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Grading Results:
30 out of 30 are correct. Scroll down to view the rationale (if available) for each question.
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Question 1
Evaluation and Management documentation is often captured in SOAP format, which is
the acronym for:
A. Subjective, Objective, Assessment, Procedure
B. Subjective, Observation, Assessment, Plan
C. Subjection, Objection, Assessment, Plan
D. Subjective, Objective, Assessment, Plan
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Question 2
Failure to have which of the following forms in the medical record will result in payment being
sent to the beneficiary?
A. Patient registration form
B. Assignment of benefits form
C. Confirmation of Receipt of Privacy Notice
D. Release of Information form
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Question 3
Prior to undergoing a specific medical intervention, law requires the provider to obtain an
informed consent for treatment signed by the patient. In addition to the nature or purpose of
the treatment and risks and benefits involved, the informed consent must include which of the
following information?
A. The treating physicians experience in performing the procedure
B. Alternative treatment options and the risks and benefits of alternative treatment options.
C. The cost of the treatment.
D. The length of time for full recovery.
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Question 4
Outpatient physical therapy services cannot be initiated until:
A. an initial plan of care has been established.
B. the afternoon to achieve maximum therapeutic outcome.
C. the patient is mentally prepared for services.
D. primary care provider approves.
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Question 5
When auditing operative reports, the header describing the procedure is:
A. always accurate in describing the procedure that was performed.
B. all that is needed to assign the correct procedure code.
C. may not fully support the procedure documented in the body of the report.
D. the only documentation to be considered during the audit.
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Question 6
During an audit of a paper medical record, the auditor finds a correction was made using white-
out and initialed by the nurse. This method of correction is:
A. acceptable because it was initialed by the person altering the medical record entry.
B. unacceptable because the original content is not readable.
C. unacceptable because a black marker should have been used.
D. acceptable because it provided space to make the correction.
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Question 7
An auditor identifies claims for services provided by a non-physician provider as Incident-to
during the month the physician was on vacation. This would be considered:
A. fraud.
B. abuse.
C. common billing procedure.
D. compliant with False Claim Act.
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Question 8
The penalties for violation of the Stark law include program exclusion for knowing violations and:
A. potential $25,000 CMP for each service.
B. potential $18,000 CMP for each service.
C. potential $15,000CMP for each service.
D. maximum of $25,000 CMP annually.
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Question 9
You audit a provider who performs and bills for an arthroscopic rotator cuff repair, 29827, and for an
arthroscopic debridement, 29822. The payer contract specifies NCCI edit rules will be applied. There is
an NCCI edit against reporting both procedures during the same operative session; in
reviewing the surgeons documentation, you find that the debridement was performed in a
different site supporting the 59 modifier, which is allowed under NCCI. This is an example of:
A. fraud.
B. abuse.
C. proper coding and billing practice.
D. none of the above.
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Question 10
The False Claims Act allows for reduction of penalties to two times the amount of damages (as
opposed to three times) under what condition(s)?
A. The person committing the violation self discloses within 30 days of violation notification.
B. The accused person willfully opts out of the Medicare program.
C. The person fully cooperates with the investigation of the violation.
D. Both a and c
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Question 11
The compliance program guidance (CPG) document identifies four risk areas most likely to
affect a physicians practice. The risk areas include:
A. Coding and billing, malpractice insurance, patient dissatisfaction, increasing health risks.
B. Coding and billing, reasonable and necessary services, documentation, improper inducements.
C. Reasonable and necessary services, patient dissatisfaction, documentation, improper
inducements.
D. Improper inducements, kickbacks, self-referrals and malpractice insurance.
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Question 12
The manager of a small physicians practice who also is the compliance officer, contacts you an
auditor, stating that a coding and billing violation has been identified by the billing department
manager. You advise the compliance officer to document which of the following in the
practices compliance file:
A. date of incident, name of reporting party, name of person responsible for taking action, follow-up
action taken
B. date of incident, identify previous violations, name of individual involved in violation, final outcome.
C. date of incident, nature of violation, name of person responsible for taking action, follow-up action
taken.
D. date of incident, name of reporting party, name of person committing violation, name of per
responsible for taking action.
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Question 13
According to CPT
coding guidelines for inpatient consultation services, which statement is correct?
A. Subsequent consultation is reported with established patient codes.
B. Only one consultation is reported by consultant per day.
C. Only one consultation is reported per hospital admission.
D. If consultation is initiated on day 2 following admission, report subsequent hospital care codes.
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Question 14
Minor procedures as defined by Medicare have a zero or 10-day postop period. Which statement is true
regarding minor and endoscopic procedures?
A. a. An office visit on the same day of the minor or endoscopic procedure is billable if it corresponds
to the procedure being performed.
B. b. There is no preoperative period and an office visit is billable if a significant and separately
identifiable service is performed in addition to the procedure.
C. c. There is a one day preoperative period and modifier 25 is not allowed under any circumstances.
D. d. A hospital visit on the same day of a minor endoscopic procedure can be reported without
modifier 25.
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Question 15
Based on CPT coding guidelines, which of the following scenarios identifies the correct use of modifier
25?
