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Must be included when billing an insurance company:

DOS, POS, TOS, and dx or DX

DOS

Date of Service

POS

Place of service

TOS

type of service

DX or dx

diagnosis

HIPAA

under what rule mays use patients Protected Health Information (PHI) with out specific authorization for treatment, payment, and operation purposes (TPO).

T in TPO?

treatment

P in TPO?

Payment

O in TPO?

Operations

What does (T)reatment in TPO mean?

primarily for the purpose of discussion of the patients case with other providers

What does (P)ayment in TPO mean?

where providers submit claims on behalf of patients

What does (O)perations in TPO mean?

for purposes such as staff training and quality improvement

Employer Liability

physicians are legally responsible for their own conduct and any actions of their employees.

Employee Liability

"errors and omissions insurance" a protection against a loss of monies caused by failure through error or unintentional omission on the part of the individual or service submitting the insurance claim

Let the master answer

means an employee can be sued and brought to trial

Medical Record

: documentation on the patients social and medical history, family history, physical examination findings, progress notes, radiology and lab results, consultation reports and correspondence to patient

Reason 1 for Documentation of Pt Records

avoiding denied payments by insurance carriers investigating the medical necessity of services

Reason 2 for Documentation of Pt Records

enforcement of record keeping rules by insurance carriers requiring accurate documentation that supports procedure and diagnostic codes

Reason 2 for Documenting of Pt Records

Subpoena of medical records by state investigators of the court review

Reason 4 for Documenting of Pt Records

Defense of a professional liability claim

Indefinitely

a M.D. must keep living Pt records for

5 years

a MD must keep deceased Pt records for

pain

-algia

blood condition

-emia

inflammation

-itis

enlargement

-megaly

measure

-meter

tumor, mass

-oma

abnormal condition

-osis

disease condition

-pathy

bursting forth of bloos

-rrhagia

discharge or flow

-rrhea

hardening

-sclerosis

to view

-scopy

surgical puncture

-centesis

removal

-ectomy

record

-gram

process of recording

-graphy

seperation

-lysis

surgical fixation

-pexy

suture

-rrhaphy

visual examination

-scopyy

opening

-stomy

treatment

-therapy

incision

-tomy

without

an

before

ante

against

anit

slow

brady

painful

dys

inside, within

endo

upon, above

epi

out, out of

ex

below

hypo

between

inter

scanty

oligo

beside

para

through

per

before, infront of

pre

false

pseudo

above, beyond

supra

four

tetra

cartilage

arth

head

cephal

heart

cardi

gall bladder

cholecyst

cartlige

chondro

vagina

colp

intestine

enter

vulva

episi

stomach

gastro

tounge

gloss

liver

hepto

uterus

hyster

abdomen

lapar

stone

lith

breast

mast

muscle

myo

ovary

oophor

lung

pneum

fallopian tubes

salping

mouth

stomat

anterior, ventral

front surface of the body

posterior, dorsal

back side of the body

superior

above another structure

inferior

below another structure

proximal

near the point of attachment to the trunk

distal

far from the point attachment to the trunk

medial

pertaning to the middle of the body

lateral

pertaining to the side

frontal, coronal

vertical plane diving the body by the front and the back

sagittal

vertical plane diving the body by the right to left sides

transverse

horizontal plane dividing the body into upper and lower portions

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