COMPLETE QUESTIONS AND DETAILED CORRECT
CORRECT CORRECT CORRECT ANSWER {ALREADY
GRADED A+} BRAND NEW VERSION
SOAP - CORRECT ANSWERSubjective, Objective, Assessment, Plan
CHEDDAR - CORRECT ANSWERChief complaint, Hx, Exam, Details of problem/complaint, Drugs &
dosages, Assessment, Return visit
Subjective - CORRECT ANSWERPt complaint
Objective - CORRECT ANSWERProvider observation
Assessment - CORRECT ANSWERMedical Dx
Plan - CORRECT ANSWERTreatment
You are performing an audit of e/m services for a FP office. In the encounter you read the physician
ordered and reviewed a differential WBC. What elements would you expect to see in the medical
records? - CORRECT ANSWERPatient ID, assignment of benefits, pt's medical hx, immunizations, physical
examination, lab report, clinical impression & physician orders. When labs are ordered, there must be a
copy of the order and the lab report that the physician has reviewed.
, What is the minimum requirement for the signature of the author of an entry in the medical records? -
CORRECT ANSWERThe first initial, last name and credentials
Based on JCAHO accreditation guidance for personal data, what two elements must be evident in the
medical records? - CORRECT ANSWERPersonal biographical data and consent for Treatment or
authorization for Treatment form.
What is a comprehensive/focus review audit? - CORRECT ANSWERA large number of claims are selected
for review that might be focused on specific procedure and/or dx codes
What is RAT-STATS used for by an auditor? - CORRECT ANSWERSoftware used in performing statistical
random samples and evaluating results.
The Stark Statute applies to who and states what? - CORRECT ANSWERApplies to government payers.
States the provider cannot refer pts to a health care facility where they or immediate family members
has a financial relationship.
What are the recommended number of charts to audit per provider and the minimum frequency of the
audit? - CORRECT ANSWER10 records per provider each year.
When can a RAC extrapolate the overpayment(s) on claim? - CORRECT ANSWERIf a RAC can
demonstrate a high level of error, the RAC can then extrapolate the findings and request a refund.
Patients can request copies of disclosure of PHI under HIPAA for how long? - CORRECT ANSWERA six
year period of time.
What are the civil monetary penalties for false or fraudulent claims? - CORRECT ANSWERUp to 11,000
per claim and three times the amount improperly claimed.
The Claims Review procedure requires a full sample of 50 sampling units be randomly selected for
review when the net financial error rate reaches what % - CORRECT ANSWER5%