CPMA practice exam A

CPMA practice exam A SOAP Subjective, Objective, Assessment, Plan CHEDDAR Chief complaint, Hx, Exam, Details of problem/complaint, Drugs & dosages, Assessment, Return visit Subjective Pt complaint Objective Provider observation Assessment Medical Dx Plan Treatment 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? Patient 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? The first initial, last name and credentials Based on JCAHO accreditation guidance for personal data, what two elements must be evident in the medical records? Personal biographical data and consent for Treatment or authorization for Treatment form. What is a comprehensive/focus review audit? A 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? Software used in performing statistical random samples and evaluating results. The Stark Statute applies to who and states what? Applies 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? 10 records per provider each year. When can a RAC extrapolate the overpayment(s) on claim? If 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? A six year period of time. What are the civil monetary penalties for false or fraudulent claims? Up to 11,000 per claim and three times the amount improperly claimed.