AAPC CPMA Practice Exam Study Guide
1.What elements must be in a medical record: Patient ID, Assignment of Bene- fits, medical history, immunizations, physical exam, lab report, clinical impression, physician orders
2.What is the minimum signature assignment of the author of entry in the medical record?: First initial, Last Name and credentials
3.Based on the JC accreditation guidelines for personal data, what 2 elements must be evident in the medical record?: 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.
4.What is the appropriate way to dispose of PHI that is no longer needed?: -
Discard it in a locked shredding receptacle
5.When must ABNs be signed?: 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?: S in SOAP and H in CHEDDAR
7.Patients can request copies of disclosure of PHI under HIPAA:: For a six (6) year period of time
8.When can a RAC extrapolate the overpayment(s) on claims?: If a RAC can demonstrate a high level of error, the RAC can then extrapolate the findings and request a refund.
9.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:: Only appropriate
if the two procedures are performed on separate lesions or at separate patient encounters.
10.Is reporting 14000 with 11401 unbundling?: Yes according to CPT guidelines the excision of a benign lesion or malignant lesion is not separately reportable.
11.Commercial and Government carriers audit medical records. Select the
1.What elements must be in a medical record: Patient ID, Assignment of Bene- fits, medical history, immunizations, physical exam, lab report, clinical impression, physician orders
2.What is the minimum signature assignment of the author of entry in the medical record?: First initial, Last Name and credentials
3.Based on the JC accreditation guidelines for personal data, what 2 elements must be evident in the medical record?: 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.
4.What is the appropriate way to dispose of PHI that is no longer needed?: -
Discard it in a locked shredding receptacle
5.When must ABNs be signed?: 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?: S in SOAP and H in CHEDDAR
7.Patients can request copies of disclosure of PHI under HIPAA:: For a six (6) year period of time
8.When can a RAC extrapolate the overpayment(s) on claims?: If a RAC can demonstrate a high level of error, the RAC can then extrapolate the findings and request a refund.
9.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:: Only appropriate
if the two procedures are performed on separate lesions or at separate patient encounters.
10.Is reporting 14000 with 11401 unbundling?: Yes according to CPT guidelines the excision of a benign lesion or malignant lesion is not separately reportable.
11.Commercial and Government carriers audit medical records. Select the
