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You Be The Coder: November

Test your medical terminology knowledge! Can you match up the appropriate numbers from 1-10 that correspond to each of the medical terms? Visual exam of the urinary bladder Deficiency of red blood cells Pain in joint Inflammation of the small intestine Benign tumor of gland High blood sugar Removal of Kidney Red blood cell Removal…

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You Be The Coder: October

Can you identify what these medical abbreviations stand for? DOE ICP LBW NST PUD PWB AFB LUE NVD PAT Answers:  Dypsnea on Exertion Intra Cranial Pressure Low Birth Weight Non Stress Test Peptic Ulcer Disease Partial Weight Bearing Acid Fast Bacilli Left Upper Extremity Nausea, Vomiting, Diarrhea Paroxysmal Atrial Tachycardia

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Compliance Corner – October

If a patient is deceased, may a covered entity disclose to a family member who was involved in the patient’s care or payment for healthcare prior to the death, PHI of the deceased? Answer: Yes, unless there is an expressed statement to the contrary. (45CR 164.510)

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You Be The Coder: September

How many physical examination elements can you extract from this documentation? VS: 124/80, Pulse: 74, Weight: 174 pounds CTA A&Ox3 No CCE Answer below:   Answer: Six Constitutional – Vital Signs Respiratory – Clear to Auscultation (CTA) Psych – Alert and Oriented X 3 (A&Ox3). No CCE; (Clubbing, Cyanosis, Edema) Musculoskeletal (Clubbing) Cyanosis (Skin) Edema…

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Compliance Corner: September

What are the 3 core health activities where a covered entity could disclose a patient’s PHI? Answer: The core health care activities of “Treatment,” “Payment,” and “Health Care Operations” are defined in the Privacy Rule at 45 CFR 164.501.

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You Be The Coder: August

What would the correct CPT code assignment be for this scenario? A male patient, 54 years of age, comes in on May 3, 2014 for a scheduled transurethral resection of the prostate (TURP). The patient had an initial TURP back in August 2012 but is still experiencing difficulty voiding. A. 52601 B. 52648 C. 52630…

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Compliance Corner: August

Define the principle of “minimum necessary”? Answer: a covered entity must make reasonable efforts to use, disclose and request only the minimum amount of PHI needed to accomplish the intended purpose of it’s use

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You Be the Coder: July

Test your knowledge The Advanced Beneficiary Notice of Non-coverage (ABN)  A 67 year old Medicare patient comes into the office for a cosmetic skin procedure. The following day the billing office staff checked and found the reason for service was not medically reasonable as per the Local Coverage Determination. The patient had not been made…

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You Be the Coder: June

38 year old Female presented to the office for scheduled Essure sterilization. Patient identified, local anesthesia administered and the patient was placed in dorsal recumbent position. The physician uses a speculum to open the cervix and then places the hysteroscope to carry the coils into the fallopian tubes. Multiple attempts were taken to place the…

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