FREE RHIA Questions and Answers
When an exploratory laparotomy is performed then a therapeutic procedure, the coder reports this information in ICD-9-CM.
In a completely computerized patient record system, similar measures can be implemented to govern the use of electronic signatures. Electronic signatures are used to authenticate entries and ensure the integrity of electronic records.
A new patient with an ulcerative sore on the hip who was residing in a nursing home received medical attention from the doctor. A straightforward medical choice was made after a problem-focused history and physical examination.
CPT code 99324 corresponds to a nursing facility service, also known as a domiciliary, rest home, or custodial care visit. This code is used when a physician provides evaluation and management services to a new patient in a nursing facility, such as a rest home.
Continuous record reviews are a crucial technique for guaranteeing data quality by using accurate medical records. These evaluations assess
The performance of ongoing record reviews is indeed an important tool in ensuring data quality through accurate health records. These reviews play a crucial role in evaluating the completeness, adequacy, and quality of documentation within health records.
Ongoing record reviews involve the systematic assessment and analysis of health records on a regular basis. The primary purpose of these reviews is to identify any deficiencies or inconsistencies in the documentation, which can impact the accuracy and reliability of the health records.
Edward was diagnosed with congestive heart failure and acute pulmonary edema when he was released from the hospital. Edward's record is being coded by you, and you will code
As a coder, it is important to accurately code all relevant diagnoses documented by the physician. In the case of Edward, if the physician listed both congestive heart failure (CHF) and acute pulmonary edema as diagnoses, it would be appropriate to code both conditions.
Special precautions must be taken to prevent the stamp from being used by a delegate when personal signature stamps are used to authenticate entries in a paper-based record. Similar controls might be used to control the usage of electronic medical records in a fully computerized patient record system.
In a completely computerized patient record system, similar measures can be implemented to govern the use of electronic signatures. Electronic signatures are used to authenticate entries and ensure the integrity of electronic records.
All lab results from one hospitalization must be rapidly compared by a health record analyst. The paper-based health record design that works well for this objective is
Please select 2 correct answers
The source-oriented format organizes the health record based on the source or provider of the information. This format is less efficient for quickly comparing lab values across the entire hospitalization since the lab results may be scattered across different sections or sources within the health record.
Known or suspected prenatal abnormalities affecting the mother codes from category 655 should
Codes from category 655 in the International Classification of Diseases, Tenth Revision, Clinical Modification (ICD-10-CM) should be assigned when there is a known or suspected fetal abnormality that affects the management of the mother's condition. These codes are used to capture information about conditions or abnormalities in the fetus that impact the medical care or treatment provided to the pregnant woman.
