AAPC CPMA Prac ce Exam Study| Updated RATED A+
2026
What elements must be in a medical record
Pa ent ID, Assignment of Benefits, medical history, immuniza ons, physical exam, lab report,
clinical impression, physician orders
What is the minimum signature assignment of the author of entry in the medical record?
First ini al, Last Name and creden als
Based on the JC accredita on guidelines for personal data, what 2 elements must be evident in
the medical record?
There must be a pa ent informa on sheet that contains biographical data, name, address, etc.
along with authoriza on for treatment whether it is an office visit, diagnos c services or surgical
procedure.
What is the appropriate way to dispose of PHI that is no longer needed?
Discard it in a locked shredding receptacle
When must ABNs be signed?
Far enough in advance that the beneficiary or representa ve has me to consider the op ons
and make an informed decision.
SOAP and CHEDDAR are two formats of medical record documenta on. Which sec on of each
format would you find the pa ent's history?
S in SOAP and H in CHEDDAR
Pa ents can request copies of disclosure of PHI under HIPAA:
For a six (6) year period of me
When can a RAC extrapolate the overpayment(s) on claims?
If a RAC can demonstrate a high level of error, the RAC can then extrapolate the findings and
request a refund.
Example: Column 1 Code/Column 2 Code 45385/45380 CPT Code 45385 - Colonoscopy, flexible,
proximal to splenic flexure; with removal of tumor(s), polyp(s), or other lesion(s) by snare
, technique CPT Code 45380 - Colonoscopy, flexible, proximal to splenic flexure; with biopsy,
single or mul ple Policy: More extensive procedure Modifier -59 is:
Only appropriate if the two procedures are performed on separate lesions or at separate pa ent
encounters.
Is repor ng 14000 with 11401 unbundling?
Yes according to CPT guidelines the excision of a benign lesion or malignant lesion is not
separately reportable.
Commercial and Government carriers audit medical records. Select the statement that is TRUE
regarding commercial and government carriers.
Commercial carriers and Government carriers both use claims data to iden fy providers and
services to audit.
A comprehensive audit is:
some mes referred to as a focused review, is an audit of a specified number of medical records
in which a previous audit has iden fied problems based on procedure and/or diagnosis codes or
other audit findings.
What are the recommended number of charts to audit per provider and the minimum
frequency of the audit according to the OIG Recommended Compliance Plan?
10 records per provider each year
True or False: When a CRNA and a Anesthesiologist both have a part in the procedure and
belong to the same prac ce they can both bill on the same claim
TRUE
What should an auditor review for an opera on?
The opera ve note, codes selected, payer payment policy and NCCI edits prior to claim
submission
What informa on should be reported to the OIG in the Claims Review findings as part of an
en ty's Annual Report?
Claims review methodology, sta s cal sampling documenta on, and claim review findings
An analysis that provides the organiza on an overview of the deficit areas captured by a
medical record audit is called what?
2026
What elements must be in a medical record
Pa ent ID, Assignment of Benefits, medical history, immuniza ons, physical exam, lab report,
clinical impression, physician orders
What is the minimum signature assignment of the author of entry in the medical record?
First ini al, Last Name and creden als
Based on the JC accredita on guidelines for personal data, what 2 elements must be evident in
the medical record?
There must be a pa ent informa on sheet that contains biographical data, name, address, etc.
along with authoriza on for treatment whether it is an office visit, diagnos c services or surgical
procedure.
What is the appropriate way to dispose of PHI that is no longer needed?
Discard it in a locked shredding receptacle
When must ABNs be signed?
Far enough in advance that the beneficiary or representa ve has me to consider the op ons
and make an informed decision.
SOAP and CHEDDAR are two formats of medical record documenta on. Which sec on of each
format would you find the pa ent's history?
S in SOAP and H in CHEDDAR
Pa ents can request copies of disclosure of PHI under HIPAA:
For a six (6) year period of me
When can a RAC extrapolate the overpayment(s) on claims?
If a RAC can demonstrate a high level of error, the RAC can then extrapolate the findings and
request a refund.
Example: Column 1 Code/Column 2 Code 45385/45380 CPT Code 45385 - Colonoscopy, flexible,
proximal to splenic flexure; with removal of tumor(s), polyp(s), or other lesion(s) by snare
, technique CPT Code 45380 - Colonoscopy, flexible, proximal to splenic flexure; with biopsy,
single or mul ple Policy: More extensive procedure Modifier -59 is:
Only appropriate if the two procedures are performed on separate lesions or at separate pa ent
encounters.
Is repor ng 14000 with 11401 unbundling?
Yes according to CPT guidelines the excision of a benign lesion or malignant lesion is not
separately reportable.
Commercial and Government carriers audit medical records. Select the statement that is TRUE
regarding commercial and government carriers.
Commercial carriers and Government carriers both use claims data to iden fy providers and
services to audit.
A comprehensive audit is:
some mes referred to as a focused review, is an audit of a specified number of medical records
in which a previous audit has iden fied problems based on procedure and/or diagnosis codes or
other audit findings.
What are the recommended number of charts to audit per provider and the minimum
frequency of the audit according to the OIG Recommended Compliance Plan?
10 records per provider each year
True or False: When a CRNA and a Anesthesiologist both have a part in the procedure and
belong to the same prac ce they can both bill on the same claim
TRUE
What should an auditor review for an opera on?
The opera ve note, codes selected, payer payment policy and NCCI edits prior to claim
submission
What informa on should be reported to the OIG in the Claims Review findings as part of an
en ty's Annual Report?
Claims review methodology, sta s cal sampling documenta on, and claim review findings
An analysis that provides the organiza on an overview of the deficit areas captured by a
medical record audit is called what?
