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 ...
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.
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