NHA CEHRS EXAM NEWEST ACTUAL EXAM QUESTIONS AND DETAILED CORRECT ANSWERS 2024-2025|A+GRADE, Exams of Nursing

Download NHA CEHRS EXAM NEWEST ACTUAL EXAM QUESTIONS AND DETAILED CORRECT ANSWERS 2024-2025|A+GRADE and more Exams Nursing in PDF only on Docsity! NHA CEHRS EXAM NEWEST ACTUAL EXAM QUESTIONS AND DETAILED CORRECT ANSWERS 2024-2025 | A+GRADE CERTIFIED ELECTRONIC HEALTH RECORDS SPECIALIST Training new administrative employees in family medicine office. Which reference to use teaching staff the patient registration process collection? Correct Answer The Uniform Ambulatory Care Data Set (used for registration in offices/clinics)(Similar answer choice Clinical Decision Support) Which is a computer protocol that specifically supports both clinical and administrative data? Correct Answer Health Level 7(HL7) Registering a new patient. Which of the following documents ensure patient's signed acknowledgement understanding of why (PHI) released? Correct Answer Notice of Privacy Practices (NPP) (Not ABN) Which document is patient required to sign for health organization to receive payment directly from patient's 3rd- party payers? Correct Answer Assignments of Benefits(AOB) Assisting the billing department and researching a claim for patient who has Medicare and a procedure not covered. Which verification was completed prior to billing the patient? Correct Answer Advance Beneficiary notice (Not NPP) Which patient portal features meet criteria for patient engagement as part of EHR incentive program? Which is required to submit public health agencies? Correct Answer Send clinical summaries (Similar q/a Reportable lab results) Educating new staff member about security management process. Which of the procedures indicates regularly review records, access reports, tracking? Correct Answer Information system activity review Which is most important factor in compiling data reports for Medicare Merit-Based Incentive Payment System (MIPS)? Correct Answer Accuracy of clinical documentation Which security management process is performed first by covered entity to determine threats to confidentiality, integrity, availability of PHI? Correct Answer Risk analysis (Similar to information activity review question) Clinical coder trained in billing with (CAC). Which action should billers take creating a claim assigned with accurate procedure code? Which action coder takes regarding Medicare diagnosis codes for admitted patient? Correct Assisting a provider to enter a clinical order to obtain three blood draws. Which component of EHR should assist the provider to access? Correct Answer CPOE (Computerized Provider Order Entry) Assisting with obtaining the history of a patient. Which documented information is in the history section of a progress note? Correct Answer Medication list (NOT cognitive status, temperature, ,) Developing template to create authorizations for health clinic to send immunization records for college-bound patients. Remain compliant with Privacy Rule, which is to be understood as a required item on template? Correct Answer Date signed (NOT birth) When obtaining data from new clinic patient. Which statement is to be understood that patient indicates a history of present illness? Correct Answer "I came because I've been coughing for several days." In which of the following sections should EHR specialist locate objective findings from a patient's previous visit? Correct Answer Past medical history Which action should a patient take to authorize a participating health organization to receive payment from a 3rd-party payer? Correct Answer Provide a signature for assignment of benefits to the health care organization. (NOT contact 3rd-party) Collaborating with certified coder in training session for outpatient billers after getting new EHR. Which statement about ICD-10-CM codes to make? Correct Answer "The ICD-10-CM code needs to be as specific as possible." Assisting a nurse who receives prescription for morphine sulfate sent via EHR system"Increase MS to 2 mg IV Q4H." Which statement reconciles to read as? Correct Answer Morphine sulfate 2 mg IV Q4H. (NOT 2.0 mg intravenously) Training a on the use of health system's EHR. A provider asks how to correct deficiencies in their documentation. Which statement to make? Correct Answer "Using a template for your documentation will allow the system to produce a report that indicates required fields to complete" Reviewing the outstanding balances that were submitted to collection agency. What document verifies correct accounts submitted? Correct Answer Patient aging report (Not patient ledger,day sheet, deposit) Preparing to generate a report for a supervisor that indicates amount of revenue from throat cultures. Which report should EHR specialist generate? Correct Answer Production by procedure report Collaborating with a coder about reports available in new EHR. Which of the following reports shows the income generated by 3rd-party payers? Correct Answer Production by insurance report Training a new billing specialist "What is the purpose of a billing and payments status report?" Response: Correct Answer "It lists the standing of each patient's account". Which report is the practice manager creating to assist the scheduling of staff? Correct Answer Production by provider report Which provides a snapshot of how much money is due to facility from 3rd-party payers and patients in computer management system? Correct Answer Aging A/R report New coder states ''There is no need to review both superbill and the health record documentation" Response: Correct Answer "Verify superbill against the health record documentation" Performing an internal audit of EHR records and discovers improper billing potential fraud abuse with private 3rd party payers. Which agency to call: Correct Answer Office of Inspector General (OIG) Which sections of HIPAA Security Rule governs the encryption and decryption of data for secure transmission? Correct Answer Technical safeguards (ex. Authentication controls, access to PHI without treatment purposes- payment-healthcare operations) reconciled by using. Which type of data? Correct Answer Coded data Which data type exchange between facility and diagnostic lab can generate visual representation of trends in lab results over time? Correct