PTP 2 FINAL QUESTIONS & ANSWERS
What is the purpose of a daily encounter note? - answers :to create a record all all
skilled interventions to justify the use of billing codes
3 types of daily encounter notes - answers :pomr (problem oriented medical record),
narrative note, soap note
Soap w/ coding*
Pomr - answers :patient problem list
Sub/objective data
Overall impression
Tx provided
Plan for each problem
What does soap + code include that the other types don't include? - answers :skilled
verbiage by code, clinical rationale
What should be included in a daily encounter note? - answers :date
Objective measurements
Education
Skilled verbiage by code
Total time billed for each
Signature/ credentials
Doc by excerption
Subjective
Assessment
Clinical rationale
Plan
Within which section of the soap note would you document the obstacles impacting
clinical progress? - answers :assessment
Therapeutic exercise code includes what? - answers :transfers
Throwing/ catching
Bed mobility
Lifting
Carrying
Reaching/crossing midline
What is included in the gait training code? - answers :pre gait activity
Maneuvering around obstacles
Antalgic/ stappage/ festinating gait
Stair climbing
Difference surfaces
`
, What is included in neuro- reeducation code? - answers :ndt/ pnf/ bobath
Postural control
Proprioception
Bilateral integreation
Crossing midline
Stepping strategies
What is included in the therapeutic exercise code? - answers :isokinetic exercise
Lumbar stabilization
Gymnastic ball
Stretching
Pre
What is included in manual therapy? - answers :mobilization
Manips
Manual lymphatic drainage
Manual traction
Within which section of the soap note would you document skilled interventions, broken
down by cpt code? - answers :objective
National correct coding initiative purpose - answers :that codes are being billed
appropriately, and are not overlapped
For the ncci modifier indicators
What does a 0 and 1 mean? - answers :0- not allowed to be paired
1- allowed
What is modifier 59? - answers :a modifier in documentation that states that you are
billing for 2 codes that are allowed to both be reimbursed for but are distinct and
separate services
What is something to be cautious about when using modifier 59? - answers :what other
providers are doing with the patient and make sure you are both not billing for the same
things
What is modifier xe used for? - answers :if column 1 and 2 codes are billed to the same
patient in a separate encounter
What is document by exception? - answers :anything out of the ordinary-
-patient self-report
-adverse reactions to interventions
-comm/consultation with other providers
What is the purpose of a daily encounter note? - answers :to create a record all all
skilled interventions to justify the use of billing codes
3 types of daily encounter notes - answers :pomr (problem oriented medical record),
narrative note, soap note
Soap w/ coding*
Pomr - answers :patient problem list
Sub/objective data
Overall impression
Tx provided
Plan for each problem
What does soap + code include that the other types don't include? - answers :skilled
verbiage by code, clinical rationale
What should be included in a daily encounter note? - answers :date
Objective measurements
Education
Skilled verbiage by code
Total time billed for each
Signature/ credentials
Doc by excerption
Subjective
Assessment
Clinical rationale
Plan
Within which section of the soap note would you document the obstacles impacting
clinical progress? - answers :assessment
Therapeutic exercise code includes what? - answers :transfers
Throwing/ catching
Bed mobility
Lifting
Carrying
Reaching/crossing midline
What is included in the gait training code? - answers :pre gait activity
Maneuvering around obstacles
Antalgic/ stappage/ festinating gait
Stair climbing
Difference surfaces
`
, What is included in neuro- reeducation code? - answers :ndt/ pnf/ bobath
Postural control
Proprioception
Bilateral integreation
Crossing midline
Stepping strategies
What is included in the therapeutic exercise code? - answers :isokinetic exercise
Lumbar stabilization
Gymnastic ball
Stretching
Pre
What is included in manual therapy? - answers :mobilization
Manips
Manual lymphatic drainage
Manual traction
Within which section of the soap note would you document skilled interventions, broken
down by cpt code? - answers :objective
National correct coding initiative purpose - answers :that codes are being billed
appropriately, and are not overlapped
For the ncci modifier indicators
What does a 0 and 1 mean? - answers :0- not allowed to be paired
1- allowed
What is modifier 59? - answers :a modifier in documentation that states that you are
billing for 2 codes that are allowed to both be reimbursed for but are distinct and
separate services
What is something to be cautious about when using modifier 59? - answers :what other
providers are doing with the patient and make sure you are both not billing for the same
things
What is modifier xe used for? - answers :if column 1 and 2 codes are billed to the same
patient in a separate encounter
What is document by exception? - answers :anything out of the ordinary-
-patient self-report
-adverse reactions to interventions
-comm/consultation with other providers
