Dr. Glover's office has one vendor for their Practice Management software and another for their electronic health record, but the systems are able to communicate with one another without duplicating data entry. The systems are able to:
answer
interface.
An interface allows different software packages to communicate without re-entering data.
question
In order to file a claim to Medicare, a physician's office submits a ___________ form.
answer
CMS-1500.
In a physician's office, the required claim form is CMS-1500.
question
You are about to enter the marital status of a patient, and upon clicking in that field, the following appears:
___ Single
___ Married
___ Separated
___ Divorced
___ Widow/Widowed
These possible values are derived from a _____________ within the system.
answer
Library.
A collection of possible responses for each field is known as a library.
question
Susan is collecting data from a patient, and she asks him for his address. The patient asks whether she means his P.O. box number or his physical street address. Susan would find the meaning of the field permanent address in the practice's ______________________.
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Data dictionary.
For consistency, each field is pre-defined using a data dictionary so that only valid entries are entered in the field and so that each staff member interprets the field consistently.
question
Demographic data is a subset of ____________________ data.
answer
administrative.
Demographic data is a subset of administrative data which identifies the patient and usually includes name, date of birth, gender, social security number, marital status, address, and telephone number.
question
Clinical Documentation Architecture (CDA) and Quality Reporting Documentation Architecture (QRDA) are both specific data standards of the broader _________ standards.
answer
Health Level Seven (HL7).
HL7 is the software standards most widely used in healthcare. The CDA and QRDA are more specific standards recognized by HL7.
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A major goal of use of an electronic health record is the sharing of important clinical information about a patient. The use of ________________________ is directly related to this goal.
answer
Continuity of Care Documents (CCD).
The CCD is used to electronically transmit information about a patient's clinical care between and among caregivers.
question
The name, address, NPI number, and telephone number of a physician is known as ____________ information.
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provider.
A physician is also known as a provider
question
The subscriber and patient information section of a claim form includes all of the following except:
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assignment of benefits authorization.
The assignment of benefits refers to the payer, not the patient/subscriber.
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The setting where services took place is known as ______________________.
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the place of service code.
Each claim form must include the setting (place) where the services were rendered, known as the place of service code.
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There are certain pieces of data that must be collected in order to meet Meaningful Use requirements. Which of the following data does that?
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race.
Meaningful use regulations require the collection of patients' race and ethnicity.
question
Malone's health (medical) record number at Memorial Medical Center is 482638. This is an example of a/an ______________________.
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unique identifier.
Each patient only has one health (medical) record number at a particular hospital or healthcare facility, therefore it is a unique identifier.
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The required code set for documenting diagnoses on all patients in any care setting is known as:
answer
ICD-10-CM.
CPT codes are used to code procedures, HCPCS are codes for tangible items such as crutches, canes, and transport, ICD-10-PCS is used to code procedures.
question
Greenway Medical Center has partnered with five area physician's offices as well as a rehabilitation facility nearby for the purpose of offering high quality, coordinated care to patients in that geographic area. This partnership is known as a/an _________________.
answer
Accountable Care Organization.
Accountable Care Organizations consist of groups of care providers in a coordinated effort to provide quality care while controlling costs.
question
In order for ACOs to prove that they have provided quality care while controlling costs, what is necessary?
answer
data.
Data is necessary to prove that the ACO member organizations are able to coordinate care, show minimal duplication in testing, and the ability share health information.
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Where does the data originate that is used to prove Accountable Care Organization (ACO) success?
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the patients' health records.
The health record is the source document for all data.
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The master patient (person) index is:
answer
An index of all patients ever treated in a hospital.
An index of all patients ever treated in a hospital setting is kept in the MPI.
question
In a hospital, what piece of data included in master patient (person) index (MPI) which allows a hospital to locate the corresponding health (medical) record for each patient?
answer
medical (health) record number.
Each patient is assigned a medical record number for identification and filing purposes, and is found in the MPI.
question
Daniel Allen has been a patient at Greenway Hospital for the following ailments: January 8, 2012, inpatient for appendicitis; April 16, 2012, emergency department for an asthma attack; May 12, 2013, urgent care for a viral illness, May 13, 2013, inpatient for pneumonia, and once on June 4, 2013 in the emergency department for a sprained arm. How many times will Daniel Allen's name and demographic information be entered in the MPI of Greenway Hospital?
answer
one.
Regardless of the number of times the patient is seen, he/she is entered only one time in the MPI.
question
Daniel Allen has been a patient at Greenway Hospital for the following ailments: January 8, 2012, inpatient for appendicitis; April 16, 2012, emergency department for an asthma attack; May 12, 2013, urgent care for a viral illness, May 13, 2013, inpatient for pneumonia, and once on June 4, 2013 in the emergency department for a sprained arm. How many encounters for Daniel Allen will be found in the MPI of Greenway Hospital?
answer
five.
Daniel Allen's name and identifying information should only be found once in the MPI, but each visit is an encounter and there will be a record of each of those encounters in the MPI.
question
In a physician's practice, the index of all patients seen in that practice is most commonly known as the:
answer
Patient list.
In a physician's practice, this list of patients is more frequently referred to as the patient list than the master patient index.
question
A patient at Heller Memorial Hospital, Lisa Ford, was a patient in the emergency department in 1998, has had outpatient lab work in 2003 and 2005; she was then married. Her name changed to Lisa Ford Haver, and she had her twins at Heller County Memorial Hospital in 2010. How many times will her name and demographic information appear in the hospital's MPI?
answer
once.
Though she has been seen in the hospital numerous times and has been seen under two different names, as a patient she will only appear once.
question
The MPI and patient list should be kept:
answer
Permanently.
The MPI or patient list should be kept permanently since that is the record of every patient who has received care at the facility.
question
In which healthcare setting is a patient not registered prior to receiving care?
acute care hospital
a) physician's office
b) dental office
c) both acute care hospital and dental office
d) patients are registered in all of these settings
answer
d) patients are registered in all of these settings.
Patients in all settings must be registered before being seen initially, and then at the time each visit or stay takes place
question
At Heller Memorial Hospital, all patients regardless of the type of patient, emergency department, inpatient, outpatient diagnostics, etc., are registered through the same department. This is known as:
answer
Centralized registration.
Registration that takes place from the same department or area is known as centralized (or central) registration.
question
The amount of time allotted for a patient's office appointment is largely dependent on the _______________________.
answer
reason for the visit.
The reason for the visit largely affects the amount of time allotted for the appointment. The fact that a patient is new does not necessarily mean a longer appointment than for an established one.
question
Virginia Reed called Greensburg Medical Center to make an appointment for her annual physical exam. This step in the process is called:
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Scheduling.
Registration may be part of scheduling, but is considered a separate function.
question
Amy Shaw arrives for her appointment at Dr. Rodriguez's office. She has moved since her last visit and her last name has changed due to her marriage. The healthcare professional will __________ the patient's demographic information.
answer
edit.
The process of updating demographic information is known as editing.
question
When certain fields are clicked, the most common response to that field may appear. This is known as a _________ value.
answer
Default.
The most common value appears by default so the healthcare professional does not have to scroll through every choice on every patient.
question
The step that occurs after a patient is seen by the care provider is:
answer
patient stops at the cashier or check-out desk.
question
Each time a patient presents for care, the ______________ should be viewed or copied to ensure accurate information is on file for billing purposes.
answer
insurance card.
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