A. A dermatologist sees a patient at the request of his primary care physician with multiple lesions on
the left and right hands. The dermatologists performs a history pertinent to the presenting problem. The
lesions are determined to be actinic keratosis and are cryosurgically removed.
B. A patient came in for a monthly follow up for chronic shoulder pain. Physician reviewed a current
series of shoulder X-rays and discusses the patients impending return to work. The patient was also
complaining of a severe headache. The physician performed a neurological exam and did not find any
evidence of vascular or CNS etiology. He then performed bilateral occipital block for the headache.
C. An OB/GYN sees a patient who is complaining of severe abdominal pain. The physician obtains a
pelvic ultrasound and other diagnostic testing and determines that the patient has a tubal pregnancy. The
OB/GYN decides that laparoscopic surgery will be performed on the same day.
D. A new patient presents for an annual well-woman exam. A complete review of systems is obtained
and an interval past, family, and social history is reviewed and updated. A neck-to-knees exam is
performed, including a pelvic exam, and a Pap smear is taken. Counseling is given on diet and exercise.
Appropriate labs are ordered. The patient also complains of vaginal dryness. Her prescription for oral
contraception is renewed.
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Question 16
An audit of 20 family practice charts for code 20552-20553 reveals that the provider used fluoroscopic
guidance when performing trigger point injections. In reviewing claims data for these charts, it is found
that 76942 was reported with 20552-20553. What should be stated on the audit findings report?
A. Coding is incorrect, code 77002 should be reported for these cases.
B. Coding is correct, radiologic guidance is reported separately.
C. Coding is incorrect, radiologic guidance is included in codes 20552-20553.
D. Coding is incorrect, code 77021 should be reported for these cases.
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Question 17
A provider performs two procedures that NCCI edits state should not be reported together. However if
the NCCI edit does not allow use of NCCI-associated modifiers to bypass it and the documentation
supports and qualifies as an unusual procedure, the physician may report the column one HCPCS/CPT
procedure code of the NCCI edit with which of the following modifiers?
A. 52
B. 59
C. 22
D. 51
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Question 18
An auditor identifies a procedure that has a modifier appended. This is an indication that:
A. the procedure performed was altered, but the definition of the code has not changed.
B. the procedure performed was altered and the definition of the code has changed.
C. the procedure should not be reported if it was altered.
D. a special report should be submitted with the claim
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Question 19
Sarah Smith works for an emergency physician group. She has been given the responsibility to perform a
baseline E/M audit for the physicians in the group. What is the first step she should take to begin this
process?
A. Run a revenue report of all services performed
B. Review all level four and five E/M services.
C. Run a utilization report of E/M services
D. Identify the providers who have been with the group the longest.
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Question 20
An audit performed on one provider would be considered a:
A. Retrospective audit
B. Focused audit
C. Random audit
D. Perspective audit
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Question 21
When performing a retrospective audit, the auditor will need to have which of the following materials?
A. Coding manuals, medical record, audit form, CMS 1500 form, billing policies, release of
information form.
B. Medical record, audit form, coding manuals, EOB or Medicare RA, payer policies and CMS-1500
form.
C. Release of information form, coding manuals, audit form, medical record, EOB or Medicare RA.
D. Coding manuals, audit form, CMS 1500 form, assignment of benefits, payer policies, medical
record.
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Question 22
The OIG is investigating a medical practice. You have been hired by an attorney to audit medical charts
to validate the coding of office services. The OIG requests the auditor to pull medical records with a
confidence level of 95 percent based on and Excel file given to the auditor. Based on this request, how
many charts need to be pulled?
Confidence Level
Precision 80% 90% 95% 99%
1% 7254 13596 19763 32064
2% 2089 3432 4856 8349
5% 338 684 752 1356
10% 82 139 165 339
15% 38 64 79 154
25% 14 23 32 57
A. 3432
B. 4856
C. 752
D. 19763
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Question 23
A sample is gathered of the CPT/HCPCS codes that have the highest dollar charges. This would be
considered which type of sampling?
A. Non-statistical
B. Numerical
C. Judgmenta
D. Proportional
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Question 24
Using RAT-STATS to create a Discovery Sample for a CIA Claims Review serves what purpose?
A. Identify the estimated dollar difference between billed and paid claims.
B. Identify the financial error rate of the selected sample
C. Estimate the net underpayment.
D. Estimate the net overpayment.
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Question 25
A provider receives denials from a private payer for E/M services performed on the same date as a minor
procedure. You review documentation for 25 records and the payer contract which states the provider
must follow CMS coding guidelines. You determine that 20 of the records have appropriate
documentation to support both E/M and the procedure and were coded correctly when the claim was
originally submitted. You submit an appeal for the 20 dates of service that are supported by
documentation. To support you findings, you will include in the appeal a letter reporting your findings,
claim forms, copies of documentation, EOB copies and:
A. CPT description for modifier 25 use.
B. NCCI policy manual for modifier 25.
C. CPT Assistant article
D. NCCI Edits for major procedures.
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Question 26
Nancy prepares to begin a focused audit for Dr. Jacobsen, a general surgeon.The resources
that she will gather in addition to the CPT