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NHA CEHRS PRACTICE EXAM 202 5 / LATEST ACTUAL
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Current Procedural Terminology (CPT) 4th edition - ANSWER>>a coding classification system used to report professional services and procedures provided to a patient at ambulatory care centers, medical clinics, and other outpatient care facilities de-identification - ANSWER>>the process of removing personal health information accessible to providers and other staff members with login credentials regardless of location (NCPDP) national council for prescription drug programs - ANSWER>>an organization that creates standards for transmitting prescription information between pharmacies and providers. abbreviations - ANSWER>>American Hospital Association policy states that they should be eliminated from vital parts of the medical record, including final diagnoses and discharge summaries. advanced directive (living will) - ANSWER>>legal document that contains information about the patients treatment choices when they are unable to make healthcare decisions
aging report - ANSWER>>report that identifies past due patient or insurance account balances and is usually run monthly assignment of benefits - ANSWER>>a patient authorization to allow health insurance payment to be made directly to the provider of services authorization - ANSWER>>a document that approves disclosure of protected health information unrelated to treatment under the HIPAA privacy rule benchmark - ANSWER>>a measure of performance against industry standards business associate - ANSWER>>a third party entity that has contact with protected health information to provide services unrelated to treating patients business associate agreement - ANSWER>>a legal contract dictating a business associate to comply with protection of protected health information under the HIPAA privacy rule Centers for Medicare and Medicaid Services (CMS) - ANSWER>>a federal regulated agency that is part of the Department of Health and Human Services, administers Medicare, works with the state governments to administer Medicaid programs, sets standards for interoperability of EHR, and overseas implementation of federal legislation clinical documentation improvement (CDI) - ANSWER>>process for executing and improving and reviewing clinical documentation to ensure that it accurately reflects and supports CPT and ICD- 10 - CM codes submitted with claims for payment compliance program - ANSWER>>internal policies designed to prevent claim error,
encounter form - ANSWER>>and itemized bill for services that contains diagnosis and procedure codes and is used by administrative staff to complete claims forms; also known as a superbill, fee slip, or charge form encryption - ANSWER>>converting email or other information into a code that only intended recipients can read explanation of benefits (EOB) - ANSWER>>a statement that shows a patient how services provided were processed by the insurance carrier Health Information Technology for Economic and Clinical Health (HITECH) Act - ANSWER>>federal legislation that expands consumer rights and protections outlined by HIPAA and sets standards for quality and use of EHR Health Insurance Portability and Accountability Act (HIPAA) - ANSWER>>a federal law that regulates use of patient personal identifiable information Healthcare Common Procedure Coding System (HCPCS) - ANSWER>>a coding classification system in which level I (CPT codes) are used to bill outpatient procedures and physician services, and level II (HCPCS codes) are used to bill professional services, supplies, and products not included in CPT codes human factors engineering - ANSWER>>attempt to address human strengths and weaknesses into programs or systems hybrid system - ANSWER>>system that uses both paper and electronic based
processing for documentation of health information internal audit - ANSWER>>examination of in house government and financial processes for appropriateness and accuracy International Classification Of Disease, 10th revision, Clinical Modifications (ICD- 10 - CM) - ANSWER>>a diagnostic classification and coding system for diagnosis used by healthcare organizations International Classification Of Disease, 10th revision, Procedural Coding System (ICD- 10 - PCS) - ANSWER>>a classifications system for procedures performed at inpatient facilities interoperability - ANSWER>>the ability of systems to share and use information laboratory information system (LIS) - ANSWER>>a data base or prescribed laboratory test and results transferred from instruments used to analyze the test medical record number (MRN) - ANSWER>>a set of numbers used to identify a patient and associated recorded health data minimum necessary concept - ANSWER>>protecting private health information by limiting access to information based on minimum need notice of privacy practices (NPP) - ANSWER>>a document that is required by law to inform patient how the organization will use their health care information
rollout - ANSWER>>a start of a process upcoding - ANSWER>>assigning a higher level service or procedural code usability - ANSWER>>the ease with which a person can interact with hardware and software to provide safe, efficient, quality patient care precertification - ANSWER>>the process of determining whether a procedure or test is covered under the insurance contract. review of systems - ANSWER>>The review of systems section is used to record the subjective physical assessment of each body system. It would not include vital signs. past medical history - ANSWER>>The past medical history section contains the objective findings from a patient's previous visit, including operations, injuries, and treatments. superbill - ANSWER>>form generated for billing that includes commonly used services and diagnoses. It would not include vital signs.
