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18 Cards in this Set
- Front
- Back
- 3rd side (hint)
What are the four required documentation items in the record for a specific DOS.
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Patient Name
DOS Provider Signature written or EMR Rendering provider credentials |
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What type of diagnosis may not be coded.
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History of codes
Exception, amputation, old MI |
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May the DOS be obtained from a face sheet or lab report?
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no
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Dos may be obtained from a face to face visits.
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If there are more then one encounter on a page does the patient name have to be on each encounter?
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no
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As long as the patients name is on the page, it can be used for the other encounters on the same page.
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If a DOS is altered, what are the requirements for it to be a valid correction of the DOS
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The DOS has to be initialed and dated.
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If there is an addendum to a record, the addendum has to be dated?
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With in 30 days of the orginal visit.
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d02, " No provider Signature" can NOT be used with what d0 codes?
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d25, d26 and d27
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A digitalized signature on and EMR record does not require a date true or false
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true
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A 2009 chart would be reported how?
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DOS 12/31/1999 and c06
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The current submission period is? (DOS range).
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2011-2012
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If we were missing part of the chart, no plan or assessment pages we would?
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List DOS 12/31/1999 and c06
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A active cancer treatment period would be described as?
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Current CA treatment 5 yrs or less.
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If the signture was a squiggy line but no credential would we use eo code d09 and d02?
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No, only one of them, d09 or d02 n ot both
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The abbreviation MEAT stands for?
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Monitored
Evaluated Assesed Treatment |
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When can HCCs be coded from a list?
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From the discharge summary.
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IDDM
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Insulin dependent diabetes mellitus
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CKD
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Chronic Kidney Disease
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CAD
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Coronary artery disease
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