AAPC CPMA Practice Exam Study Guide with Complete Solutions
What elements must be in a medical record Correct Answer-Patient 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? Correct Answer-First initial, Last Name and credentials
Based on the JC accreditation guidelines for personal data, what 2 elements must be evident in the medical record? Correct Answer-There 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? Correct Answer-Discard it in a locked shredding receptacle
When must ABNs be signed? Correct Answer-Far 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? Correct Answer-S in SOAP and H in CHEDDAR Patients can request copies of disclosure of PHI under HIPAA: Correct Answer-For a six (6) year period of time
When can a RAC extrapolate the overpayment(s) on claims? Correct Answer-If 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: Correct Answer-Only appropriate if the two procedures are performed on separate lesions or at separate patient encounters.
Is reporting 14000 with 11401 unbundling? Correct Answer-Yes 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. Correct Answer-Commercial carriers and Government carriers both use claims data to identify providers and services to audit.
A comprehensive audit is: Correct Answer-sometimes referred to as a focused review, is an audit of a specified number of medical records in which a previous audit has identified problems based on procedure and/or diagnosis codes or other audit findings.
What elements must be in a medical record Correct Answer-Patient 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? Correct Answer-First initial, Last Name and credentials
Based on the JC accreditation guidelines for personal data, what 2 elements must be evident in the medical record? Correct Answer-There 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? Correct Answer-Discard it in a locked shredding receptacle
When must ABNs be signed? Correct Answer-Far 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? Correct Answer-S in SOAP and H in CHEDDAR Patients can request copies of disclosure of PHI under HIPAA: Correct Answer-For a six (6) year period of time
When can a RAC extrapolate the overpayment(s) on claims? Correct Answer-If 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: Correct Answer-Only appropriate if the two procedures are performed on separate lesions or at separate patient encounters.
Is reporting 14000 with 11401 unbundling? Correct Answer-Yes 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. Correct Answer-Commercial carriers and Government carriers both use claims data to identify providers and services to audit.
A comprehensive audit is: Correct Answer-sometimes referred to as a focused review, is an audit of a specified number of medical records in which a previous audit has identified problems based on procedure and/or diagnosis codes or other audit findings.
