CCA PREP! 362 QUESTIONS WITH COMPLETE SOLUTIONS

Audit trails Correct Answer: can provide tracking information such as who accessed which records and for what purpose AMA Correct Answer: CPT was developed and is maintained by: The discharge summary Correct Answer: is a concise account of the patient's illness, course of treatment, response to treatment, and condition at the time the patient is discharged.Ensuring the continuity of future care by providing information to the patient's attending physician, referring physician, and any consulting physicians is a function of the discharge summary. The discharge summary must be completed within ________ after discharge for most patients but within __________ for patients transferred to other facilities. Discharge summaries are not always required for patients who were hospitalized for less than __________ hours. 30 days/24 hours/48 hours Medically unlikely edits (MUEs) Correct Answer: CMS developed MUEs to prevent providers from billing units in excess and receiving inappropriate payments. This new editing was the result of the outpatient prospective payment system which pays providers passed on the HCPCS/CPT code and units. Payment is directly related to units for specified HCPCS/CPT codes assigned to an ambulatory payment classification CPT Assistant Correct Answer: provides additional CPT coding guidance on how to assign a CPT code by providing intent on the use of the code and explanation of parenthetical instructions. The American Medical Association publishes the guidance monthly Software interface Correct Answer: is a computer program that allows different applications to communicate and exchange data National Correct Coding Initiative (NCCI) Correct Answer: CMS developed to control improper coding practices leading to inappropriate payments in Part B claims. NCCI polocies are based on: -Coding conventions defined in CPT -National and local policies and coding edits -Analysis of standard medical and surgical practice -Review of current coding practices **(would include code pairs)