Chapter 6

The physician's diagnosis(es) based on the objective findings. Possible diagnoses are usually listed in order of the most likely to the least likely.

Assessment

The patient's condition from the practitioner's perspective. It generally includes the vital signs and findings from the physical exam (i.e., what the physician sees, feels, hears, etc.).

Objective

The patient's current medical condition from the patient's point of view. It generally includes the signs and symptoms, history of the present illness, and a review of the patient's body systems (i.e., what the patient thinks and feels).

Subjective

SOAP is an acronym for which of the following?

Subjective, Objective, Assessment, and Plan.

E&M Coder

The Evaluation & Management Coder is a built-in function of many EHR programs that recommends the appropriate Evaluation & Management code for office visits. The coder looks for keywords used within the review of systems and physical exam in the office visit note. The E&M coder then uses this information, in conjunction with the diagnoses, to determine the most appropriate E&M code level for billing.

Evaluation & Management (E&M) Code

The Evaluation & Management code is a five-digit number used by a physician to report evaluation & management services provided to a patient. The E&M encounter may include documenting a patient's medical history, a physical examination, and medical decision making. For example, a 99213 code indicates an outpatient visit with a limited amount of diagnoses and limited complexity and complications.

Notes from previous encounters are dated and organized by the most __ first.

recent

Which of the following describes the location of the H&P generator?

In the Tools menu within the OV screen.

Which of the following describes the scenario when a clinician can code or bill for services not supported by the office visit note documentation?

It is never acceptable to code or bill for services not supported by documentation.

How many addenda may be added to the same locked office visit note?

Multiple

Data can be entered into the office visit note by:

1. Tapping on the pop-up text with a stylus tool (as with a tablet PC) 2. Clicking on pop-up text items with a mouse 3. Typing directly into the text box at the bottom of the middle panel 4. Dictating through a third-party voice recognition program, causing the dictated text to enter the text box

Which of the following can also be created by the order form?

?

Review of Systems (ROS)

A review of systems is a structured technique used by providers to gather healthcare history covering the organ systems from a patient. It is therefore a component of the 'subjective' portion of the SOAP note. There are 14 body systems recognized by the CMS.

History & Physical (H&P) Report

An H&P report documents the patient's healthcare history, such as past medical history, family medical history, routine medications, problem list, and so on, as well as the details of the current physical exam. The H&P report is a required document when admitting a patient to a hospital as an inpatient.

SOAP

An acronym for subjective, objective, assessment, and plan. The SOAP note is a convenient format for healthcare providers to document a patient's healthcare evaluation in a typical office visit.

Addendum

An addendum is a notation added to an office visit note, after it has been permanently signed and locked, to supplement the information in the original note.

Body Mass Index (BMI)

BMI is a measure of body fat based on height and weight that applies to adult men and women. BMI is the measurement of choice for studying obesity. It is calculated by a mathematical formula that divides a person's weight in kilograms by their height in meters squared (BMI=5 kg/m2).

BMI is an acronym for which of the following?

Body Mass Index

Which of the following is represented by CPOE?

Computerized Provider Order Entry

Coordination of Care

Coordination of care comprises making available all resources to ensure healthcare providers have access to all required information on a patient's conditions and treatments and that the patient receives appropriate healthcare services.

Which of the following is a five-digit number used by a physician to report the office visit encounter with a patient?

Evaluation and Management Code

The physician's diagnosis(es) based on the objective findings. Possible diagnoses are usually listed in order of the most likely to the least likely.

Plan

Which of the following is represented by the abbreviation ROS?

Review of Systems

Which of the following features contain the procedure and diagnosis codes and descriptions that were selected in the office visit and are used for billing?

Routing Slip

The Date of Service will automatically default to which date?

The date the office visit note was first created.

Routing Slip

The routing slip is a form that contains the medical office's most common procedure and diagnosis codes and descriptions. It also contains the patient's name, demographics, and billing information and may or may not include pricing. In a paper environment the physician usually indicates on the routing slip which procedures and diagnoses were used in the office visit. With an EHR program only the codes and description that were selected in the office visit will print on the routing slip. Some other names for a routing slip are superbill, encounter form, charge ticket, and fee ticket.