Chapter 19 Flashcards
What is the standard system for reporting diagnoses?
ICD, or International Classification of Diseases Clinical Modification.
Coding is the process of selecting appropriate Current Procedural Terminology (CPT) for exams, testing services, and surgical procedures and linking the to associated ICD codes.
You observe a provider visits in a way the constitutes fraud, what should you do?
Notify the compliance officer or office manager.
HIPAA prescribes how providers must protect the dissemination of specific patient information.
OSHA (Occupational Safety and Health Administration) established by the Department of Labor protects the health and safety of employees.
CMS (Centers for Medicare and Medicaid Services) provides online PECOS enrollment to verify patient’s Medicare status and verify DMEPOS supplies accreditation.
A tech takes a photo of an office procedure, how does this pertain to HIPAA?
This is a violation as Photos are considered protected Health information.
A patient complains of blurry vision after cataract surgery, the physician requests an OCT to determine if retina edema is present. What diagnosis code should the tech order?
Blurry vision.
Cording should be linked to the Pt’s core complaint until the diagnosis changes.
OSHA protects what?
Employee health and safety.
When is it appropriate to use an “unspecified” ICD code?
When no other code accurately describes the condition.
The diagnosis code should be finalized to the highest level of specificity; however, a suspected diagnosis should not be coded. A diagnosis of symptoms or signs is appropriate until a definite diagnosis has been made.
What behavior is inappropriate for a technician?
Discussing clinical findings with the patient.
It is not your job to diagnosis or discuss prospective diagnosis.
What is not a measure of practice efficiency?
Number of follow-up visits.
Common measures are number of visits per full time equivalent (FTE) doctor, number of visits per treatment room per hour, number of patient workups per FTE assistant, revenue generated per patient visit, annual revenue per FTE staff person, annual revenue per FTE technician.
How can techs help create an effective schedule?
Develop schedule templates appropriate for each provider. The template should match doctor’s practice style and change over time.
What’s an example of a quality measure under the merit based incentive payment system?
Documentation of the current medications in the medical record.
Patient Clipboard and Review of Systems are important measures for MIPS.
