AAPC CPMA PRACTICE EXAM STUDY
CORRECT 100%
What elements must be in a medical record - ANSWERPatient 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?
- ANSWERFirst initial, Last Name and credentials
Based on the JC accreditation guidelines for personal data, what 2 elements must be
evident in the medical record? - ANSWERThere 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.
What is the appropriate way to dispose of PHI that is no longer needed? -
ANSWERDiscard it in a locked shredding receptacle
When must ABNs be signed? - ANSWERFar 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? - ANSWERS in SOAP and H in
CHEDDAR
Patients can request copies of disclosure of PHI under HIPAA: - ANSWERFor a six (6)
year period of time
When can a RAC extrapolate the overpayment(s) on claims? - ANSWERIf a RAC can
demonstrate a high level of error, the RAC can then extrapolate the findings and
request a refund.
Example: Column 1 Code/Column 2 Code 45385/45380 CPT Code 45385 -
Colonoscopy, flexible, proximal to splenic flexure; with removal of tumor(s), polyp(s), or
other lesion(s) by snare technique CPT Code 45380 - Colonoscopy, flexible, proximal to
splenic flexure; with biopsy, single or multiple Policy: More extensive procedure Modifier
-59 is: - ANSWEROnly appropriate if the two procedures are performed on separate
lesions or at separate patient encounters.
Is reporting 14000 with 11401 unbundling? - ANSWERYes according to CPT guidelines
the excision of a benign lesion or malignant lesion is not separately reportable.
Commercial and Government carriers audit medical records. Select the statement that
is TRUE regarding commercial and government carriers. - ANSWERCommercial
CORRECT 100%
What elements must be in a medical record - ANSWERPatient 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?
- ANSWERFirst initial, Last Name and credentials
Based on the JC accreditation guidelines for personal data, what 2 elements must be
evident in the medical record? - ANSWERThere 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.
What is the appropriate way to dispose of PHI that is no longer needed? -
ANSWERDiscard it in a locked shredding receptacle
When must ABNs be signed? - ANSWERFar 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? - ANSWERS in SOAP and H in
CHEDDAR
Patients can request copies of disclosure of PHI under HIPAA: - ANSWERFor a six (6)
year period of time
When can a RAC extrapolate the overpayment(s) on claims? - ANSWERIf a RAC can
demonstrate a high level of error, the RAC can then extrapolate the findings and
request a refund.
Example: Column 1 Code/Column 2 Code 45385/45380 CPT Code 45385 -
Colonoscopy, flexible, proximal to splenic flexure; with removal of tumor(s), polyp(s), or
other lesion(s) by snare technique CPT Code 45380 - Colonoscopy, flexible, proximal to
splenic flexure; with biopsy, single or multiple Policy: More extensive procedure Modifier
-59 is: - ANSWEROnly appropriate if the two procedures are performed on separate
lesions or at separate patient encounters.
Is reporting 14000 with 11401 unbundling? - ANSWERYes according to CPT guidelines
the excision of a benign lesion or malignant lesion is not separately reportable.
Commercial and Government carriers audit medical records. Select the statement that
is TRUE regarding commercial and government carriers. - ANSWERCommercial
