2026 CPMA Study Guide: Certified Professional
Medical Auditor Practice Questions with Answer
Explanations Medical Auditing | CPT
Documentation | Compliance | Risk Management
| Coding Review
SECTION 1: MEDICAL RECORD STANDARDS AND
DOCUMENTATION GUIDELINES (Questions 1–30)
1. What does the acronym CHEDDAR stand for in medical documentation?
A. Chief complaint, History, Examination, Diagnosis, Drugs, Assessment, Return
visit
B. Chief complaint, History, Examination, Details of problem/complaint,
Drugs, Assessment, Return visit
C. Chief complaint, History, Evaluation, Diagnosis, Documentation, Assessment,
Referral
D. Chief complaint, History, Examination, Data, Diagnosis, Assessment, Referral
Rationale: CHEDDAR is a mnemonic for the components of a complete medical
record: Chief complaint, History, Examination, Details of problem/complaint,
Drugs and dosages, Assessment, and Return visit instructions. This framework
ensures comprehensive documentation that supports code selection and medical
necessity.
2. Which type of medical record documentation is created by the provider at
the time of the patient encounter?
A. Operative report
B. Progress note
C. Discharge summary
D. Consultation report
Rationale: A progress note is created by the provider during or immediately after
the patient encounter to document the patient's condition, the provider's findings,
and the plan of care. It is the primary documentation source for E/M auditing.
,3. What is the required timeframe for documenting an operative report after
a surgical procedure?
A. Within 24 hours
B. Immediately after the procedure or as soon as possible
C. Within 72 hours
D. Within one week
Rationale: The operative report must be written or dictated immediately after an
operation or other high-risk procedure and entered into the medical record. Delays
in documentation can compromise patient care and create audit risks.
4. Which of the following is an essential element of an operative report?
A. Patient's insurance information
B. Preoperative and postoperative diagnoses
C. Provider's NPI number
D. Referring physician's address
Rationale: Essential elements of an operative report include patient identification,
preoperative diagnosis, postoperative diagnosis, procedures performed, description
of the procedure, findings, complications, and postoperative plan. The preoperative
and postoperative diagnoses are critical for medical necessity and coding.
5. What is the primary purpose of the medical record?
A. To serve as a billing document only
B. To document patient care and support clinical decision-making
C. To meet insurance requirements
D. To protect the provider from lawsuits
Rationale: The primary purpose of the medical record is to document patient care
and support clinical decision-making. Accurate and complete documentation also
supports coding, billing, quality improvement, and legal defense.
6. Which of the following describes the "minimum necessary" standard under
HIPAA?
A. Disclosing all PHI to any requesting party
B. Limiting PHI use, disclosure, and requests to the minimum amount
necessary to accomplish the purpose
,C. Disclosing PHI only with patient authorization
D. Retaining PHI for a minimum of 10 years
Rationale: The HIPAA minimum necessary standard requires covered entities to
make reasonable efforts to limit protected health information (PHI) to the
minimum necessary to accomplish the intended purpose of the use, disclosure, or
request. This does not apply to treatment disclosures.
7. How long must HIPAA policies and procedures be maintained by a covered
entity?
A. 3 years
B. 6 years
C. 10 years
D. Indefinitely
Rationale: Policies and procedures required under HIPAA must be maintained by
the covered entity in written or electronic form for at least six years. This includes
documentation of requests for PHI and the covered entity's responses.
8. Which of the following is considered protected health information (PHI)?
A. De-identified health data
B. Patient's name, address, and medical record number
C. Aggregate statistical data
D. Publicly available hospital directory information
Rationale: PHI includes individually identifiable health information such as
names, geographic designations smaller than a state, dates (except year), telephone
numbers, medical record numbers, and other unique identifiers. De-identified data
is no longer PHI.
9. What is the minimum retention period for adult medical records according
to most state regulations?
A. 3 years
B. 7 years past the last date of service
C. 15 years
D. Lifetime of the patient
Rationale: Most state regulations require adult medical records to be retained for
at least seven years past the last date on which services were given. Pediatric
, records are typically retained until the minor's 24th birthday or five years from the
date of service, whichever is later.
10. What is the primary purpose of an Advance Beneficiary Notice (ABN)?
A. To obtain patient authorization for treatment
B. To inform Medicare beneficiaries that a service may not be covered and to
obtain agreement to pay
C. To document patient consent for surgery
D. To authorize release of medical records
Rationale: An Advance Beneficiary Notice (ABN) is a written notice given to a
Medicare beneficiary before a service is provided when the provider believes
Medicare may deny payment. It shifts financial liability to the patient if the service
is denied.
11. When must an ABN be provided to a Medicare beneficiary?
A. After the service is provided
B. Before the service is provided
C. At the time of billing
D. Only if the patient requests it
Rationale: An ABN must be provided to the beneficiary before the service is
furnished. This gives the patient the opportunity to make an informed decision
about whether to receive the service and accept financial responsibility if Medicare
denies coverage.
12. Which of the following is an example of a "problem-focused" history?
A. Complete review of all body systems
B. Chief complaint and a brief history of the present illness
C. Comprehensive past medical, family, and social history
D. Full review of systems and past medical history
Rationale: A problem-focused history is limited to the chief complaint, a brief
history of the present illness, and a limited review of systems. It is typically used
for low-complexity encounters.
