AAPC CASES CPMA Review Correct Questions & Answers!

You are performing an audit of evaluation and management services for a family practice office. In the encounter, you read the physician ordered and reviewed a differential WBC. Which of the following best describes what you would expect to see in the medical record? - ANSWER Patient identification, assignment of benefits, patient's medical history, immunizations, physical examination, lab report, clinical impression, and physician orders. As an auditor, who of the following would NOT be expected to submit operative notes? - ANSWER Surgical assistants A provider knows that an evaluation and management service they provide on the same date as a major procedure will be bundled, so he submits the claim for the E/M with a different date of service. This is an example of: - ANSWER Fraud In preparation for a high volume of patients coming in for chemotherapy, the nurse documents the chemotherapy treatments in advance. The purpose is to speed up the treatment process so patients do not have to wait long. Would this cause concern in an audit? - ANSWER Yes, chart entry should not be made in advance of the treatment. Patients can request copies of disclosure of PHI under HIPAA: - ANSWER For a six (6) year period of time 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 C in CHEDDAR 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 choice What is the appropriate way to dispose of PHI that is no longer needed? - ANSWER Discard it in a locked shredding receptacle Which of the following would NOT be expected to fall under the responsibility or oversight of an organization's compliance committee? - ANSWER C. Recommending a specific merit increase in pay for employee's adherence to the code of conduct A family physician requests a post payment audit on claims from a particular commercial payer from which he is receiving denials. Whenever the provider performs a minor procedure with an E/M service, the minor surgery is reimbursed but the E/M service is denied. You review 10 charts and all cases are documented and coded