CPMA Study guides, Class notes & Summaries

You are performing an audit of evaluation and management services for a family practice office. In the encounter, you read the physician order 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. What is the minimum signature assignment(s) of the aut...

When auditing operative notes, the auditor will expect to see documentation from all of the following except - ANSWER Surgical assistants According to the Health Insurance Portability and Accountability Act of 1996 (HIPAA), an outside auditor must sign which of the following agreements prior to reviewing and auditing any medical records? - ANSWER Business Associate Agreement The HIPAA Privacy Rule defines "minimum necessary" as typically requiring healthcare employees to - ANSWER Follow ...

CMS Fraud Definition - ANSWER Making false statements or misrepresenting facts to obtain an undeserved benefit or payment from a federal healthcare program CMS Fraud Definition - ANSWER Making false statements or misrepresenting facts to obtain an undeserved benefit or payment from a federal healthcare program CMS Abuse Definition - ANSWER An action that results in unnecessary costs to a federal healthcare program, either directly or indirectly CMS Abuse Definition - ANSWER An action th...

SOAP - ANSWER Subjective, Objective, Assessment, Plan CHEDDAR - ANSWER Chief complaint, Hx, Exam, Details of problem/complaint, Drugs & dosages, Assessment, Return visit Subjective - ANSWER Pt complaint Objective - ANSWER Provider observation Assessment - ANSWER Medical Dx Plan - ANSWER 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 t...

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 exp...

When auditing operative notes, the auditor will expect to see documentation from all of the following except: - ANSWER Surgical assistants. According to the Health Insurance Portability and Accountability Act of 1996 (HIPAA), an outside auditor must sign which of the following agreements prior to reviewing and auditing any medical records? - ANSWER Business Associate Agreement When auditing an ENT practice, you discover the practice uses an EMR. Which of the following options would you loo...

If a covered entity identifies material breach of a contract agreement with a business associate and the contract is terminated the problem is reported to: - ANSWER Office for Civil Rights (OCR) Which is an example under the Privacy Rule that requires a written agreement to disclose protected health information? - ANSWER A physician sending patients treatment plan to a marketing pharmaceutical company

Which statement is true regarding an audit performed on charts for Medicare beneficiaries? - ANSWER National CMS policies and local MAC policies should be utilized when performing Medicare audits. In addition to CMS it is necessary to know your Medicare Administrative Contractor that supports the location where services are rendered for example 4x4 rule. How often should an internal audit be conducted minimally? - ANSWER Annually (more often if problem is

The first initial, last name and credentials - ANSWER What is the minimum signature assignment(s) of the author of an entry in the medical record? Personal biographical data and consent for treatment or authorization for treatment form - ANSWER Based on Joint Commission accreditation guidance for personal data, what two elements must be evident in the medical record Surgical assistants - ANSWER As an auditor, who of the following would NOT be expected to submit operative notes? Discard ...

Which option is NOT part of the seven elements that should be included in a compliance plan based on the OIG's recommendations? a. Responding promptly to detected offenses and developing corrective action. b. Conducting effective training and education. c. Identifying employees on the exclusions list. d. Developing effective lines of communication. - ANSWER c. Identifying employees on the exclusions list. The OIG's Compliance Program Guidance for Individual and Small Physician Group Pra...