Chapter 4 - Medical Documentation - Lesson 2

18 cards

Lesson 2 - General Principles of Medical Record Documentation


 
  
Created Apr 14, 2010
by
jerzegirl

 

 
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  Side A   Side B
1
State how Medicare Defines "Medically Necessary"
 
Services or items reasonable and necessary for the diagnosis or treatment of illness or injury...
2
Identify the broadly accepted maximum for documentation.
 
If it isn't documented, it didn't happen.
3
List the three most important requirements for medical records:
 
Correct
Complete
Legible
4
What should medical record documentation always support on the health CMS-1500 claim form (select...
 
- CPT Codes
- ICD-9-CM Codes
5
What are reasons for accurate documentation from the PAYER'S point of view (Select all that...
 
- Ensure that services billed were actually provided
- Ensure that the services are consistent...
6
Medicare will always pay for a service that is reasonable and necessary.
a. True
b. False
 
b. False - Coverage can be limited if the service is provided more frequently than allowed.
7
Mistakes, errors, misunderstanding of the rules or negligence are not necessarily considered...
 
a. True - Mistakes, error, misunderstanding of the rules or negligence are not necessarily...
8
Failure to document medical necessity and failure to document services furnished and billed...
 
a. True
9
AMA
 
American Medical Association
10
E/M
 
Evaluation and Management
11
CPT
 
Current Procedural Terminology
12
CMS
 
Centers for Medicare and Medicaid Services
13
3 Terms for Medicare Administrative Contractors
 
1.  Fiscal Intermediaries
2.  Fiscal Agents
3.  Fiscal Carriers
14
ABM
 
Advanced Beneficiary Notice
15
What is an Advanced Beneficiary Notice?
 
An agreement given to the patient to read and sign before rendering a service if the participating...
16
What is a Signature Log?
 
A list of all staff members, names, titles, signatures and initials.
17
What are the 4 R's of Documentation Guidelines?
 
1.  REQUESTING Physician
2.  Consultant must RENDER an opinion and send a REPORT
3, ...
18
What could be the 5th R of Documentation Guidelines?
 
Consultation RETURNS - Consulting Physician must RETURN the patient to the requesting Physician.


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