Answer Fielded and Coded data Which EHR tool documents a provider adding comments for increasing the specificity of physical examination findings? Correct Answer Free-text box Importing transcribed encounter notes that were dictated the previous day. Which data format would these notes be saved? Correct Answer Text files (provide current narrative) When generating admission documentation for patient. Which information is entered in the legal data section of EHR? Correct Answer Advance Directives (Not emergency contact) A facility's software reflects a change in patient's baseline platelet count. Which methods of notification does the software use to inform the provider? Correct Answer An automatic alert message (Similar q/a Known medical allergies) EHR specialist should identify that which process for converting text into code for secure transmission? Correct Answer Encryption Assisting facility implementing a recent upgrade to EHR system. Which question would be the best to ask in preparation for Implementation? Correct Answer "What is the timeline for these changes?" Receiving a phone call from established patient with multiple chronic conditions thinks they have pneumonia and would it affect any other conditions. Which sections of record would chronic condition be located? Correct Answer Problem list (ex. patient seen in urgent care following leg injury question Similar answer/q) Accessing the results of a patient's MRI. Which radiology department software is used to store diagnostic images? Correct Answer Picture archiving and communications system (PACS) (Not radiology RIS) Which information is required from a prescribing provider to complete an electronic laboratory order? Correct Answer Diagnosis code A provider at an inpatient facility is reviewing pending tasks and messages through the EHR 's message feature. Which task is most important ? Correct Answer Signing a history and physical for patient admitted 36 hr ago. or Completes history and physical within 24hr after admission. Which patient identifiers should the EHR specialist verify before documentation is entered into an EHR? Correct Answer Patient's medical record number Which data information should be obtained during a patient's history and physical exam to be included in history section? Correct Answer Benign colon polyps (Not laceration,respitory rate,disoriented time) Which statements to make regarding e-prescribing feature of EHR? Correct Answer "A renewal authorization can be transmitted" or "E-prescribing helps decrease medication errors" (Similar q/a) Preparing to perform a statistical review of infection rates at a facility for quality improvement purposes. compare data with other facilities. The EHR system should be integrated with which of the following? Correct Answer Clinical Decision Support System (CDSS) uses Protocols to present provider with therapies for documented diagnoses A new medical group hires a privately owned information technology company to manage IT operations. Which action ensures the IT company will maintain security of all data transmissions? Correct Answer Enter into a business associates contract with IT contractors. (NOT review company record) Preparing to obtain information about patient outcomes by individual providers for quality improvement. Which action Which statement made by EHR specialist describes a function of EHR system? Correct Answer "it streamlines the clinician's workflow" Which example of data backup method that is HIPAA complaint and allows for the recovery of data in natural disasters? Correct Answer Maintaining severs that are off site in a different region. Which method should EHR specialist use to make changes or corrections to entries in EHR? Correct Answer Write an addendum to the existing entry. (with a Date, initials, strike line) Medical office receives an imaging report via fax machine and EHR specialist scans it into patient's record. This is an example of which data collection? Correct Answer Manual (Not interfacing, automated,) A provider orders a laboratory test in the EHR. Which describes the way laboratory specimens are labeled and tracked? Correct Answer Labels are automatically printed at the point of care as part of the requisition process. Reading a provider progress note "Patient diagnosis:Lymphoma, Received six rounds of chemotherapy beginning June 2020. Patient reported diarrhea, loss of appetite, and fatigue with treatment. Last cycle of chemo was administered Nov. 2019; now in remission" Which action should EHR specialist take? Correct Answer Query the provider to resolve the discrepancy. Assisting clinical coder with code verification and notes that there is insufficient information to support diagnosis coding. Which action should specialist instruct coder to request additional documentation from provider? Correct Answer Send a provider query. Assisting medical assistant with entering a patient's ongoing temperature measurements into the EHR. The EHR specialist should document result in which location? Correct Answer Flow sheet Which function allows coders to query health care providers for clarification during a patient's inpatient hospitalization? Correct Answer Concurrent coding Assisting a clinic nurse with data entry related to well-baby check-up. When entering weight into record it is understood that data would result in which type of documentation? Correct Answer Growth chart Information about patient weight control. Which format is most useful for visual representation of weight fluctuations over timeframes? Correct Answer a graph sheet (not table, progress note, pe template) Assisting with providing user training to staff members regarding an upgrade to EHR. Which statement to maker when asked about way to help minimize number of patients who miss their scheduled appointments? Correct Answer "An automated confirmation of appointments may be set in EHR system." Which statement correctly deidentifies a patient's information when speaking to pharmaceutical representative about coverage for new meds heartburn? Correct Answer "Our facility has patient who is indigent and has stomach problems who could benefit from this medication." Providing patient with information about patient portal. Which statement indicates patient's understanding of