A 6-month-old infant, born prematurely, presents for his monthly injection for RSV. The nurse documents Synagis 40 mg, IM. Which of the following code sets is correct for reporting this office visit?
90378 Respiratory syncytial virus, monoclonal antibody, recombinant, for intramuscular use, 50 mg, each
90471 Immunization administration (includes percutaneous, intradermal, subcutaneous, or intramuscular injections); 1 vaccine (single or combination vaccine/toxoid)
96372 Therapeutic, prophylactic, or diagnostic injection (specify substance or drug); subcutaneous or intramuscular.
99212 Office or other outpatient visit for the evaluation and management of an established patient, which requires at least 2 of these 3 key components; a problem focused history; a problem focused exam; straightforward medical decision making. Counseling and/or coordination of care with other providers or agencies are provided consistent with the nature of the problems and the patient's and/or family's needs. Usually, the presenting problem(s) are self-limited or minor.
J1459 Injection, immune globulin (privigen), intravenous, non-lyophilized (e.g. liquid), 500 mg
99212, 90378, 96372
90378, 96372
99212, J1459
90378, 90471
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Terms in this set (35)
Which of the following best describes the most important function of the health record?
storing patient care documentation
Which of the following HIM tasks is eliminated by the electronic health record system?
assembly
Reviewing the health record for missing signatures, missing medical reports, and ensuring that all documents belong in the health record is an example of what type of analysis?
quantitative
The coding of clinical diagnoses and healthcare procedures and services after the patient is discharged is what type of review?
retrospective
Which filing system is best suited for a small healthcare facility such as a one-physician practice?
alphabetical filing system
The release of information function requires the HIM professional to:
Disclose patient identifiable information to a third party
In which of the following systems does an individual receive a unique numerical identifier at the time of first encounter with a healthcare facility and maintain that identifier for all subsequent encounters?
Unit numbering system
clinical professionals who provide direct patient care are _______ users of health records
primary user
A record not completed within the time frame specified in the medical staff rules and regulations is called a ____________.
delinquent record
Which of the following should be taken into consideration when designing a health record form?
including original and revised dates
File the record alphabetically by the last name, followed by the first name, and then the middle initial.
alphabetical filing
Which of the following is a micrographic method of storing health records in which each document page is placed sequentially on a long strip?
microfilm roll
what filing method is considered the most efficient?
terminal digit filing
which of the following indexes is key to locating a health record?
master patient index
29. An addendum to the health record should be dated _____.
the day the addendum was created
which of the following elements is typically found in the paper health record
patient identification
why should the copy and paste function not be used in the electronic health record?
the content may contain outdated information
what committee oversees the development and approval of new forms for the health record?
health information management committee
what is the software that is used for voice recognition known as
natural language processing
Critique this statement: Version control is not an issue in the EHR.
There are issues related to versions of documents, such as there must be a flag to indicate a previous version.
Dr. Smith wants to use a lot of free text in his EHR. What should be your response?
Dr. Smith, we recommend that you use little, if any, free text in the EHR.
Which of the following is a secondary purpose of the health record?
support for research
Which of the following is a disadvantage of alphabetic filing?
Uneven expansion in file shelves or cabinets
Which of the following is a request from a clinical area to charge out a health record?
requisition
"The number of patients discharged has increased 175% over the past year." is an example of:
information
What would be the linear filing inch capacity for a shelving unit with 6 shelves, each measuring 36 inches?
216 inches
A quantitative review of the health record for missing reports and signatures that occurs when the patient is in the hospital is referred to as a _______ review.
concurrent
In which department or unit does the health record typically begin?
patient registration
The term used for health record moved to an inactive file area because they have not been at the healthcare facility for a predefined period of time is:
Purged
Our transcription is performed by a company outside of our organization. What is this called?
Outsourcing
Calculate the number of shelving units required for 35,000 linear filing inches of records if the shelving unit has 7 shelves and is 36 inches wide
139
Which of the following is an argument against the use of the copy and paste function in the EHR?
inability to identify the author
Which of the following assists in locating misfiles in the paper-based filing systems?
color coding
Which one of the following are included in a list of institutional users of the health record?
blue cross blue shield
The patient registration department assists the HIM department in what way?
assigning the health record number
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