Relational database structures - ANSWER An entity relationship diagram was developed to depict A data map or crosswalk consists of: - ANSWER Terms used to describe paths between classifications and vocabularies An object-oriented database contains: - ANSWER Data and their relationships within a single structure Structured query language - ANSWER The most common language used for both data defintion language and data manipulation language Manipulation CPT - ANSWER Is the same as "Reduction" in ICD9 Outpatient Prospective Payment System (OPPS) began - ANSWER To be used for Medicare in August 2000. Ambulatory Payment Classification (APCs) - ANSWER Reimbursement for hospital-based outpatient services such as outpatient surgery, emergency department visits, outpatient clinic visits, and outpatient ancillary tests. How are APCs similar to MS-DRGs? - ANSWER They are both prospective payment methodologies and both have relative weights How are APCs different from MS-DRGs? - ANSWER Outpatients can have multiple APCs for a given encounter, whereas an inpatient can have only one MS-DRG. What services are generated with APCs? - ANSWER X-rays, medical tests, clinic or emergency visits, surgical procedures, devices, drugs and biologicals, and parital hospitalizations. What is the billing number in APCs? - ANSWER The billing number is the connecting identifier for a given patients encounter that results in multiple APCs. Case Mix - ANSWER A description of patient population based on any number of specific characteristics, including age, gender, type of insurance, diagnosis, risk factors, treatment received, and resources used. Case-mix index - ANSWER The average relative weight of all cases treated at a given facility or by a physician, Case Mix Index - ANSWER Is the average of all weight together with highest sum. Ex: 3.7533÷3=1.2511 Case Mix - ANSWER Is all the weights add together. Ex: 0.7870 + 1.1510 +1.4653= 3.7533 Medical Staffbylaws - ANSWER The requirements for documentation and record completion (documents such as history and physicals, discharge summaries, and consultations) as well as penalties for nonaherence must be specified. Data Quality - ANSWER Ensuring the accuracy and completeness of an organization's data. A method of checking the accuracy of data is to: - ANSWER Ensure that each record or entry within the database is correct. When applying AHIMA's 10 data characteristics to a patient encounter, a data quality checkpoint for data timeliness during medication reconciliation would be: - ANSWER Ensuring a standardized formulary. Before an organization can measure the quality of information it produces it must: - ANSWER Establish data standards within the organization. E/M example for hospital acuity points assignment? - ANSWER Number of test ordered, supplies used, medication given. Most Hospitals require a medical record is completed within - ANSWER 30 days To correct an entry in the record, the provider should: - ANSWER Draw a single line through the error, add a note explaining the error, initial and date, add the correct information in chronological order. After a patient is discharged from the Hosiptal, the medical record must be reviewed for: - ANSWER Certain basic reports (for example H&P, discharge summary, etc.) According to CPT, an endoscopy that is undertaken to the level of the mid transverse colon would be coded as a: - ANSWER Colonoscopy Iatrongenic - ANSWER Of or relating to illness caused by medical examination or treatment A patient is admitted with hypotension due to dobutamine taken, administered, and prescribed correctly. How should this be coded? - ANSWER 458.29, other Iatrongenic hypotension and E941.2, Adverse effects of dobutamine Pseudoaneurysm usually occurs at the site of previous vascular surgery or: - ANSWER Vessel puncture, which occurs secondary to rent or defect in the vessel. Ex: The vessel was intentionally punctured in order to accomplish the procedure. If a patient is admitted with pneumococcal pneumonia and pneumococcal sepsis, the coder should:H - ANSWER Assign a code for the sepsis, pneumonia, and SIRS