What elements must be in a medical record - ANSWER Patient ID, Assignment of Bene-
fits, 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? -
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? - ANSWER There must be a patient information sheet that con-
tains 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? - ANSWER Dis-
card it in a locked shredding receptacle
When must ABNs be signed? - 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? - ANSWER S in SOAP and H in CHEDDAR
Patients can request copies of disclosure of PHI under HIPAA: - ANSWER For a six (6) year
period of time
When can a RAC extrapolate the overpayment(s) on claims? - ANSWER If a RAC can
demonstrate a high level of error, the RAC can then extrapolate the findings and request a
refund.
1
, Example: Column 1 Code/Column 2 Code 45385/45380 CPT Code 45385 - Colonoscopy, flexi-
ble, 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 bi-
opsy, single or multiple Policy: More extensive procedure Modifier -59 is: - ANSWER Only
appropriate if the two procedures are performed on separate lesions or at separate patient
encounters.
Is reporting 14000 with 11401 unbundling? - 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. - ANSWER Commercial carriers and
Government carriers both use claims data to identify providers and services to audit.
A comprehensive audit is: - ANSWER sometimes referred to as a focused review, is an au-
dit of a specified number of medical records in which a previous audit has identified prob-
lems based on procedure and/or diagnosis codes or other audit findings.
What are the recommended number of charts to audit per provider and the minimum fre-
quency of the audit according to the OIG Recommended Compliance Plan? - ANSWER 10
records per provider each year
True or False: When a CRNA and a Anesthesiologist both have a part in the procedure and
belong to the same practice they can both bill on the same claim - ANSWER TRUE
What should an auditor review for an operation? - ANSWER The operative note, codes
selected, payer payment policy and NCCI edits prior to claim submission
What information should be reported to the OIG in the Claims Review findings as part of an
entity's Annual Report? - ANSWER Claims review methodology, statistical sampling docu-
mentation, and claim review findings
2
fits, 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? -
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? - ANSWER There must be a patient information sheet that con-
tains 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? - ANSWER Dis-
card it in a locked shredding receptacle
When must ABNs be signed? - 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? - ANSWER S in SOAP and H in CHEDDAR
Patients can request copies of disclosure of PHI under HIPAA: - ANSWER For a six (6) year
period of time
When can a RAC extrapolate the overpayment(s) on claims? - ANSWER If a RAC can
demonstrate a high level of error, the RAC can then extrapolate the findings and request a
refund.
1
, Example: Column 1 Code/Column 2 Code 45385/45380 CPT Code 45385 - Colonoscopy, flexi-
ble, 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 bi-
opsy, single or multiple Policy: More extensive procedure Modifier -59 is: - ANSWER Only
appropriate if the two procedures are performed on separate lesions or at separate patient
encounters.
Is reporting 14000 with 11401 unbundling? - 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. - ANSWER Commercial carriers and
Government carriers both use claims data to identify providers and services to audit.
A comprehensive audit is: - ANSWER sometimes referred to as a focused review, is an au-
dit of a specified number of medical records in which a previous audit has identified prob-
lems based on procedure and/or diagnosis codes or other audit findings.
What are the recommended number of charts to audit per provider and the minimum fre-
quency of the audit according to the OIG Recommended Compliance Plan? - ANSWER 10
records per provider each year
True or False: When a CRNA and a Anesthesiologist both have a part in the procedure and
belong to the same practice they can both bill on the same claim - ANSWER TRUE
What should an auditor review for an operation? - ANSWER The operative note, codes
selected, payer payment policy and NCCI edits prior to claim submission
What information should be reported to the OIG in the Claims Review findings as part of an
entity's Annual Report? - ANSWER Claims review methodology, statistical sampling docu-
mentation, and claim review findings
2