portal? Correct Answer "I can schedule my own appointments." Assisting with check out. patient says"I hope I can remember everything about this new medication." Response: Correct Answer " Before you leave let me show you where to find this medication education on patient portal." Discussing hardware costs with the department controller. Which statement by department describes advantage purchasing server hardware for LAN? Correct Answer "Dedicated servers for LAN ensure safe exchange of data between workstations." Patient with occupational injury covered under worker's compensation. Collect proof identity and demographics. Which additional info to request? Correct Answer A A patient brings a copy of a recent hematology result to their first visit with an oncologist and gives the document to an EHR specialist. Which of the following actions should the EHR specialist take? Correct Answer Scan the document into the patient's EHR An EHR specialist is explaining to a patient about the process for accessing the patient portal. The EHR specialist should instruct the patient to use the provided username and which of the following other items to gain entry into the portal? Correct Answer Access code An EHR specialist is assisting with moving a provider's office into a new building. To which portion of the Device and Media Controls standard is the EHR specialist adhering when creating a record of hardware and media to move? Correct Answer Accountability An EHR specialist notes that a patient has a different MRN in the EHR than the organization's administrative database. Which of the following actions should the EHR specialist take? Correct Answer Report the discrepancy to a supervisor Which of the following methods should an organization use to disseminate new information to staff members about changes to implement due to an upgrade to the EHR general compliance software? Correct Answer Conducting a training session for staff members Which of the following actions ensures that a digital image imported from a fax machine with scanning capabilities is linked to the correct patient in the EHR? Correct Answer Cataloging the image Which of the following information about a patient should an EHR specialist match with the patient's name to verify the patient's identity before entering information into the EHR? Correct Answer MRN An EHR specialist receives a patient prescription stating, "Give Aspirin 81 mg PO QD." The EHR specialist confirms the prescription with the provider and reconciles the information to read as which of the following in the patient's medical record? Correct Answer Aspirin 81 mg PO daily When generating admission documents for a patient, which of the following information should be entered into the EHR under the administrative section? Correct Answer Emergency contact An EHR specialist has obtained medical records from an institutional database, and the data needs to be integrated into a patient's EHR. Which of the following information should the EHR specialist use to identify the patient before integrating the data? Correct Answer DOB Which of the following would be helpful to a health care organization when initiating inventory tracking of e- signature pads? Correct Answer Universal Medical Device Nomenclature What type of data should an EHR specialist reference to determine which patients are covered by a specific insurance carrier? Correct Answer Financial Which of the following medical record review findings indicates upcoding of clinical documentation in the EHR? Correct Answer Using a CPT code that yields a higher reimbursement than what was documented Which of the following components of a SOAP note would pull in real-time results from the EHR? Correct Answer Objective An EHR specialist is speaking with a patient who states, "I don't know where to access education materials about my disease." Which of the following responses should the EHR specialist make? Correct Answer "You can access patient education materials using the patient portal." An EHR specialist in a clinic is assisting a patient with documenting past medical, social, and family history. The patient completing the electronic questionnaire asks, "Where do I include drug use?" The specialist should reply that drug use should be documented in which of the following social history components? Correct Answer Recreational use following actions should the EHR specialist take to protect the information? Correct Answer Share the spreadsheet password with the provider Which of the following actions would generate a real-time alert message in the EHR? Correct Answer The provider enters a prescription for a duplicate therapy An EHR specialist is providing support for a provider who is entering prescriptions into a patient's chart using a new EHR system. The provider asks the EHR specialist which pharmacy will automatically receive the prescriptions. How should the EHR specialist respond? Correct Answer The patient's preferred pharmacy must be entered An EHR specialist is training providers on required clinical documentation in the hospital setting. A provider asks, "How can I make sure to include all relevant data elements?" Which of the following statements should the EHR specialist make? Correct Answer Use a progress note template Which of the following actions by a staff member should an EHR specialist identify as a threat to the security of PHI? Correct Answer Using public internet access Which of the following penalties does Medicare impose when providers have not implemented certified EHR technology? Correct Answer They can no longer receive the full reimbursement for services An EHR specialist receives a request for the release of PHI. Which of the following steps must be taken in the ROI workflow process before honoring the request? Correct Answer The request is reviewed to verify legitimacy for the ROI When EHR downtime procedures are initiated during a power outage, which of the following should be implemented to restore any lost data? Correct Answer Disaster recovery plan In order to limit the use of, disclosure of, and request for PHI the HIPAA Privacy Rule requires covered entities to adhere to which of the following concepts? Correct Answer Minimum Necessary What part of the EHR indicates if a health record documentation