your password
  9. Do not post any work-related information on social media
  10. Report all incidents or concerns to ScribeAmerica management .
50
Q

HIPAA/HITECH violations will end up in…

A
  • Being fired
  • Reported to the Office of Civil Rights
  • Charged with civil and criminal offense (criminal charges)
  • Black-listed from medical schools
  • Fined tens of thousands of dollars (minimum fee of $50,000)
51
Q

Disposition

A

The pt’s destination after they leave the ED.

52
Q

Hospitalist

A

Physician who cares for hospitalized pt

53
Q

E&M Levels

A

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

54
Q

Level 5

A

Highest billing leve

55
Q

Down-coded

A

When a physician can only be reimbursed for a lower level of care due to inadequate documentnation

56
Q

Caveat

A

A disclaimer

57
Q

Core Measure

A

A national standard among EP that dictates the care and documentation required for each Dx or complaint

58
Q

Protected Health Information

A

Any information that can be tied to a particular pt

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