Medical Documentation & Coding Compliance
Practice Exam: CPT®, HIPAA & Hospital Standards|
Complete Exam Questions Verified with Answers
Graded A+ Latest Updated 2026
Documentation standards are classified into the following categories:
a. Patient specific data and information
b. Additional standards for specific patient populations, for example, operative/invasive
procedures, ambulatory care, emergency, clinical trials, etc.
c. Inpatient or Outpatient
d. a and b
d.
According to the CMS Transmittal A-03-021, which of the following does NOT meet
specifications for verification of an electronic signature in the hospital setting?
a. A system in which the physician signs off against a list of entries that must be verified in the
individual record.
b. Computerized systems that require the physician to review the document on-line and
indicate that it has been approved by entering a computer code.
c. A mail system in which transcripts are sent to the physician for review, and then he or she
signs and returns a postcard identifying the record and verifying its accuracy.
d. A system of auto-authentication in which a physician or other practitioner authenticates a
report before transcription.
d.
What is the unit of measurement for coding the length of lacerations?
a. Inches
b. Square centimeters
c. Square inches
d. Centimeters
d.
, When coding an operative report, do NOT:
a. Use a copy of the operative report.
b. Code from the Postoperative Diagnosis and Title of the Operation listed.
c. Code for lysis of adhesions when it is related to another procedure.
d. b. and c.
d.
Which is an example of blunt dissection?
a. Cutting of a section made across the long axis of a structure.
b. Separation of tissues using an instrument for cutting, such as a scalpel.
c. Division by cutting into two parts.
d. Separation of tissues with a finger or blunt instrument without cutting.
d.
The statement "signed but not read" is adequate documentation to have included on a
transcribed note.
a. True. Hospital documentation is understood to have been reviewed by the provider of service
or physician review board.
b. False. The provider of service is liable for the documentation within the report and the
provider's signature serves as attestation that the provider agrees with what is in the report.
c. False. The documentation would be required to have the provider's name typed next to this
statement.
d. True. Documentation with a note stating, signed but not read, with the provider's typed
name is adequate documentation.
b.
Modifiers used by the physician are approved for use by the facility.
a. True. All CPT® modifiers are approved for facility use.
b. False. The facility may only use the same modifiers if documented.
c. False. Facilities have approved modifiers. Not all CPT modifiers are approved for facility use.
d. True. If the physician uses certain modifiers this gives the facility approval to use the same
modifiers.
c.
Practice Exam: CPT®, HIPAA & Hospital Standards|
Complete Exam Questions Verified with Answers
Graded A+ Latest Updated 2026
Documentation standards are classified into the following categories:
a. Patient specific data and information
b. Additional standards for specific patient populations, for example, operative/invasive
procedures, ambulatory care, emergency, clinical trials, etc.
c. Inpatient or Outpatient
d. a and b
d.
According to the CMS Transmittal A-03-021, which of the following does NOT meet
specifications for verification of an electronic signature in the hospital setting?
a. A system in which the physician signs off against a list of entries that must be verified in the
individual record.
b. Computerized systems that require the physician to review the document on-line and
indicate that it has been approved by entering a computer code.
c. A mail system in which transcripts are sent to the physician for review, and then he or she
signs and returns a postcard identifying the record and verifying its accuracy.
d. A system of auto-authentication in which a physician or other practitioner authenticates a
report before transcription.
d.
What is the unit of measurement for coding the length of lacerations?
a. Inches
b. Square centimeters
c. Square inches
d. Centimeters
d.
, When coding an operative report, do NOT:
a. Use a copy of the operative report.
b. Code from the Postoperative Diagnosis and Title of the Operation listed.
c. Code for lysis of adhesions when it is related to another procedure.
d. b. and c.
d.
Which is an example of blunt dissection?
a. Cutting of a section made across the long axis of a structure.
b. Separation of tissues using an instrument for cutting, such as a scalpel.
c. Division by cutting into two parts.
d. Separation of tissues with a finger or blunt instrument without cutting.
d.
The statement "signed but not read" is adequate documentation to have included on a
transcribed note.
a. True. Hospital documentation is understood to have been reviewed by the provider of service
or physician review board.
b. False. The provider of service is liable for the documentation within the report and the
provider's signature serves as attestation that the provider agrees with what is in the report.
c. False. The documentation would be required to have the provider's name typed next to this
statement.
d. True. Documentation with a note stating, signed but not read, with the provider's typed
name is adequate documentation.
b.
Modifiers used by the physician are approved for use by the facility.
a. True. All CPT® modifiers are approved for facility use.
b. False. The facility may only use the same modifiers if documented.
c. False. Facilities have approved modifiers. Not all CPT modifiers are approved for facility use.
d. True. If the physician uses certain modifiers this gives the facility approval to use the same
modifiers.
c.