has been modified? Correct Answer User activity feed In order to obtain a Certificate of Need for a new cancer center, an EHR specialist is asked to collect data about patients in the region who have a cancer dx. What action should the EHR specialist take when preparing the data? Correct Answer De-identify PHI prior to release An EHR specialist is working in a hospital setting. Which personnel should have access to the financial data set of a patient's EHR in order to fulfill their responsibilities? Correct Answer Billing clerks Which of the following prescriptions is written correctly according to the Joint Commission's "do not use" list of abbreviations? Furosemide 20mg IV QD NPH Insulin 20u SC daily before breakfast Morphine Sulfate 2.0mg IV daily before dressing change Levothyroxine 0.1mg PO every morning before breakfast Correct Answer Levothyroxine 0.1 mg PO every morning before breakfast What does the abbreviation SOF mean? Correct Answer Signature on file An EHR specialist is educating a newly hired staff member about safeguarding patient information in the EHR. What statement should the EHR specialist make? Correct Answer Biometric measurements are acceptable for individual identification for EHR system access What behavior should an EHR specialist identify as a threat to data security when transmitting electronic PHI? Correct Answer Sending an unencrypted email to a pharmacy What staff member should an be assigned access to authorize new prescriptions electronically in the EHR system? Correct Answer Providers Identify a term on the Joint Commission's "do not use" list of abbreviations: Correct Answer IU An EHR specialist is compiling a report for marketing. The EHR specialist should identify that which of the following is a secondary data source? Correct Answer Cancer registry An EHR specialist needs to create a financial report that shows a patient's financial status in detail as well as insurance payments that have been made to the provider and the amount the patient still owes. Which of the following reports should the EHR specialist use? Correct Answer Patient ledger An EHR specialist is assisting a provider to generate a report regarding patient health outcomes for the purpose of attestation for a new EHR system. Which of the following is used for this purpose? Correct Answer Clinical quality measures (CQM) An EHR specialist is generating a report for the Centers for Disease Control and Prevention (CDC) about the number of patients in the practice who have tested positive for measles within the past year. This is an example of which of the following types of data? Correct Answer Notifiable condition An EHR specialist is compiling data about patient immunization records to report to the public health department. Which of the following sources should the EHR specialist use to create the report? Correct Answer Immunization registries Which of the following data formats serves to eliminate ambiguity through the use of a standardized system of universally understood documentation and promotes system interoperability? Correct Answer Coded data An EHR specialist is preparing to generate a production report. The EHR specialist should use which of the following processes to verify the accuracy of the report? Correct Answer Internal Audit An EHR specialist is creating a scheduling report to bill all patients who missed their appointments for the day. Which of the following actions should the EHR specialist take to verify the information in the report? Correct Answer Create a no-show report An EHR specialist is researching the number of patient falls per year within the facility over the past 5 years. Which of the following health care initiatives is addressed using this data? Correct Answer Clinical quality improvement Which of the following elements of the EHR is required for eligibility in the Quality Payment Program (QPP) and promotes interoperability? Correct Answer E-prescribing Which of the following fields is included in a production by procedure report in the EHR system? Correct Answer CPT codes Which of the following reports should an EHR specialist run to determine the amount of money due to the organization from each individual patient or insurance carrier? Correct Answer Patient aging report Which of the following methods should an EHR specialist use to arrange information by procedure on the production by procedure report? Correct Answer Data sort An EHR specialist receives a request to generate a report for a patient's workers' compensation case. Which of the following actions should the EHR specialist take? Correct Answer Ensure that the patient's private health record is not included with their workers' compensation record Which of the following can be used to generate statistical information as an early warning for public health agencies? Correct Answer Syndromic surveillance A claim was denied for a recent surgery performed due to the allowance of another procedure that had already been adjudicated. Which of the following actions should the EHR specialist take? Correct Answer Submit a corrected claim with the appropriate modifier A provider entered one diagnosis on a superbill for services that required three diagnoses for a patient who has Medicare. Which of the following actions should an EHR specialist complete next in the EHR system if the claim has already been paid? Correct Answer Submit a Claim Adjustment Reason Code (CARC) Which of the following forms generated from the EHR would be given to a patient upon leaving a provider's office? Correct Answer Charge slip Which of the following codes is found in ICD-10-CM database? Correct Answer Acute bronchitis Which of the following should be included in a nonsufficient funds (NSF) letter? Correct Answer Check number Which of the following types of information is included when entering the Current Procedural Terminology (CPT) code form the superbill into the EHR system? Correct Answer Procedure Which of the following is a computerized service that converts data into a standardized, HIPPA compliant billing format transaction and checks for all diagnoses and procedural description errors in the EHR? Correct Answer Clearinghouse Which of the following detects and eliminates errors in billing codes prior to submission to the