EHR Study Guide Flashcards
establish guidelines specific to research..
health level 7
an EHRS would use what to locate the number of medication refills for a patient?
MAR (medication administration record)
what feature could you utilize for ordering multiple labs?
check boxes
where would you gather education material for a patient?
clinical decision support
EHR templates increase what?
accuracy and completeness
what is considered real-time clinical data?
subjective data
what is a barrier to EHR transition?
cost
what would you use to generate a charge report for a provider?
CPT Codes
what form contains the diagnostic codes for billing?
encounter form
when would you post patient payments?
at check in
What is needed for an EHR to be interoperable?
Unified Medical Language System
What would you utilize to cross-check data report accuracy?
data registry
how is biomedical device information transferred?
telemetry
utilizing digital image data is the best method to prevent what?
discrepancies in data
what data is accessible between different providers?
continuity of care data
what must occur before billing is submitted to verify completed forms match?
prospective review
how can you increase schedule efficiency when overlapping appointments?
determine type of appointment
When must an ABN be signed?
when medicare will not cover services
who/what uses merit-based incentives?
medicare
where can an EHRS document?
3rd party payment
what allows billing info exchange with 3rd party payers?
Electronic Data Interchange
What is listed as DO NOT USE in the abbreviations?
MSO4
formulary compliance is used where within EHR?
E-scribing
what prevents facility coding inaccuracies?
routine audits
where do you find E/M codes?
CPT manual
what prevents prescription duplicating?
CPOE
what does an aging report provide?
past due accounts information
why would you generate a provider report?
to track revenue per provider
what is an example of structured data?
ICD codes
what is the best place to obtain education resources?
CDC.gov
which safeguard includes annual security awareness training?
administrative
what can you eliminate to streamline workflows?
written prescriptions
where are patient transactions documented?
day sheet
to locate revenue associated with specific CPT codes you go to?
accounts receivable
What maps lab results from vendors?
LOINC (logical observation identifiers names and codes)
what would you utilize if you think someone has accessed charts inappropriately?
activity review
how would you abstract a medical record?
clinical and administrative decision making
what would a patient identifier be?
appointment time
How long do you have to notify a patient about a data breach?
60 days
how would you code a bilateral diagnosis?
each side separately
who sets the standard for who can access PHI?
DHHS
Insurance claims that are past due are run how?
aging report by carrier
what is always required on completed lab results?
provider signature
what is syndromic surveillance
to report outbreaks of disease to the public
whose insurance pays first if both parents cover the child?
use the birthday rule
whhere would you place a new template for mammogram results?
radiology
outdated documentation is a result of?
cloned progress notes
What is a PACS (picture archiving communications sytem) used for?
radiology images
how often is an encounter form updated?
minimum of once a year
this is needed to determine if a procedure is a covered service..
preauthorization
what shoiuld always match when requesting insurance reimbursement?
dx code and procedure
In this model, PCP is selected, and one must see this person first for illness or injury. Costs typically less than other insurance forms. Network restriction for care. Care outside network requires physician referral. These are typically sought after more because they cost less.
HMO (Health maintenance organization)
In this model, there may be no requirement for PCP. Network of various providers provided for selection based on need. Greater flexibility for provider selection. Out of network care is provided. Increased cost. (Can typically see anyone you choose with no referral)
PPO (preferred provider organtization)
This model includes characteristics of both HMO and PPO. It does not require a PCP and access to specialized care does not require a referral. The network may restrict specialized care access. (restrictive in who you can see)
EPO (exclusive provider organziation)
establishes national standards to protect electronic personal information that is created, received, used or maintained by entities with permission to use them
The HIPPA security rule
Key is electronic PHI
sets limits and conditions on uses and disclosures of PHI without a person’s authorization.
The HIPPA privacy rule
Compliance with HIPPA is mandatory, and enforcement falls under the obligation of the ( )
office of civil rights (OCR)
makes funds available for states to provide health care coverage to low income uninsured children through the age of 18 and pregnant women who have an income too high to qualify for Medicaid.
CHIP (children’s health insurance program)
HIT
health insurance technology
MIPS is a performance-based payment system with five healthcare participation options, which are..
Individual, group, virtual groups, subgroup, APM entity
MIPS
Merit based incentive payment system
CMS offered ( ) for the use of certified EHR technology.
incentives
Meaningful use leveraged EHR technology to achieve the best ( )
outcomes for patients
( ) are currently not regulated by the US FDA
EHRs
Are CPT or ICD codes billed for first?
CPT
A secure way to transmit information between insures, institutions and patients..
EDI (Electronic data interchange)
a set of standardized codes used for processing, billing and reimbursement of health insurance claims
health care common procedure coding system (HCPCS)
( ) document clinical encounters, which include the chief complaint, diagnoses, treatment plans with ( ), and ( ).
Providers, medicinal prescriptions, progress notes
( ) allows providers to manage patient orders in a fashion that reduces errors in duplicate orders by allowing medication reconciliation and identification of potential interactions
Order Management
( ) is the electronic sharing of healthcare information between various providers and settings
Health Information Exchange
