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CPMA CHAPTER #2 EXAM QUESTIONS WITH COMPLETE ANSWERS
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CPMA CHAPTER #2 EXAM QUESTIONS WITH COMPLETE ANSWERS
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CPMA CHAPTER #2 EXAM QUESTIONSWITH COMPLETE ANSWERS
For therapy services, what is the reason for a progress note? - Answer-To provide
justification for the medical necessity of treatment information. Documentation
requirements for therapy services include progress reports which provide justification for
the medical necessity of treatment. Information required in the progress reports should
be written by a clinician.
What must be included in a business associate agreement? - Answer-The permitted
and required uses of PHI by the business associate. The contract must describe the
permitted and required uses of protected health information by the business associate,
limit the business associate from using or further disclosing the protected health
information (except where permitted by contract or required by law), and require the
business associate to follow appropriate safeguards to prevent use or disclosure of the
protected health information, except as expressly defined in the contract.
What information does a privacy practice notice contain? - Answer-Elements to notify
individuals as to how the covered entity will use and disclose the PHI. A privacy practice
notice must be provided by each covered entity, and must contain certain elements to
notify individuals as to how the covered entity will use and disclose the individual's
protected health information. The notice must clearly explain the covered entity's
obligation to protect privacy, provide a notice of privacy practices, and abide by the
terms of the current notice. The covered entity must also inform the patient of his or her
individual rights, and the steps to follow (including a point of contact for further
information) if an individual feels his or her privacy rights have been violated.
Which of the following is an example of information that may be transmitted
electronically and covered under the privacy rule? - Answer-Claim forms. All health care
providers who electronically transmit health information through certain transactions are
covered entities. Some examples of transactions that may be submitted electronically
are claim forms, inquiry about eligibility of benefits, and requests for authorization of
referrals.
How must medical records be retained? - Answer-A specific requirement does not exist.
There are no specific requirements as to how the medical records must be retained.
They may be kept in their original format, or reproduced in a way that is legally
acceptable. The most important component of retention is that the record is protected,
to ensure the security and integrity of the records.
What is CHEDDAR? - Answer-An optional way of documenting E/M services.
CHEDDAR is a format that can be (not required) used to document E/M services. Chief
complaint, History of present illness, Exam, Details, Drugs and dosages, Assessment,
Return visit information or referral.
,In evaluation and management services, what does the A stand for in SOAP and what
is included in this section? - Answer-Assessment; the provider documents an
assessment of the patient's condition. Assessment; the provider's assessment of the
patient's condition, and where the provider indicates either a definitive or working
diagnosis. In absence of a diagnosis, signs and symptoms may be documented until
further testing can be performed.
Which one in NOT a term used for a radiological view in a radiology report? - Answer-
Prone. Anteroposterior, Oblique, and Swimmers are types of radiological views used in
a radiology report. Prone is not a radiological view, but a body position when the patient
is face down.
What is the Health Care Fraud and Abuse Control Program? - Answer-A program
established by HIPAA to combat fraud and abuse in healthcare. HIPAA also established
the Health Care Fraud and Abuse Control Program, a far-reaching program to combat
fraud and abuse in healthcare, including both public and private health plans.
When a laboratory report has an abnormal finding, what should be documented? -
Answer-Circle and sign the abnormal finding and address the abnormality in the
diagnosis. When the lab report reveals an abnormal finding, the physician should circle
and sign the abnormal result to indicate it was seen. The physician must also make sure
to address the abnormality in the diagnosis and treatment plan.
What form is used to authorize payment from the insurance carrier to go directly to the
provider? - Answer-Assignment of benefits. Assignment of benefits—This is an
authorization form signed by the patient that allows their insurance carrier to pay the
provider directly. Without this, the payment will go to the beneficiary and the provider
will be required to collect payment from the beneficiary.
Which type of signature will CMS allow only in the case of a provider with a proven
disablity affecting their ability to provide a signature? - Answer-Rubber Stamp. The
method used (e.g. handwritten or electronic) to sign an order or other medical record
documentation for medical review purposes in determining coverage is not a relevant
factor. The Centers for Medicare & Medicaid Services allows rubber stamps only in the
case of a provider with a proven disability affecting their ability to provide a signature,
but other carriers may still allow it.
If a covered entity identifies a material breach of a business associate agreement, and it
is not possible to cure the breach or end the violation, what should occur? - Answer-The
contract must be terminated, and the problem reported to the HHS Office for Civil rights.
If a covered entity identifies a material breach or violation of the contract or agreement,
reasonable steps must be taken to cure the breach or end the violation. If that is not
possible, the contract must be terminated, and the problem reported to the Department
of Health and Human Services (HHS) Office for Civil Rights (OCR).
, What form is required to be obtained from the patient prior to completing a surgical
procedure? - Answer-Informed consent. Prior to a patient undergoing a specific medical
intervention, state law requires that the provider obtain an informed consent for
treatment. This form is signed by the patient to verify that the patient understands
procedures, outcomes, and options.
What section of an operative report typically contains the date of the surgery,
preoperative diagnosis, postoperative diagnosis, and operation performed? - Answer-
Header. The header of an operative note is designed to identify the patient name, date
of surgery, preoperative diagnosis, postoperative diagnosis, the procedures performed,
primary surgeon, assistant surgeon(s), anesthesia administered, and the
anesthesiologist.er.
Why is it important to read the body of an operative note as an auditor? - Answer-To
identify if the details in the documentation support the surgery listed in the header, if
additional procedures have been performed, or if modifiers should be used. Reading
and analyzing an operative report requires time and great attention to detail. Challenges
arise when the report indicates a specific procedure as being performed in the header,
but the details in the body of the note do not support that procedure, or indicate
additional procedures not reported in the title. For this reason, it is very important to
read the entire note slowly and carefully. Attempt to gain an understanding of the entire
surgical case before taking more time to read the report thoroughly to analyze for proper
code assignment.
What is appropriate to document in a radiology report for contrast material used in a
radiologic study? - Answer-The type and amount of contrast used, along with the route
of administration is documented. Contrast material may be used to enhance the view of
an internal structure. There are different types of contrast material. The amount and
type of contrast material should be documented in the radiology report along with the
route of administration.
Which section of an operative report would you expect to find the reason or medical
necessity for the procedure? - Answer-Indication for surgery. The indication typically
gives a brief history outlining the reasons for or medical necessity for the procedure.
When a minor procedure is performed in the office, what is the documentation
requirement? - Answer-The detail of the procedure can be included in the
documentation for the office visit. If a minor office procedure is performed during an
evaluation and management service, the documentation for that procedure can be
included in the notes for the evaluation and management service. It is not necessary to
have a separate operative report.
In evaluation and management services, what does the O stand for in SOAP and what
is included in this section? - Answer-Objective; indicates the physical exam findings of
the provider. O is the objective portion of the visit which indicates the provider's
objective findings during the exam.
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