SUCCESS TO THE PEAK

What is documentation? - the record of clinical observations and care a patient receives at a health care facility. It is used to communicate relevant patient information among health care professionals. It also serves as the basis of info conveyed to third party (insurance Medicare and Medicaid) payers who are responsible for reimbursing providers. Disclosure refers to the way health information is - disseminated from a covered entity or its Business associate BA to an outside person or or...

Differentiate essential hypertension and secondary hypertension – -Essential hypertension (primary hypertension): cause of the increased blood pressure is unknown. -Secondary hypertension: elevated blood pressure is caused by another disease. Sites of action of major antihypertensive medications – the brain, heart, blood vessels, and kidneys

9. Minimum Data Sheet (MDS) - Gives background and demographic info on the point as well as their communication level. The nurse fills it out- we need to make sure what they say about their communication matches our notes

10. Paramedics transported a 50-year-old female patient from a house fire to the Emergency Department without any obvious burns. She is covered in soot, coughing, and reporting nausea and anxiety. The emergency department provider plans to treat the patient for possible cyanide poisoning. In addition to oxygen, what medication should the nurse anticipate administering? - Hydroxocobalamin

When it is documented that the patient is both using tobacco and has a dependence on tobacco, hos is this reported in ICD-10-CM? - The dependence on tobacco is the only code reported based on the hierarchy in the ICD-10-CM guidelines. What does MRSA stand for? - Methicillin Resistant Staphylococcus Aureus

Downcoding - the document does not justify the level of service Most common billing errors - Billing non-covered services Billing over limit services Upcoding Downcoding Billing without signatures Using outdated codes

When we are not given more information as to a specific type of tumor, whether its benign or malignant, what do we code it as? - Unspecified Behavior When it is documented that the patient is both using tobacco and has a dependence on tobacco, hos is this reported in ICD-10-CM? - The dependence on tobacco is the only code reported based on the hierarchy in the ICD-10-CM guidelines. What does MRSA stand for? - Methicillin Resistant Staphylococcus Aureus

NEC - Not Elsewhere Classifiable - can be used in two instances: 1) not enough info available to determine which specific diagnosis code should be used in situations where ICD-9 provides very specific diagnoses. 2) The coder has specific information about the diagnosis that is not an option in the choice of ICD-9 codes

13. Lean Six Sigma - Combines Six Sigma with concepts of "lean" thinking, focusing process improvement on strategic goals rather than on a project-by-project basis. This type of program is driven by strong senior leadership that outlines long-term goals and strategies. The basis is to reduce error and waste within the organization through continuous learning and rapid change. Characteristics include: • Long-term goals with strategies in place for one- to three-year periods. • Performance...

A 36-year-old man presents to the emergency department with a tight bandage around his chest to help reduce pain from a chest wall injury on his right side that occurred during mixed martial arts sparing. Physical exam reveals dullness to percussion, dry crackles and diminished breath sounds over the right lower lobe. Chest x-ray shows elevation of the right hemi-diaphragm. What is the most likely diagnosis? A Atelectasis B Bronchiectasis C Pleural Effusion D Pneumothorax E Pulmonary ...