Pills and Potions
This class of medications is commonly prescribed for bacterial infections.
What are antibiotics?
This prefix means “inflammation of.”
What is -itis?
What is the note routing expectation for tenured CIS?
What is 24 hour turnaround?
This vital sign is considered hypotensive when it drops below 90/60 mmHg.
What is blood pressure?
E&M stands for this.
What is Evaluation & Management?
Metoprolol, atenolol, and propranolol belong to this class of medications.
What are beta-blockers?
Bradycardia refers to a heart rate that is _________.
What is slow?
AT LEAST, what tab(s) should be open when documenting a patient encounter?
What is..
1. GWY note!!
2. Abridge, if applicable
3. Canopy ?
This lab test measures kidney function by assessing creatinine levels.
What is a BMP or CMP?
This OSH-given tool can be used to capture the length of non-WRV visits.
What is Abridge?
This common pain reliever is known for its anti-inflammatory properties.
What is ibuprofen?
This medical term means “difficulty breathing.”
What is dyspnea?
CDR prep should be completed during this time.
What is (at least 1)
1. Admin time
2. Down time not spent completing other tasks
3. CDR prep time, admin day the week before CDR.
This common vital sign measurement is abbreviated as "HR" in the medical record.
What is "heart rate"?
The two primary components used to bill an E&M visit are medical decision-making and this.
What is time?
Warfarin and apixaban are used to prevent this condition.
What are blood clots?
Hematemesis is the medical term for vomiting this substance.
What is blood?
Before EOD, what are the expectations for note completion? I.E. What parts of the note should be completed?
What are scribe disclaimer, HPI, and clicked diagnoses in the assessment?
The most common cause of non-traumatic chest pain.
What is GERD?
These activities that are completed outside of the patient's encounter count towards E&M billing. (Name 3)
What is...
Preparing to see the patient (e.g., review of tests)
Obtaining and/or reviewing separately obtained history
Performing a medically necessary appropriate examination and/or evaluation
Counseling and educating the patient/family/caregiver
Ordering medications, tests, or procedures
Referring and communicating with other health care professionals (when not reported separately)
Documenting clinical information in the electronic or other health record
Independently interpreting results (not reported separately) and communicating results to the patient/family/caregiver
Care coordination (not reported separately)
This over-the-counter medication is commonly used to reduce fever and relieve mild to moderate pain but does not have anti-inflammatory properties.
What is acetaminophen?
The suffix “-algia” refers to this symptom.
What is pain?
The importance of real-time documentation is..
*Answers may vary* Up to SCIS discretion.
What are the kidneys?
*Double Jeopardy!*
Picture this: A patient is seen for a WRV. The provider discussed all of the patient's chronic conditions, screening and vaccinations, ACP, and acute knee pain from a recent fall. The visit lasted 50 minutes, with 10 minutes used to discuss the patient's knee pain. This is how you should document in the E&M and superbill.
What is
1. Update E/M section: click 'yes' for time based visit. Enter "10 minutes" in "time spent with patient". Press calculate and make sure the E&M codes match.
2. Keep the office outpatient visit code code and add "25".
3. Map the annual visit code.