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Exam (elaborations)

AAPC CPMA Practice Exam Study Questions and Answers (100% Pass)

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What elements must be in a medical record Patient ID, Assignment of Benefits, 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? First initial, Last Name and...

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  • October 18, 2024
  • 8
  • 2024/2025
  • Exam (elaborations)
  • Questions & answers
  • AAPC CPMA
  • AAPC CPMA
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1 | P a g e | © copyright 2024/2025 | Grade A+




AAPC CPMA Practice Exam Study
Questions and Answers (100% Pass)
What elements must be in a medical record


✓ Patient ID, Assignment of Benefits, 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?


✓ 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?


✓ There must be a patient information sheet that contains 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?


✓ Discard it in a locked shredding receptacle




When must ABNs be signed?



Master01 | September, 2024/2025 | Latest update

, 1 | P a g e | © copyright 2024/2025 | Grade A+

✓ 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?


✓ S in SOAP and H in CHEDDAR




Patients can request copies of disclosure of PHI under HIPAA:


✓ For a six (6) year period of time




When can a RAC extrapolate the overpayment(s) on claims?


✓ If a RAC can demonstrate a high level of error, the RAC can then

extrapolate the findings and request a refund.




Example: Column 1 Code/Column 2 Code 45385/45380 CPT Code 45385 -

Colonoscopy, flexible, 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 biopsy, single or

multiple Policy: More extensive procedure Modifier -59 is:


✓ Only appropriate if the two procedures are performed on separate

lesions or at separate patient encounters.



Master01 | September, 2024/2025 | Latest update

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