AAPC CPMA Practice Exam Study
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What elements must be in a medical record
Ans: 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?
Ans: 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?
Ans: 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.
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What is the appropriate way to dispose of PHI that is no longer
needed?
Ans: Discard it in a locked shredding receptacle
When must ABNs be signed?
Ans: 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?
Ans: S in SOAP and H in CHEDDAR
Patients can request copies of disclosure of PHI under HIPAA:
Ans: For a six (6) year period of time
When can a RAC extrapolate the overpayment(s) on claims?