CPMA Practice Exam A| 25 Questions| Correct Answers!

You are performing an audit of evaluation and management services for a family practice office. In the encounter, you read the physician order and reviewed a differential WBC. Which of the following best describes what you would expect to see in the medical record? - ANSWER Patient identification, assignment of benefits, patient's medical history, immunizations, physical examination, lab report, clinical impression, and physician orders. What is the minimum signature assignment(s) of the author of an entry in the medical record? - ANSWER The first initial, last name and credentials Based on Joint Commission accreditation guidance for personal data, what two elements must be evident in the medical record - ANSWER Personal biographical data and consent for treatment or authorization for treatment form As an auditor, who of the following would NOT be expected to submit operative notes? - ANSWER Surgical assistants 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 In preparation for a high volume of patients coming in for chemotherapy, the nurse documents the chemotherapy treatments in advance. The purpose is to speed up the treatment process so patients do not have to wait long. Would this cause concern in an audit? - ANSWER Yes, chart entry should not be made in advance of the treatment A provider knows that an evaluation and management service they provide on the same date as a major procedure will be bundled, so he submits the claim for the E/M with a different date of service. This is an example of: - ANSWER Fraud F