third-party payer? Correct Answer Claim scrubber how does the registration process begin in an outpatient setting? Correct Answer when a new patient calls the office for an appointment to see a provider. what does a front staff member do once they obtain information from a new patient? Correct Answer they create an account that includes the patient's identity, medical condition, and insurance/payment info. what does a front staff member do once they obtain information from an established patient? Correct Answer the staff member searches for the patient record by using demographic data once the data is verified, followed by a review and update of the patient's insurance or third party payer, and the guarantor on the account. what happens once the financial data is verified? Correct Answer the patient is given a NPP, and other documents like an advance directive and assignment of benefit forms. what is a notice of privacy practices (NPP) form? Correct Answer a document that is required by law to inform a patient how an organization will use their health care information. what is an advance directive? Correct Answer a legal document that contains information about a patient's treatment choices when they are unable to make health care decisions. what is an assignment of benefits form? Correct Answer a patient's authorization to allow health insurance payment to be made directly to the provider of service. how are patients registered in an ambulatory setting? Correct Answer the patient info is used to generate wristbands, which are used for identification and can display health info. what are color coded wristbands? Correct Answer they are used to alert providers of allergies, blood type, or DNR. what clinical information are entered by providers and support staff? Correct Answer review of systems, physical examination, diagnosis, and treatment are all included in an encounter note. what is internal data? Correct Answer it is recorded by providers(sometimes patients) during an encounter. what is included within internal data? Correct Answer financial information entered during scheduling and patient registration to enable reimbursement for services. what is external data? Correct Answer (digital images, lab results) often starts outside the office where the patient record lives. directing info into the patient's electronic record helps create complete record of the patient what is common to find in a fully integrated EHR environment? Correct Answer only electronic documentation of all patient care data, these organizations what if a provider requests a referral? Correct Answer a template can be used to enter the info for the referred provider to review. how can a patient present for inpatient admission? Correct Answer emergency department or surgery department also after an office visit or if a patient was transferred from another facility how does inpatient workflow begin? Correct Answer with recording demographic data and identifying the patient as an active care recipient in the system. what may physical, speech, and occupational therapists provide? Correct Answer rehabilitation services and document patient progress in the EHR. how are test results from laboratory diagnostics transmitted? Correct Answer from the LIS into the patient record to enable multiple providers to access data when making treatment or care decisions. the LIS interfaces with the EHR system to deliver results to the patient's record. how is laboratory testing batch processed? Correct Answer by entering info into an automated analytical instrument where the evaluation of the sample is completed. what do hospitals that have a radiology info system (RIS) commonly user? Correct Answer a PACS, picture archiving, and communication system to store and report results of diagnostic imaging. where are electronic orders entered by providers in clinics transmitted? Correct Answer to the RIS, and patient images are captures during a test. the image stored in the PACS is associated with the order in the RIS. a report is then generated from the radiologist's interpretation of the image, and the report is automatically transferred to the EHR. what are IT professionals enlisted to enable? Correct Answer interoperability and data exchange with other systems, it prevents delays in treatments. how is real-time data trasnmitted? Correct Answer from one unit to another, enabling users to make decisions of follow-ups to speed up delivery of care. observing standards or protocols also promotes safe transfer of data for quality, cost- effective care. Laboratory Information System (LIS) Correct Answer receive pathology orders & transmit results from the analyzer to EHR. -can also generate reports on laboratory results Computerized provider order entry (CPOE) Correct Answer enable valid ID to match the prescription with the patient. Practice management system (PMS) Correct Answer manages revenue cycle processes & appointments picture archiving and communication system (PACS) Correct Answer store images of diagnostic tests & interpretations of studies. Radiology Info System (RIS) Correct Answer transfer imaging orders & patient data to testing devices. how is training for clinical staff commonly administered? Correct Answer by trainers or staff from the IT department during the implementation phase. what do other organizations used to train staff? Correct Answer vendors as part of the functional testing of the system. how is training in organizations with multiple clinic locations? Correct Answer they are generally centralized, it is common to find trainers from the IT department *the patient's wrist band is also scanned to match the info on the eMAR. where are alerts like CPOE and non-coverage generated? Correct Answer they are coordinated to include info stored in LIS & PMS how do billing staff adjust the charge entry form? Correct Answer as appropiate to generate claims for reimbursement of services. what is the process of E&M with a provider? Correct Answer the provider reviews the diagnosis and procedure codes, accepts it, and signs off to complete the encounter documentation. the EHR system automatically transfers the info to the billing software or PMS, where the billing staff review and post the charges. *this minimized billing errors and