Course 6: Billing

Question 1

Discharged Home (DC’D): Document (5)

Answer 1

1. Follow-up
2. Time period in which to follow-up.
3. Specific conditions for return to the ED (specific emergency sx to return for)
4. “Stable for discharge”.
5. Time of disposition

Question 2

Admitted: Document (5)

Answer 2

1. Admitting physician: ED physician will consult another physician to admit.
2. Patient condition: physician will give “good, fair, serious, critical.”
3. Time of consult with admitting physician
4. Admission location- where transported to (which section of hospital)
5. Admission time

Question 3

Transferred: Document (4)

Answer 3

1. “Patient stable for transfer.”
2. Time of consult with accepting facility: document TIME and NAME of person spoken to, NAME of accepting physician, and “they will accept this pt in transfer”.
3. “ED records accompanying pt”: ED records sent with pt, i.e. your chart needs to be done.
4. “Appropriate mode of transfer arranged.”

Question 4

Level 5 Care Elements

Answer 4

HPI= 4 elements
ROS= 10 elements
PMH/SH/FH=2 elements
PE = 8 elements

Question 5

Level 5 HPI

Answer 5

4 Elements:

location, quality, timing, severity, duration, assoc sx, modifying factors, context

Question 6

Level 5 ROS

Answer 6

10 Elements:
Const.
Eyes
ENT
Cardiovascular
Respiratory
GI
GU
Musculoskeletal
Neurological
Integumentary
Hematological
Lymphatic
Immunological
Psychological 

-OR- 2 Elements and “all systems neg”

Question 7

Level 5 PMHx

Answer 7

2 Elements:
Past Medical/Surgical Hx
Social Hx
Family Hx

Question 8

Level 5 PE

Answer 8

8 Elements (or 8 dif organ systems)
Const.
Eyes
ENT
Cardiovascular
Respiratory
GI
GU
Musculoskeletal
Neurological
Integumentary
Hematological
Lymphatic
Immunological
Psychological

Question 9

Caveats to the Level 5 Elements (6)

Answer 9

Respiratory Distress
Unresponsiveness
Clinical condition
Dementia
AMS
Limited cognitive ability 

“Unable to obtain a complete __ due to __” in EACH section independently.

Question 10

Level 5 MDM

Answer 10

Old records ordered and results
lab and radiology orders and results
consults
discussions with pt/family
multiple DDx
Multiple final Dx
References to lab/rad results
meds and treatments in the ED
multiple re-evals
arranging follow-up
discussion of specific risks

Question 11

Additional Documentation: CCT

Answer 11

Min of 30 min

Question 12

Additional Documentation: Pulse Ox Interpretation

Answer 12

Normal or hypoxic

Question 13

Additional Documentation: Xray interpretation

Answer 13

Record # OF VIEWS, as well as “interpreted by EP”.

Include 3 findings.

Question 14

Additional Documentation: EKG Interpretation

Answer 14

Must have RATE, RHYTHM, and 2 OTHER FINDINGS

Question 15

Additional Documentation: ED Procedures

Answer 15

Commonly missed are Splint applications, laceration repairs, bedside ultrasounds, and foreign body removals

Question 16

Abnormal Vital Signs for CCT

Answer 16

HR: Normal 60-100 ; Abnormal 120 (Adults)
BP: Normal 90/60 - 140/90 ; Abnormal less than 80/– or greater than 180/–
O2 Sat: Normal 96% + on RA ; Abnormal less than 90%
T: Normal 97 to 99. Fever is greater than 100.4 F. ; Abnormal 104

Question 17

Common O2 Routes (4)

Answer 17

1. Room Air (RA)
2. Nasal Cannula (NC) - usually 2 LPM (liters per min)
3. Facial Mask (FM) - set from 6 to 15 LPM
4. Non-rebreather mask (NRB): reservoir bag attached, 10-15 LPM

Question 18

CCT O2 Routes (4)

Answer 18

1. Continuous Positive Airway Pressure (CPAP)
2. Biphasic Positive Airway Pressure (BiPAP)
3. Bag-Valve-Mask (BVM)
4. Endotracheal Tube (ETT)

Question 19

Core Measure: Acute MI

Answer 19

“Aspirin 324 mg given at arrival”

Question 20

Core Measure: Chest Pain (non-traum)

Answer 20

“12-Lead EKG performed in ED”

Question 21

Core Measure: Syncope

Answer 21

“12-Lead EKG performed in ED”

Question 22

Core Measure: CVA

Answer 22

Document “Last Known Well” date and time.

Document tPA eligibility (within 3 hours of onset).

Question 23

Core Measure: PNA

Answer 23

Document vital signs, O2 Sat, Mental Status
Document abs selection and timing
Document BCx

Question 24

Core Measure: Acute PE

Answer 24

“Anticoagulation (heparin) ordered.”

Question 25

Core Measure: Acute Otitis Externa

Answer 25

"Topical therapy. Pain assessment. Avoidance of PO (systemic) abx"

Question 26

Core Measure: Abdominal Pain- Female Pt

Answer 26

"Pregnancy test (uHCG) was ordered."

Question 27

Core Measure: Pregnant Abdominal Pain

Answer 27

"US was ordered to determine the location of the pregnancy (r/o ectopic)."

Question 28

Core Measure: Pregnant and Rh Neg

Answer 28

"Rhogam was ordered."

Question 29

Core Measure: Central Line Placement

Answer 29

"Sterile technique: cap, mask, sterile gown, sterile gloves, sterile sheet, hand hygiene, 2% chlorohexidine"