13. What is the difference between a consultation and a transfer of care?
A. No difference; they are interchangeable terms
B. A consultation is a request for opinion or advice; a transfer of care is a
Medical Auditor Practice Questions with Answer
Explanations Medical Auditing | CPT
Documentation | Compliance | Risk Management
| Coding Review
SECTION 1: MEDICAL RECORD STANDARDS AND
DOCUMENTATION GUIDELINES (Questions 1–30)
1. What does the acronym CHEDDAR stand for in medical documentation?
A. Chief complaint, History, Examination, Diagnosis, Drugs, Assessment, Return
visit
B. Chief complaint, History, Examination, Details of problem/complaint,
Drugs, Assessment, Return visit
C. Chief complaint, History, Evaluation, Diagnosis, Documentation, Assessment,
Referral
D. Chief complaint, History, Examination, Data, Diagnosis, Assessment, Referral
Rationale: CHEDDAR is a mnemonic for the components of a complete medical
record: Chief complaint, History, Examination, Details of problem/complaint,
Drugs and dosages, Assessment, and Return visit instructions. This framework
ensures comprehensive documentation that supports code selection and medical
necessity.
2. Which type of medical record documentation is created by the provider at
the time of the patient encounter?
A. Operative report
B. Progress note
C. Discharge summary
D. Consultation report
Rationale: A progress note is created by the provider during or immediately after
the patient encounter to document the patient's condition, the provider's findings,
and the plan of care. It is the primary documentation source for E/M auditing.
,3. What is the required timeframe for documenting an operative report after
a surgical procedure?
A. Within 24 hours
B. Immediately after the procedure or as soon as possible
C. Within 72 hours
D. Within one week
Rationale: The operative report must be written or dictated immediately after an
operation or other high-risk procedure and entered into the medical record. Delays
in documentation can compromise patient care and create audit risks.
4. Which of the following is an essential element of an operative report?
A. Patient's insurance information
B. Preoperative and postoperative diagnoses
C. Provider's NPI number
D. Referring physician's address
Rationale: Essential elements of an operative report include patient identification,
preoperative diagnosis, postoperative diagnosis, procedures performed, description
of the procedure, findings, complications, and postoperative plan. The preoperative
and postoperative diagnoses are critical for medical necessity and coding.
5. What is the primary purpose of the medical record?
A. To serve as a billing document only
B. To document patient care and support clinical decision-making
C. To meet insurance requirements
D. To protect the provider from lawsuits
Rationale: The primary purpose of the medical record is to document patient care
and support clinical decision-making. Accurate and complete documentation also
supports coding, billing, quality improvement, and legal defense.
6. Which of the following describes the "minimum necessary" standard under
HIPAA?
A. Disclosing all PHI to any requesting party
B. Limiting PHI use, disclosure, and requests to the minimum amount
necessary to accomplish the purpose
,C. Disclosing PHI only with patient authorization
D. Retaining PHI for a minimum of 10 years
Rationale: The HIPAA minimum necessary standard requires covered entities to
make reasonable efforts to limit protected health information (PHI) to the
minimum necessary to accomplish the intended purpose of the use, disclosure, or
request. This does not apply to treatment disclosures.
7. How long must HIPAA policies and procedures be maintained by a covered
entity?
A. 3 years
B. 6 years
C. 10 years
D. Indefinitely
Rationale: Policies and procedures required under HIPAA must be maintained by
the covered entity in written or electronic form for at least six years. This includes
documentation of requests for PHI and the covered entity's responses.
8. Which of the following is considered protected health information (PHI)?
A. De-identified health data
B. Patient's name, address, and medical record number
C. Aggregate statistical data
D. Publicly available hospital directory information
Rationale: PHI includes individually identifiable health information such as
names, geographic designations smaller than a state, dates (except year), telephone
numbers, medical record numbers, and other unique identifiers. De-identified data
is no longer PHI.
9. What is the minimum retention period for adult medical records according
to most state regulations?
A. 3 years
B. 7 years past the last date of service
C. 15 years
D. Lifetime of the patient
Rationale: Most state regulations require adult medical records to be retained for
at least seven years past the last date on which services were given. Pediatric
, records are typically retained until the minor's 24th birthday or five years from the
date of service, whichever is later.
10. What is the primary purpose of an Advance Beneficiary Notice (ABN)?
A. To obtain patient authorization for treatment
B. To inform Medicare beneficiaries that a service may not be covered and to
obtain agreement to pay
C. To document patient consent for surgery
D. To authorize release of medical records
Rationale: An Advance Beneficiary Notice (ABN) is a written notice given to a
Medicare beneficiary before a service is provided when the provider believes
Medicare may deny payment. It shifts financial liability to the patient if the service
is denied.
11. When must an ABN be provided to a Medicare beneficiary?
A. After the service is provided
B. Before the service is provided
C. At the time of billing
D. Only if the patient requests it
Rationale: An ABN must be provided to the beneficiary before the service is
furnished. This gives the patient the opportunity to make an informed decision
about whether to receive the service and accept financial responsibility if Medicare
denies coverage.
12. Which of the following is an example of a "problem-focused" history?
A. Complete review of all body systems
B. Chief complaint and a brief history of the present illness
C. Comprehensive past medical, family, and social history
D. Full review of systems and past medical history
Rationale: A problem-focused history is limited to the chief complaint, a brief
history of the present illness, and a limited review of systems. It is typically used
for low-complexity encounters.
13. What is the difference between a consultation and a transfer of care?
A. No difference; they are interchangeable terms
B. A consultation is a request for opinion or advice; a transfer of care is a
