AAPC CPMA Practice Exam Study|
Updated RATED A+ 2026
What elements must be in a medical record - answer- Patient ID, Assignment of
Benefits, medical history, immunizations, physical exam, lab report, clinical impression,
physician orders
What is the minimum signature assignment of the author of entry in the medical record?
- answer- First initial, Last Name and credentials
Based on the JC accreditation guidelines for personal data, what 2 elements must be
evident in the medical record? - answer- There must be a patient information sheet that
contains biographical data, name, address, etc. along with authorization for treatment
whether it is an office visit, diagnostic services or surgical procedure.
What is the appropriate way to dispose of PHI that is no longer needed? - answer-
Discard it in a locked shredding receptacle
When must ABNs be signed? - answer- Far enough in advance that the beneficiary or
representative has time to consider the options and make an informed decision.
SOAP and CHEDDAR are two formats of medical record documentation. Which section
of each format would you find the patient's history? - answer- S in SOAP and H in
CHEDDAR
Patients can request copies of disclosure of PHI under HIPAA: - answer- For a six (6)
year period of time
When can a RAC extrapolate the overpayment(s) on claims? - answer- 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 multiple Policy: More extensive procedure Modifier
-59 is: - answer- Only appropriate if the two procedures are performed on separate
lesions or at separate patient encounters.
Is reporting 14000 with 11401 unbundling? - answer- Yes according to CPT guidelines
the excision of a benign lesion or malignant lesion is not separately reportable.
Updated RATED A+ 2026
What elements must be in a medical record - answer- Patient ID, Assignment of
Benefits, medical history, immunizations, physical exam, lab report, clinical impression,
physician orders
What is the minimum signature assignment of the author of entry in the medical record?
- answer- First initial, Last Name and credentials
Based on the JC accreditation guidelines for personal data, what 2 elements must be
evident in the medical record? - answer- There must be a patient information sheet that
contains biographical data, name, address, etc. along with authorization for treatment
whether it is an office visit, diagnostic services or surgical procedure.
What is the appropriate way to dispose of PHI that is no longer needed? - answer-
Discard it in a locked shredding receptacle
When must ABNs be signed? - answer- Far enough in advance that the beneficiary or
representative has time to consider the options and make an informed decision.
SOAP and CHEDDAR are two formats of medical record documentation. Which section
of each format would you find the patient's history? - answer- S in SOAP and H in
CHEDDAR
Patients can request copies of disclosure of PHI under HIPAA: - answer- For a six (6)
year period of time
When can a RAC extrapolate the overpayment(s) on claims? - answer- 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 multiple Policy: More extensive procedure Modifier
-59 is: - answer- Only appropriate if the two procedures are performed on separate
lesions or at separate patient encounters.
Is reporting 14000 with 11401 unbundling? - answer- Yes according to CPT guidelines
the excision of a benign lesion or malignant lesion is not separately reportable.