discrepancies. what happens if there's an error in billing? Correct Answer the provider receives an electronic message to correct the error prior to billing. info in the electronic message will state a time within which the mistake or incomplete entry must be fixed. what does a personal health record (PHR) enable a patient to do? Correct Answer engagement in managing their health and conditions. a patient communicates with providers involved in decisions affecting their care. a patient has access to a patient portal to view their medical record. how do patients access their portal? Correct Answer a web link and instructions on how to register is given. what are patient portals designed to do? Correct Answer as a patient logs in and chooses a virtual office visit, it verifies identity and confirm coverage insurance copayments are collected, and once they are checked in for a virtual visit, they are prompted to complete clinical info, like history and reason for visit. all documentation is recored in real-time. what is the 3 year rule? Correct Answer a patient is determined "new" if they had a previous face-to-face service in the last 3 years from the date of service. how do health care organizations integrate paper documents into EHR systems? Correct Answer by scanning them as images, which are uploaded into the patient's EHR. ex: insurance cards are scanned into a system as well as other documents NPP, vaccine consent forms, etc, once the patient has reviewed and signed them. prevents fragmentation of patient's record how are scanners integrated in a clinical realm? Correct Answer faxed reports of diagnostic results (lab/imaging results) are scanned and uploaded into an EHR. scanned documents are labeled and coded with info that enables users to locate the, in the system. how can the process of image cataloging be automated? Correct Answer using barcoding or optical character recognition (OCR) software. what does barcoding do? Correct Answer it automatically labels the scanned image by document type, patient, and date, which makes the document easier for the user to locate. how can the optical character recognition be used? Correct Answer to find text within the scanned document, which is then stored within the image in the system. what's a downside with scanned information? Correct Answer it is often not searchable. what happens are a medication is scanned and verified in the computer? Correct Answer since bar code technology also makes charting easier, the user's login status serves as the signature for the eMAR. what does the focus of training ensure? Correct Answer that staff members understand the system and promote usability. what are clinical templates useful for? Correct Answer assisting providers and other clinical staff with charge capture, billing, and coding. how can users select common documentation elements? Correct Answer from checkboxes and dropdown menus. what can EHR vendors do? Correct Answer develop systems to meet the specific needs of an organization. the National Committee on Vital and Health Statistics Uniform Ambulatory Care Data consists of how many core elements which must be present in all ambulatory care records? Correct Answer 16 how many preloaded templates be in an outpatient setting? Correct Answer generic, or the EHR vendor may be able to customize templates for the practice. what must you do before creating your own template? Correct Answer check for system permissions. can you create customized templates in an INpatient environment? Correct Answer OFTEN not allowed what happens during the implementation phase? Correct Answer consultants and technical experts from the EHR vendor should be on-site to work with every department using the system to document workflow and ensure that templates support the organization. how do many organizations start the process of data capture? Correct Answer by asking patients to enter info about their medical, family, and social history, current medications, symptoms, and concerns. where can reports on specific quality measures (health maintenance, preventive care screenings) be sent? Correct Answer to the Centers for Medicare and Medicaid Services. can patients monitor their health status or share it with providers in their patient portal? Correct Answer YES what is a PHI? Correct Answer any information held or used by a covered entity or its business associates that identifies an individual. what are examples of covered entities? Correct Answer Healthcare providers/organizations, health plans, healthcare clearinghouses, & insurers. specifically: doctors, nurses, dentists, radiologists, laboratories, and pharmacies what doesn't apply to de-identified info used for marketing, staffing projections, or supply chain activities? Correct Answer HIPAA nor state privacy and security rules even if it is allowed under HIPAA, should a staff member still obtain written permission from a patient under the release of their PHI? Correct Answer YES what must all employees who view or use PHI do? Correct Answer sign a confidentiality agreement that ensure they are aware of their responsibility to maintain patient privacy and security. what do most inpatient documentation in the EHR consist of? Correct Answer nursing and provider notes. how can one assist providers to improve their documentation practices? Correct Answer by using EHR- generated reports about data such as number of open notes organized by provider and frequency of remote log- ins, along with observations and interactions. what is the basis of billing and payment for health services? Correct Answer clinical documentation(aka charting) -it is impt. for new patients, consultations, hospital admissions, and preoperative visits. what are included in the history component? Correct Answer chief complaint history of present illness review of systems past history family history social history what if a patient is not experiencing any of the symptoms the provider asks them in a review of systems? Correct Answer the provider checks a box corresponding to negative symptoms rather than clicking "normal." the values are automatically transferred to the ROS section of the encounter note. where are past, family, and social histories frequently entered? Correct Answer into EHR templates and stored in a separate history section. if for example, blood glucose levels in the patient's record are stored as discrete data in the EHR, what can you do? Correct Answer prepare reports as needed for the provider to show blood glucose values at the time of the office visit. how do outpatient visits occur. Correct Answer 1. if not an emergency, the patient arrives and is greeted at the office. 