PCM Exam 1 Questions with all Correct & 100% Verified
Answers |Latest Version |Already Graded A+
What is the golden rule of documentation? ✔Correct Answer-If you didn't document it, it
didn't happen
Who and in what year were guidelines to documentation published? ✔Correct Answer-CMS,
1995 and 1997
What are the 7 basic principles of documentation? (7) ✔Correct Answer-1. medical record
should be complete and legible
2. Each Patient encounter should be documented
3. Rationale for ordering diagnostic services is easily inferred
4. past/present diagnoses are accessible to consulting providers
5. Appropriate health factors identified
6. Diagnosis documentation
7. CPT/ICD 10 codes supported with documentation
Each patient encounter should include? (6) ✔Correct Answer-1. reason for encounter
2. relevant H&P
3. Diagnostic test results
4. Assessment
5. Plan
6. Date and provider identity
What should be included in diagnosis documentation? (3) ✔Correct Answer-1. patient
progress
2. Response/Changes in Treatment
3. Revisions of diagnosis
What is the current coding system for diagnoses? ✔Correct Answer-ICD 10
What can be coded for with CPT? (4) ✔Correct Answer-1. Procedures
2. Medications
3. Imaging
4. Medical devices
What are the factors of evaluation and management that affect the level of visit? (6)
✔Correct Answer-1. New/established patient
2. Where the service was provided (outpatient vs inpatient)
3. Type of service
4. Documentation
, 5. Medical decision making
6. time spent with patient
What are the requirements for EMR certification? (8) ✔Correct Answer-1. Health information
and data
2. Results management
3. Order management
4. decision support
5. electronic communication and connectivity
6. patient support
7. administrative process
8. reporting
What are disadvantages to EMR? (6) ✔Correct Answer-1. older providers have limited
computer literacy
2. less productivity
3. patient satisfaction (eye contact)
4. unreliability
5. Economic concerns
6. Ethical and legal issues
What is the greatest challenge/disadvantage to EMR? ✔Correct Answer-Interoperability
What is the definition of interoperability? ✔Correct Answer-the ability of a system or a
product to work with other systems or products without special effort on the part of the
customer.
What is the HITECH law and when was it signed into law? ✔Correct Answer-a law that
requires hospitals and providers to comply with meaningful use, 2009
How is meaningful use defined? ✔Correct Answer-Using an EMR to improve quality, safety,
efficiency, reduce disparities, engage patients, maintain privacy and security of PHI
What are the 5 goals of HIPPA and when was it instituted? ✔Correct Answer-1. reduce fraud
and abuse
2. make health insurance more affordable and accessible
3. simplify administration claims
4. allow easier access to health records
5. protect medical records from unauthorized use
1996
What is health insurance portability? (3) ✔Correct Answer-1. Protects workers who
participate in group health plans
2. limits exclusions to those with pre-existing conditions
Answers |Latest Version |Already Graded A+
What is the golden rule of documentation? ✔Correct Answer-If you didn't document it, it
didn't happen
Who and in what year were guidelines to documentation published? ✔Correct Answer-CMS,
1995 and 1997
What are the 7 basic principles of documentation? (7) ✔Correct Answer-1. medical record
should be complete and legible
2. Each Patient encounter should be documented
3. Rationale for ordering diagnostic services is easily inferred
4. past/present diagnoses are accessible to consulting providers
5. Appropriate health factors identified
6. Diagnosis documentation
7. CPT/ICD 10 codes supported with documentation
Each patient encounter should include? (6) ✔Correct Answer-1. reason for encounter
2. relevant H&P
3. Diagnostic test results
4. Assessment
5. Plan
6. Date and provider identity
What should be included in diagnosis documentation? (3) ✔Correct Answer-1. patient
progress
2. Response/Changes in Treatment
3. Revisions of diagnosis
What is the current coding system for diagnoses? ✔Correct Answer-ICD 10
What can be coded for with CPT? (4) ✔Correct Answer-1. Procedures
2. Medications
3. Imaging
4. Medical devices
What are the factors of evaluation and management that affect the level of visit? (6)
✔Correct Answer-1. New/established patient
2. Where the service was provided (outpatient vs inpatient)
3. Type of service
4. Documentation
, 5. Medical decision making
6. time spent with patient
What are the requirements for EMR certification? (8) ✔Correct Answer-1. Health information
and data
2. Results management
3. Order management
4. decision support
5. electronic communication and connectivity
6. patient support
7. administrative process
8. reporting
What are disadvantages to EMR? (6) ✔Correct Answer-1. older providers have limited
computer literacy
2. less productivity
3. patient satisfaction (eye contact)
4. unreliability
5. Economic concerns
6. Ethical and legal issues
What is the greatest challenge/disadvantage to EMR? ✔Correct Answer-Interoperability
What is the definition of interoperability? ✔Correct Answer-the ability of a system or a
product to work with other systems or products without special effort on the part of the
customer.
What is the HITECH law and when was it signed into law? ✔Correct Answer-a law that
requires hospitals and providers to comply with meaningful use, 2009
How is meaningful use defined? ✔Correct Answer-Using an EMR to improve quality, safety,
efficiency, reduce disparities, engage patients, maintain privacy and security of PHI
What are the 5 goals of HIPPA and when was it instituted? ✔Correct Answer-1. reduce fraud
and abuse
2. make health insurance more affordable and accessible
3. simplify administration claims
4. allow easier access to health records
5. protect medical records from unauthorized use
1996
What is health insurance portability? (3) ✔Correct Answer-1. Protects workers who
participate in group health plans
2. limits exclusions to those with pre-existing conditions
