Week 4 Flashcards Preview

*Financial Management > Week 4 > Flashcards

Flashcards in Week 4 Deck (27):
1

What should be clearly identified in the record in the initial visit?

chief complaint
history of present illness
family history
past health history
treatment/document physical examination
diagnosis
treatment plan

2

chief complaint

patient's stated reason for the encounter
clearly indicates symptom, problem or condition
concise

3

history of present illness (HPI)

mechanism of history
quality and character of symptoms/problem
onset, duration, intensity, frequency, location and radiation of symptoms
aggravating or relieving factors
prior interventions, treatments, medications, secondary complaints
symptoms causing patients to seek treatment

4

what other things should you include in the HPI?

review of medications
allergies
review of labs and procedure results
review of outside consultation reports
presenting complaint, including the severeity and duration of symptoms
new concern or ongoing/recurring problem
chagnes in patient's progress or health status since last visit

5

past health history

general health, prior illness, hospitalizations, allergies, medications, or surgeries
identify any contraindication to care

6

what are the extra things you need to record for medicare past health history?

social history
ongoing/recurring health concerns
patient risk factors

7

physical examination

vital signs
ROM
level of muscle spasm
performance relative to ortho/neurotesting
whatever else is an objective finding
focus on presenting complaint (PART)
positive physical findings
significant physical findings as related to CC
ROS

8

diagnosis

communicating to payers what is wrong with the patient and where the problem is located
use ICD-10-CM to code diagnosis

9

treatment plan

length or duration
frequency of treatment
what will be done
why it will be done
how it will be measured
how will you know if it is working
back up plan, refer out?

10

what does medicare say about treatment plans?

acute problems may require as many as 3 months of treatment
some require very little treatment
more frequent at first, then decrease frequency with time or as improvement is obtained

11

complicating facotrs that can increase time

symptoms present more than 8 days
skeletal anomaly
structural anomaly
severe pain
injury because of pre-existing conditions, underlying pathologies, congenital anomalies

12

what if patient returns with same symptoms 31 or more days later

start over
new history
new exam
new diagnosis
new treatment plan

13

if medical necessity has not been proven, what happens?

MAC will reject claim and will not pay
DC should have an ABN on file in order to bill patient

14

if medical necessity has not been proven after payment has been made, what will happen?

MAC will demand that the payment will be refunded with interest

15

will other payers accept medicare definition of medical necessity?

maybe, maybe not

16

what do you need to prove medical necessity

history of onset
patient complaint
exam findings
diagnosis
treatment plan
progress

17

standards for paperwork

chart/file should be in chronological order
if it's not written, it didn't happen
should contain standard abbreviations
anyone viewing the chart should be able to quickly understand the logic and course of treatment
outside reports should be read, dated and signed

18

6 components of oriented medical record

1. complete problem list with each item dated and numbered
2. determine diagnosis for each problem being treated
3. establish speciific treatment goals for each problem
4. prepare a written treatment plan for each active problem
5. use the SOAP format for ongoing treatments
6. document the resolution and/or referral dates for each complaint

19

what should you do for corrections to paperwork?

only be in the form of additions
draw single line through innaccurate information, note location of correct information, sign and date alteration
do it chonologically by date info is acually entered in chart
may use addendum with additional information
cross-reference the correct and incorrect enteries

20

other things that need to be documented

interactions between staff and patient that could potentially affect patient care
patient's intent to not follow recommendations
telephone calls
appointment cancellations and no-shows

21

what modifiers and codes does medicare reimburse for?

98940, -1, -2
AT
GA

22

when is GY used?

when the service is excluded from consideration for payment

23

when is GX used?

ABN has voluntarily been signed
patient has financial responsibility

24

when is AT used?

active, restorative, arrest of progression or corrective care

25

when is GA used?

maintenance, ABN signed, patient knows medicare won't pay, can collect from patient

26

when is GZ used?

cannot collect from patient, medicare won't pay, no ABN signed
nobody wins

27

what modifiers will medicare NOT pay for?

GZ
GY
GX