2. financial and demographic info are updated. 3. patients move to the clinical area and a nurse or med assistant updates any changes to meds, history, or allergies. 4. provider reviews patient's historical data and other data gathered into the encounter note. 5. provider interviews patient, records a SOAP note. 6. physical examination is followed. 7. provider synthesizes everything together and sets a plan for further evaluation and treatment. 8. provider links any relevant patient education material to the encounter and summarizes the encounter and follow- up plan with the patient. 9. the provider signs the documentation and the patient checks out. 10. the patient receives a follow-up reminder, summary of the visit, any relevant educational materials, and instructions for assessing the patient portal. where are vital signs and measurements documented? Correct Answer in the vital signs flowsheet of the EHR. they can then be viewed on graphs that follow trends in weight, bp, hr, & other data. what is the process of inpatient stays? Correct Answer same as OUT patient but between admission and discharge in which medical assistants, nurses, & providers gather info, it may be repeated many times. is the medical record up to date? Correct Answer YES, always, the most current info is accessible to all personal. what is the first step in helping an individual or organization adopt POC documentation? Correct Answer understanding the workflows and processes during a typical workday. -involve the clinical staff in workflow analysis -consider creating a flowchart showing each step needed to accomplish a particular task -encourage questions and comments about their individual workflow -spend time with individual members where do most difficulties encountered in POC EHR stem from? Correct Answer inadequate consideration of human factors. why is it not good to avoid using the designed system and looking for other ways? Correct Answer this is because workarounds that bypass the cumbersome workflow can also bypass associated functions critical to patient safety. when is it the ideal time to apply the principles of human factors engineering? Correct Answer when staff members are using workarounds. what contributes to the local success in an organization and global success for integration of EHRs into health care? Correct Answer Identifying workarounds and then finding system-based solutions that streamline the process what can a patient access on their online portal? Correct Answer a copy of their visit note, education materials, results, etc. how can providers locate codes at the POC? Correct Answer from a drop down menu, and coder responsibilities in the record supports the code assignment. what do encounter forms use? Correct Answer drop down menus and prepopulated lists. what does a built in software eliminate? Correct Answer eliminates potential communication problems. what versions are classification systems set in? Correct Answer electronic and a hard copy manual. when do you reference the ICD-10-CM index? Correct Answer first when searching for a code and review the tabular list to validate the accuracy of code assignment. how is the ICD-10-CM manual written? Correct Answer with specific formats and conventions that assist in coding (symbols, punctuation marks, notations, and abbreviations). when is code-first notation used? Correct Answer when two codes are used for one diagnosis. -a specific sequencing order with the underlying condition listed before the manifestation is required. what happens if only the manifestation code is entered on the claim form? Correct Answer the claim would be denied due to incorrect use of codes. what do you do when using ICD-10-PCS to locate procedures? Correct Answer reference the index first.. -the main term of the procedure will refer the coder to the appropriate table of the tabular, the table is used to build the code. how do you write a ICD-10-PCS code? Correct Answer 1. the first character matches the section where the procedure is classified(one of the 17 sections) 2. the 2nd-7th characters are defined by the section they are in. 3. any remaining characters where no other devices or qualifiers are used are Z. what's an example of a HCPCS level II code? Correct Answer A6412 (eye patch, occlusive, each) -this code is used when a patient receives an occlusive eyepatch, this level II code is submitted to the insurance carrier along with a CPT code as well. who develops, maintains, and owns the right to the copyright of the coding system? Correct Answer American Medical Association (AMA) How often is the CPT updated? Correct Answer Annually(every year) how do insurance carriers reimburse multiple procedures? Correct Answer the first procedure in full and following at a reduced rate, usually 50%-75% of the cost. does HCPCS codes guarantee a service will be rendered? Correct Answer although used for billing, NO which codes are specific to Medicare? Correct Answer G codes how often are HCPCS codes updates? Correct Answer 4x a year as they are public domain and can be located on the CMS website what did the CMS design in order to assist in controlling erroneous coding billed to Medicare and facilitate correct coding methods? Correct Answer NCCI, National Correct Coding Initiative -their edits are used in outpatient services and providers' offices. -according to Medicare, any claims denied under NCCI edits are not allowed to be billed to the patient. what do EHRs interface with insurance carriers for? Correct Answer eligibility verification another way is using a carrier's web-pased portal. why must you ask if a patient deductible applies when verifying benefits? Correct Answer because if the provider orders a lab or radiology service on-site, sometimes the patient does not have to pay the deductible. Precertification Correct Answer A process required by some insurance carriers in which