Procedures
When do you need to order a surgical tray?
When you use the following instruments:
Forceps, hemostat, scalpel
AKA when you see anything shiny, order a surgical tray
Wound repair/ I&D
Which in house order can have a capillary or a venous blood draw?
Monospot
What are the two places you need to document an occult test?
1) In the lab section.
2) In the exam section.
In your own words, how do you complete the XR documentation?
1) order the correct XR
2) get the provider interpretaion
3) Upload Overread
4) Either click the agree or disagree with the overread
What is the correct chart code: 3,4, or 5 on the following patient?
New patient with diagnosis of allergies, told to take Flonase and daily antihistamine.
3
What is the correct amount of numbers in the NDC code?
5-4-2
In the new tricore system when ordering an outside lab, what do you need to make sure is in the chart prior to ordering?
Diagnosis
How do you inform the lab that the patient is ready to DC?
Either
1) Write it on the note section
or
2) Verbally tell the lab
If your provider is signing off on a ultrasound study, who do you give the finished signed paper to?
The radiologist working that day.
What is the correct chart code: 3,4, or 5 on the following patient?
An established patient with diagnosis of allergies told to take Flonase and daily antihistamine.
4
What is the difference between a simple laceration, intermediate laceration, and a complex laceration?
Simple- clean, one layer
Intermediate- dirty, one layer
Complex- multiple layer
Why is ordering a D-dimer, Troponin different from ordering other outside labs?
Needs to order stat
Name a justifying diagnosis for IV hydration.
Dehydration, tachycardia, nausea/ vomiting
What is the process to ordering an ultrasound?
1) Find the correct CPT code in the binder and type it into the CPT code search bar in the procedure section.
2)Order a referral with the correct US and where it will be done at.
3) Tell the radiologist that you are ordering an US.
4) diagnose the patient with a workup and print them out to discharge the patient, then get out of the chart
5) When radiologist is done in the chart get back in and then you can finish the note.
What is the correct chart code: 3,4, or 5 on the following patient?
New patient comes diagnosed with R arm strain and while in clinic had a forearm XR and given 400 mg of ibuprofen. Told to use RICE, ibuprofen/ Tylenol, heat and ice.
4
Which procedure would you document an I&D of a leg.
I&D- deep extremity
When getting a gonorrhea/ chlamydia via swab in a female, what specific type of swab do you need to order?
cervical swab
Thuy Nyugen
Sydney Brito
What's wrong wit the following chart:
A new patient comes in with diagnosis of R conjunctivitis given Ezithromycin. The patient in clinic has a visual acuity screening which was normal. The chart was coded at a 4.
The visual acuity needs to be diagnostic not screening.
What is the code for critical care?
99291
Name all the labs in the STD panel?
Treponema, BV/vag swab, Hep b Ab, Hep b Ag, Hep C Ab, HIV, gonorrhea/ chlamydia
When are the chart review meetings?
Every other Wednesday.
What box do you uncheck when you order an outpatient image that we cannot do in clinic such as a CT?
code
Troubleshoot the following chart.
Established patient diagnosed with chest pain, SOB. Went to the ER for possible STEMI. Scribe correctly selects potentially life threatening illness, orders a referral, and changes disposition to ER transfer. But, the chart remains a 4. What did the scribe miss?
Differentials