A notation for a hypertensive patient is a physician ambulatory care progress note reads: "blood pressure adequately controlled." In which part of a POMR progress note would this notation be written?
The diagnosis of a patient was recorded as an abscess in the procedure report, but was listed as carcinoma on the discharge summary. This is an example of a problem with?
Which of the following promotes uniform reporting and statistical collection for medical procedures, supplies, products, and services?
Healthcare Common Procedure coding System
According to CPT, a repair of a laceration that includes retention sutures would be considered what type of closure?
What is the function of physician's orders?
Document the physician's instructions to other parties involved in providing care to a patient
Documentation of aides who assist a patient with activities of daily living, bathing, laundry, and cleaning would be found in which type of specialty record?
What term is used for retrospective cash payments paid by the patient for services rendered by a provider?
The National Correct Coding Initiative "NCCI" was developed to control improper coding leading to inappropriate payment for?
Part B Medicare claims
In processing a Medicare payment for outpatient radiology exams a hospital outpatient services department would receive payment under which of the following?
A core data set developed by ASTM to communicate a patient's past and current health information as the patient transitions from one care setting to another is?
Continuity of care record
A patient is admitted with abdominal pain. The physician states that the discharge diagnosis is pancreatitis versus noncalculus cholecystitis. Both diagnoses are equally treated. The correct coding and sequencing for this case would be?
Sequence either the pancreatitis or noncalculus cholecystitis as principal diagnosis
The admitting data of Mrs. Smith's health record indicated that her birth date was March 21, 1948. On the discharge summary, Mrs. Smith's birth date was recorded as July 21, 1948. Which quality element is missing from Mrs. Smith's health record?
To assign SNF residents to the appropriate resource utilization group data are collected using the?