assessment - ANSWER>>includes the diagnosis codes determined by the provider. It would not include vital signs. growth chart - ANSWER>>A pediatric growth chart is a graphic sheet of the measurements of a child's growth rate. preventive care screen - ANSWER>>includes suggestions of preventive care, such as cancer screenings, based on age, sex, and medical history. immunizations screen - ANSWER>>includes the patient's immunization records. The preventive care screen includes suggestions of preventive care, such as cancer screenings, based on age, sex, and medical history. test results screen - ANSWER>>includes a list of tests and results. The preventive care screen includes suggestions of preventive care, such as cancer screenings, based on age, sex, and medical history. work-list report - ANSWER>>helps coders prioritizes patient accounts for coding from oldest to newest. UB- 04 form - ANSWER>>is used for inpatient and facility billing. This form is used to submit the codes for reimbursement after they are captured during the visit. CMS-1500 form - ANSWER>>the universal claim form used for outpatient and professional billing. This form is used to submit the codes for reimbursement after they are captured during the visit.
problem list - ANSWER>>current list of any of the patient's diagnosed conditions that is maintained from visit to visit. radiology information system (RIS) - ANSWER>>database that stores information on radiology ordering, scheduling, appointments, referrals, reporting, and other items used by the radiology professionals to track patient data. RIS does not store imaging pictures. picture archiving and communication system (PACS) - ANSWER>>imaging storage system that enables radiology providers to interpret the results of imaging procedures. Information from PACS integrates into the EHR through observance of interoperability standards, such as the use of HL7. clinical encoder - ANSWER>>software that assists with assigning accurate diagnosis and procedure codes for billing purposes. clinical decision support system (CDSS) - ANSWER>>A special subcategory of clinical information systems that is designed to help healthcare providers make knowledge- based clinical decisions and integrated with the facility's EHR system to provide statistics and monitoring for a variety of health system functions and to identify areas for process and quality improvement. production by procedure report - ANSWER>>indicates the number of total procedures completed within a given timeframe along with the associated revenue generated by each type of procedure. billing/payment status report - ANSWER>>lists the financial status of every patient
account. remittance advice report - ANSWER>>lists patient information and the amount paid by third-party payers to the provider. clinical encoder program - ANSWER>>helps the coding professional with the coding pathways by assigning codes and diagnostic-related groups. security management process - ANSWER>>1st Risk analysis is performed first to identify potential security risks 2nd Risk management is performed to address the security risk. 3rd Sanction policy is performed to determine the consequences for failure to comply. 4th information system activity review is performed last because it is an ongoing process that includes record review after all the other steps are complete. physical examination section - ANSWER>>documentation of the patient's height, weight, blood pressure, temperature, pulse, and respirations. open hours scheduling - ANSWER>>patients are seen by the provider on a first-come, first-served basis. This scheduling method is often used in urgent care facilities. wave scheduling - ANSWER>>several patients are scheduled to arrive at the same time, and the number of appointments is determined by the length of the average appointment. cluster scheduling - ANSWER>>similar appointment types are scheduled together at specific times. Scheduling well-child visits in the morning and sick child visits in the afternoon is an example of cluster scheduling.
