CPT Exam Questions and Answers | Latest Version | 2025/2026 | Correct & Verified

CPT Exam Questions and Answers | Latest Version | 2025/2026 | Correct & Verified Why is accuracy important when recording the type of service performed? It ensures proper reimbursement and prevents billing errors How should a medical assistant handle a procedure that is performed differently than planned? Document the reason for the change and what was done instead Why must patient visits be recorded in chronological order? To provide a clear and organized timeline of care What is the purpose of noting the level of complexity of a medical visit? To justify the level of service provided and support billing Why is it necessary to document the patient’s chief complaint? It guides the provider’s assessment and treatment plan 2 How should follow-up care instructions be documented? Include timeframe, method of follow-up, and any restrictions Why is documentation of patient education important? It ensures understanding, promotes compliance, and supports reimbursement What should be documented if a patient refuses a recommended procedure? The refusal and the patient’s reasoning Why is it important to document communication with other providers? To coordinate care and maintain continuity How should a medical assistant document vital signs? Include the date, time, values, and any abnormal findings Why is it necessary to record a patient’s response to treatment? It helps evaluate effectiveness and plan future care 3 What should be noted when performing a procedure on a specific body site? Exact location, laterality, and method used Why should repeated procedures be clearly documented? To show frequency and support accurate billing What is the role of modifiers in documentation? To provide additional details about how, where, or why a service was performed Why is it important to include both assessment and plan in progress notes? It gives a clear rationale for care and supports reimbursement How should abnormal test results be recorded? Include value, reference range, and provider interpretation Why must documentation include medical necessity for each procedure? To justify the service and prevent claim denials 4 What should be documented if a procedure has a complication? Type of complication, interventions, and outcome How should patient allergies be recorded? Type of allergy, reaction, and severity Why is documenting patient history critical for coding and billing? It supports accurate service selection and justifies medical decisions What should be documented for telehealth visits? Mode of communication, patient consent, and services provided Why is it necessary to document all medications administered? To track treatment, prevent errors, and support billing What is the importance of documenting the start and end times of timed procedures? It reflects the duration of service for reimbursement and compliance 5 How should a provider document preventive services? Include type of service, patient age, and any counseling provided Why should a medical assistant document equipment used during a procedure? To provide a complete record and support billing How should a provider record consultations with specialists? Include reason for referral, findings,