CEHRS - Certified Electronic Health Records Specialist Medical Coding in EHR Questions and Answers

Question 1

A physician documents a patient's diagnosis as 'Type 2 diabetes mellitus with hyperglycemia' and the procedure as a 'comprehensive metabolic panel'.
Within the EHR, what is the MOST critical relationship the CEHRS must ensure is established for proper claim submission?

Accepted Answer

The ICD-10-CM code for the diagnosis demonstrates medical necessity for the CPT code of the service provided.

Answer

The CPT code for the procedure is from the most recent publication year.

Answer

The patient's insurance information is verified and active.

Answer

The physician's digital signature is applied within 24 hours of the patient encounter.

Question 2

A healthcare facility implements Computer-Assisted Coding (CAC) software integrated with its EHR. Which of the following best describes the primary function of CAC in the workflow of a coding professional?

Accepted Answer

To analyze clinical documentation and suggest appropriate codes for review and validation by a human coder.

Answer

To automatically assign and submit final codes for billing without human review.

Answer

To replace the need for certified coders by using artificial intelligence for all coding tasks.

Answer

To exclusively audit previously submitted claims for errors and compliance issues.

Question 3

A CEHRS is working in the EHR to finalize an encounter form (superbill). The physician performed a standard office visit (CPT 99213) and a separate, significant procedure on the same day. To ensure both services are billed correctly, the CEHRS should verify that the physician has linked which of the following to the CPT codes?

Accepted Answer

A specific diagnosis for each procedure and an appropriate modifier.

Answer

A referral from another physician.

Answer

The time spent on each service.

Answer

The patient's consent form for the procedure.

Question 4

Which feature within an EHR system is specifically designed to help prevent coding and billing errors, such as unbundling or using incorrect code combinations, before a claim is submitted?

Accepted Answer

Claims scrubbing and edits

Answer

Patient portal messaging

Answer

Clinical decision support alerts

Answer

Electronic prescribing functionality

Question 5

A CEHRS notices that a provider frequently uses a pre-populated EHR template for documenting patient visits for 'chronic hypertension'. The template automatically includes extensive review of systems and physical exam details, often leading to a higher-level E/M code being suggested by the EHR. This practice poses a significant compliance risk related to:

Accepted Answer

Lack of medical necessity.

Answer

HIPAA privacy violations.

Answer

Inaccurate patient demographic data.

Answer

Failure to obtain informed consent.

Question 6

When a CEHRS enters diagnosis and procedure codes into the EHR for a Medicare patient, the system should be able to check these codes against which of the following to verify that the service is covered for the given diagnosis?

Accepted Answer

National and Local Coverage Determinations (NCDs/LCDs).

Answer

The hospital's internal charge description master (CDM).

Answer

The American Medical Association (AMA) CPT codebook.

Answer

The patient's previous billing history.