technical safeguards - ANSWER>>covers automated processes, such as the encryption and decryption of data. Flow sheet - ANSWER>>used to record a patient's vital signs over time, which would include temperature values. concurrent coding - ANSWER>>allows coders to see documentation while the patient is still receiving treatment so coding can occur on an ongoing basis. Allows a coder to query a provider during patients stay care plan - ANSWER>>clinical document detailing the type of treatment that will be provided to a patient. structured data - ANSWER>>Data already stored in a specific fashion in a database. pharmacy information system (PIS) - ANSWER>>System that assists care providers in ordering, allocating, and administering medication; focuses on patient safety issues, especially medication errors and providing optimal patient care charge entry - ANSWER>>The act of entering ICD- 10 - CM, CPT, or HCPCS codes into a computerized billing system for services provided during a patient visit or procedure. In the EHR, this process occurs automatically past history - ANSWER>>⦁ Medications ⦁ Allergies ⦁ Previous health problems or injuries ⦁ Surgeries
⦁ Prior hospitalizations ⦁ Age appropriate immunization status ⦁ Age appropriate feeding/dietary status chief complaint documentation - ANSWER>>⦁ Location of pain or symptoms ⦁ Quality (sharp, dull, burning) ⦁ Severity ⦁ Duration ⦁ Timing ⦁ Context (e.g., blood sugar elevations that occur after eating certain foods) ⦁ Modifying factors ⦁ Associated signs and symptoms HIPAA eligibility transaction system (HETS) - ANSWER>>Medicare system for verifying coverage of services (eg. skilled nursing facilities and inpatient stays) EHR incentive program requirements - ANSWER>>⦁ Use of a certified EHR in a meaningful manner (e-prescribing, computerized provider order entry,
ledger report - ANSWER>>A patient's financial status is displayed in a ledger report. The report includes itemized statements, payments, and adjustments of all charges incurred by the patient for services rendered by providers in the organization. Each statement includes the amount charged, the amount paid by the insurance company, and the amount due from the patient or guarantor. This report tracks the patient's responsibility in terms of payments for services provided. optical character recognition (OCR) - ANSWER>>the capability of specialized software to interpret the actual letters and numbers on a page to create a digital document that can be edited, rather than a flat picture the joint commission (TJC) - ANSWER>>An organization that accredits health care organizations and programs risk analysis and management - ANSWER>>identifies areas of uncertainty that could negatively affect value, analyzes and evaluates those uncertainties, and develops and manages ways of dealing with the risks
objective data - ANSWER>>anything that can be observed or measured by clinical staff such as vital signs, prior records, lab results, imaging and physical examination findings narrow network - ANSWER>>A limited group of providers who contracted with an insurance company CPT category I - ANSWER>>classify medical, surgical, and diagnostic services and procedures provided for patients. These codes are used for reporting to both private and public insurers for billing. CPT category II - ANSWER>>OPTIONAL tracking codes for performance measurement., represent services and/or test results that contribute to positive health outcomes and quality patient care. 5-digit alphanumeric code with the alpha character F in the last position. CPT category III - ANSWER>>temporary codes applied to emerging technology (ends in letter T) codes are held for 5 years by FDA permanent national codes - ANSWER>>are maintained by the HCPCS National Panel, which is composed of representatives from the Blue Cross/Blue Shield, Association (BCBSA), the Health Insurance Association (HIAA), & CMS. miscellaneous codes - ANSWER>>National codes used when a supplier is submitting a bill for an item or service where no existing national code exists to describe the item or service being billed; must contain a complete description of services or product modifiers (CPT) - ANSWER>>a two-digit character that is appended to a CPT code to
LOINC (Logical Observation Identifiers Names and Codes) - ANSWER>>enables computer programs to locate and report laboratory tests. CMS Security Standards Matrix - ANSWER>>It is a set of criteria for EHR implementation and use. adjudication - ANSWER>>the process of denying or paying a claim. It is not a method used to transmit documentation. preauthorization - ANSWER>>the process of determining whether or not a procedure is covered and medically necessary. It is not a method used to transmit documentation. fee schedule - ANSWER>>a document that includes a list of procedures matched to their allowable amounts. revenue cycle phase I - ANSWER>>consists of registration functions such as insurance verification, HIPAA notification, copying insurance information, obtaining signatures, assignment of benefits, and establishing an account. fielded and coded data - ANSWER>>a unique code is assigned to each laboratory component so it can be located and organized sequentially. It is then easily placed on a graph as a visual representation of trends over time. claim scrubbing - ANSWER>>check for edits and billing rules, and it finds errors and generates error reports. This allows staff to review and correct before transmission of the final bill to the payer.
overlapping schedules - ANSWER>>Some appointments are longer than others or can be completed by a nurse or a medical assistant instead of the provider trend analysis - ANSWER>>used to compare data across multiple dates, events, and tests. medical service order - ANSWER>>authorization from the employer for the health care organization to treat an injured employee. It should be photocopied and scanned into the patient's record. office of inspector general (OIG) - ANSWER>>in the U.S. Department of Health and Human Services when improper documentation is discovered. patient-entered data - ANSWER>>the patient completes a questionnaire on their own medical history and the reason for the current visit, which makes interaction with the provider easier and less time-consuming. predetermination - ANSWER>>the process of discovering the maximum amount the third-party payer will pay for a particular service. preregistration - ANSWER>>the process of entering the patient's demographic and historical information into the EHR prior to a visit medicare severity diagnosis related group (MS-DRG) - ANSWER>>system is used for inpatient hospital billing coded data - ANSWER>>Data that are translated into a standard nomenclature of
