Which of the following is an alert that might appear as a pop-up window when accessing a patient's electronic health record?
Allergies
Illnesses
Hospitalizations
Surgeries
The Correct Answer is A
A. Allergies: Allergy information is crucial for preventing adverse reactions to medications and treatments, so it often appears as a pop-up alert in electronic health records (EHRs) to ensure that healthcare providers are aware of any potential risks.
B. Illnesses: Illnesses are typically documented in the patient's history, but they do not usually trigger a pop-up alert unless they are related to specific critical conditions or current treatment concerns.
C. Hospitalizations: Hospitalization history is important but is typically found in the patient's medical history section rather than as an immediate alert in the EHR.
D. Surgeries: Surgical history is generally noted in the patient’s medical history, and while important, it does not usually appear as a pop-up alert unless it directly impacts current treatment.
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Correct Answer is A
Explanation
A. Choose procedure codes based on the encounter form. The encounter form, also known as a superbill, lists the procedures and services provided during the visit. The correct procedure codes (CPT codes) should be selected from this form to ensure accurate billing.
B. Upcode for greater reimbursement. Upcoding, or selecting a higher-level code than justified, is illegal and unethical as it constitutes fraud. This should never be done.
C. Refer to ICD-9 for diagnostic codes. ICD-9 codes have been replaced by ICD-10 codes, which are now the standard for diagnostic coding in the United States. Referring to ICD-9 codes would result in incorrect or outdated billing.
D. Enter all data using lowercase letters. Data entry in all lowercase letters is not a standard practice in medical billing and would not affect the accuracy of the codes. Proper case usage is typically recommended for clarity.
Correct Answer is C
Explanation
A. Biannually: Biannual exams may not be frequent enough to monitor for diabetic retinopathy or other eye complications associated with diabetes. Annual exams are recommended.
B. Every 5 years: Waiting 5 years between exams is too long, as eye complications from diabetes can develop rapidly.
C. Annually: Annual dilated eye exams are recommended for patients with diabetes mellitus to monitor for diabetic retinopathy and other complications, allowing for early detection and treatment.
D. Every 10 years: A 10-year interval is far too long and could result in the progression of untreated eye disease, which could lead to blindness.