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Exam 10: Auditing

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Question 41

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An examination that involves one or more organ systems or body areas is called a: A)general multisystem exam. B)general organ system exam. C)single organ system exam. D)multibody-area exam.

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general mu...

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Question 42

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List the body areas recognized by the CPT book for reporting the level of exams.

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Body areas include head, neck,...

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Question 43

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What is the purpose of an audit tool?

If a physician considers findings from discussions with family members in his or her medical decision making, documentation in the chart can simply state "additional history obtained from family" without providing additional detail.

An audit tool utilizes number counts in different categories to determine if the correct evaluation and management (E/M) code was used in billing an insurance carrier.

In documenting a medical examination, all of the following are recognized organ systems EXCEPT the: A)eyes. B)ears, nose, mouth, and throat. C)head, including face. D)skin.

An internal audit will NOT be able to help a practice discover lost revenue.

Match the following:

If a patient states that the pain he or she is experiencing is burning, the element he or she would be describing is the: A)associated signs and symptoms. B)severity. C)context. D)quality.

An inventory of body systems obtained by asking the patient a series of questions is called a(n) __________ .

If a physician examines the system directly related to the problem plus two to nine additional systems, the review of systems (ROS) would be considered: A)problem pertinent. B)extended. C)complete. D)none of the above.

An independent audit should be performed a minimum of: A)once a month. B)once a quarter. C)twice a year. D)once a year.

The most extensive type of history is: A)problem focused. B)expanded problem focused. C)comprehensive. D)detailed.

A prospective audit would typically be done on claims that require an attachment or more information.

If a chart note documents that the patient has smoked two packs of cigarettes every day for the past 10 years, it would be an example of the patient's: A)past history. B)family history. C)social history. D)history of present illness (HPI).

If a patient presents with an acute or chronic illness that poses a threat to life or body function and requires emergency surgery, the level of risk involved with the medical decision making would be considered: A)minimal. B)low. C)moderate. D)high.

If a patient states that the pain he or she is experiencing is in the right arm, the element he or she would be describing is the: A)location. B)severity. C)context. D)quality.

What are the elements considered in medical decision making?

In general, medical decision making with respect to a diagnosed problem is harder than that for an identified but undiagnosed problem.

An audit done by a practice before submitting a claim to an insurance company would be referred to as a(n) __________ audit.