Med Records and the Prescriptions

Question 1

Any care that is _________ requires the documentation of a written physician’s order.
* approved by the physician
* provided
* billable
* approved by the insurance company

Answer 1

billable

Question 2

Dr. Valejos sent her patient Merrida M. to see the cardiologist, Dr. Jackson, for an irregular heartbeat last month. When reviewing the Electronic Health Record (EHR) what documentation do you need to see in order to verify Dr. Valejos reviewed the report?
* Since the report is only entered into the chart after the physician’s review no other documentation is needed.
* Dr. Valejos’ hand-written signature or initials
* Dr. Valejos’s electronic signature
* A note from Dr. Valejos’ nurse that verify the record has been reviewed

Answer 2

Dr. Valejos’s electronic signature

Question 3

TRUE/FALSE It is not necessary to know how to use a paper record as all healthcare facilities have progressed to the use of electronic medical records (EMR) also known as electronic health records (EHR).
* FALSE
* TRUE

Answer 3

False

Question 4

You are completing a prior-authorization request for a patient in your office. The medical record says the procedure was an excision of a lesion and the medical coder has assigned the CPT code 17110 (excision of a benign lesion). The pathology report, which was dated 14 days after the excision, shows the lesion was malignant. Will you be able to submit the claim using the assigned CPT code?
* no, because the documentation in the chart did not specify what type of excision it was
* yes, because the lesion was not identified as malignant until after the procedure was completed
* no, because the pathology report shows a malignant lesion, but the procedural code identified it as a benign lesion
* yes, because the procedure identified it as an excision ao the disease state is not necessary

Answer 4

no, because the pathology report shows a malignant lesion, but the procedural code identified it as a benign lesion

Question 5

TRUE/FALSE Consultation and abnormal laboratory and imaging study results MUST have an explicit notation in the record of follow-up plans.
* TRUE
* FALSE

Answer 5

True

Question 6

The treatment plan section of the medical record needs to be ______________ to provide a solid case for insurance approval.
* Be written in a step-by-step format
* Consistent with the diagnosis
* Clearly communicated to the patient
* Contain the physician’s signature for proof of review

Answer 6

Consistent with the diagnosis

Question 7

What does a DEA number allow a physician to do?
* purchase prescription pads
* practice medicine in the United States
* write a prescription for a controlled substance
* file for insurance reimbursement

Answer 7

write a prescription for a controlled substance

Question 8

Consultation, laboratory, and imaging reports filed in the chart must be initialed by whom in order to signify review.
* anyone who assisted in the direct patient care
* the PA specialist
* the patient themselves
* the practitioner who ordered them

Answer 8

the practitioner who ordered them

Question 9

Where does an authorizer find the information needed to substantiate an authorization request?
* From a patient’s medical records
* By speaking to the physician
* From the insurance company
* By making them up based on what they know will work for approval

Answer 9

From a patient’s medical records

Question 10

What type of authorization number is needed for controlled substance prescriptions?
* telephone number of the insurance company
* telephone number of the physician
* DEA number
* dollar amount approved by the insurance company

Answer 10

DEA number