A patient is scheduled for an orthopedic consultation. The medical assistant should ensure the health record includes which of the following?

A. Choose procedure codes based on the encounter form. The encounter form, also known as a superbill, lists the procedures and services provided during the visit. The correct procedure codes (CPT codes) should be selected from this form to ensure accurate billing.
B. Upcode for greater reimbursement. Upcoding, or selecting a higher-level code than justified, is illegal and unethical as it constitutes fraud. This should never be done.
C. Refer to ICD-9 for diagnostic codes. ICD-9 codes have been replaced by ICD-10 codes, which are now the standard for diagnostic coding in the United States. Referring to ICD-9 codes would result in incorrect or outdated billing.
D. Enter all data using lowercase letters. Data entry in all lowercase letters is not a standard practice in medical billing and would not affect the accuracy of the codes. Proper case usage is typically recommended for clarity.

A. Implied: Implied consent is assumed in certain situations where immediate treatment is necessary and no formal consent is given, but it does not involve a detailed explanation of risks and benefits.
B. Informed: Informed consent requires that the provider fully explains the risks, benefits, and alternatives of a treatment plan to the patient, ensuring the patient understands and agrees to the plan.
C. Indirect: Indirect consent is not a recognized term in medical consent practices.
D. Implicit: Implicit consent refers to situations where consent is assumed based on the patient's actions, rather than a detailed explanation of risks and benefits.