the provider must prove medical necessity before performing a procedure. Preauthorization Correct Answer prior authorization from a payer for services to be provided. who might staff members contact to obtain authorization for treatment by specialty providers? Correct Answer the insurance carrier. what are patient cost estimates based on? Correct Answer price info in the chargemaster and payer contracted rates. when must you provide patients with an estimate of their health care costs? Correct Answer before services are rendered for a timely payment. when would an advance beneficiary notice need to be given to a fee-for-service beneficiary? Correct Answer when a service exceed the limitation of liability. what are sent to patients who have insurance? Correct Answer a monthly statement for any outstanding balance where are patient statements generated from? Correct Answer the financial or billing sections of the EHR. how often are patient statements processed? Correct Answer actively each month or coordinated by a 3rd party vendor or billing company that processes the organization's financial activities and records. what might some organizations omit from patient statements? Correct Answer some specific info, like diagnostic and procedure codes. can patients pay bills online? Correct Answer YES, they can also have electronic statements and reminders sent securely through a portal and reduce processing and mailing costs. how may automatic online bill payments be set up? Correct Answer to charge patient credit or debit cards, expediting payment receipt and eliminating check-writing and postage. how are payments to third-party payers usually made? Correct Answer by direct deposit to designated account for the health care organization. what does a single deposit usually represent? Correct Answer payments for multiple patient claims, so it must be divided into multiple patient accounts based on payments made for each payment. where are posting instructions take from? Correct Answer the RA/EOB, are claims paid at 100%? Correct Answer rarely what will payment posting not to? Correct Answer cover the amounts billed, which means additional accounting is required to ensure correct payment posting. what happens when payments are not correctly posted? Correct Answer the account will continuously have a balance. does a patient have to pay the deductible if they do not have surgery? Correct Answer NO, if they do have surgery, then the first $1,000 of allowed surgical charges are patient responsibility. -the insurance company will process the claim and apply the deductible amount to the patient. what is payment is denied, delayed, or ignored, or time limit has passed? Correct Answer contact the insurance company -if the matter is addressed over the phone, note the follow-up in writing, -posta copy of the note in the patient accounts, and in any tracking file or calendar. what do you do whenever an overpayment is made in error to a patient's account? Correct Answer note the activity on the appropriate patient account who do you direct any patient requests, questions, concerns, or grievances regarding PHI? Correct Answer to the privacy officer. what do user permissions prevent? Correct Answer unnecessary internal disclosures to limi the potential for data compromise from external sources. -it also may exclude or include the ability to download from the internet or allow software updates. what do EHR vendors provide training on? Correct Answer assigning user permissions. what does a system administrator or security officer assign? Correct Answer permissions as staff is onboarded or job responsibilities change. What is ransomware? Correct Answer A computer virus that encrypts a user's storage, until the victim pays money to unlock it with who may noncompliance with privacy and security policies occur among? Correct Answer IT and administrative personnel. who must all covered entities comply with? Correct Answer HIPAA to protect the privacy and security of health info and provide individuals with privacy rights in regard to their health info. is a business associate agreement required with diagnostic of laboratories working with an organization to treat patients? Correct Answer it is NOT needed what is not essential when dealing with a business associate agreement? Correct Answer to have one with anyone whose services do not use of disclose PHI or anywhere PHI could be accessed incidentally. upon registration, what are patients asked to do? Correct Answer sign an authorization form to release health info in certain situations when should consent for treatment be obtained? Correct Answer in both an in & outpatient setting. what is general consent for a treatment? Correct Answer it is an agreement that the organization may perform treatment and care for the patient. what is consent for surgical procedures? Correct Answer the specialty provider must obtain informed consent prior to delivering the care. what is required when the provider covers the consent info and ensures the patient signature is documented? Correct Answer a witness. what will the organization complete for claims of submission, typically electronically? Correct Answer a CMS-1500 or a UB-04 form. what must you have the patient fill out? Correct Answer authorization forms to bill for services and ensure the provider signs it to keep it on file. -the third-party payer or insurance company will be informed that the patient authorized the provider to receive insurance payments directly. what can the provider indicate when submitting claims for reimbursement? Correct Answer a "Signature on File" (SOF). -this saves time and reduces paperwork and encourages payers not to hold up reimbursement due to an outstanding new signature with every claim. what can one signature on file do? Correct Answer remain in place for future claims. -health care organizations often update patient signatures annually. how quick can an organization be back and running? Correct Answer depending on the downtime cause, as little as a few hours. what must a provider's documentation during a patient's visit be complied into? Correct Answer text format to create an encounter summary report. which information is collected to produce structured reports? Correct Answer info recorded using