Deck 9: Auditing

Question 1

Key components for selecting evaluation and management (E/M) codes include all of the following EXCEPT:

A) complexity of the diagnosis.
B) complexity of the medical decision making.
C) extent of the history documented.
D) extent of the exam documented.

Answer 1

complexity of the diagnosis.

Question 2

When auditing a medical chart, the auditor should verify that all documentation is initialed or signed by:

A) the provider and the office manager.
B) the provider.
C) the office manager.
D) all office staff.

Answer 2

the provider.

Question 3

An internal audit can be conducted:

A) prospectively only.
B) retrospectively only.
C) either prospectively or retrospectively.
D) neither prospectively or retrospectively.

Answer 3

either prospectively or retrospectively.

Question 4

A prepayment audit would verify:

A) the date of service and the patient's insurance identification number.
B) accurate coding and billing.
C) appropriate documentation of the visit.
D) completeness of progress reports.

Question 5

A postpayment audit would verify all of the following EXCEPT:

A) the coder's skill and knowledge.
B) billing records.
C) patient progress notes.
D) laboratory results.

Question 6

A postpayment audit would verify:

A) date of service.
B) patient insurance identification number.
C) sign-in sheets and appointment scheduling practices.
D) patient insurance eligibility.

Question 7

An expanded problem-focused history requires all of the following elements EXCEPT:

A) chief complaint (CC).
B) history of present illness (HPI).
C) review of systems (ROS).
D) past, family, and social history (PFSH).

Question 8

If Medicare determines that an E/M service exceeds the patient's documented need, Medicare could:

A) unbundle the service.
B) upcode the service.
C) pay the service as billed.
D) deny payment.

Question 9

Types of audits for medical records include all of the following EXCEPT:

A) accreditation audits.
B) certification audits.
C) external audits.
D) internal audits.

Question 10

The most widely used Current Procedural Terminology (CPT) codes are:

A) evaluation and management (E/M).
B) surgery.
C) radiology.
D) medicine.

Question 11

The most extensive type of history is:

A) problem focused.
B) expanded problem focused.
C) comprehensive.
D) detailed.

Question 12

Physician offices should audit their medical records to:

A) ensure compliance with HIPAA regulations.
B) determine the accuracy of the physician's documentation.
C) assess the completeness of the medical record.
D) all of the above.

Question 13

An internal audit would determine:

A) the coder's skill and knowledge.
B) whether procedures were coded correctly.
C) if additional training is needed for office staff.
D) all of the above.

Question 14

If documentation in the patient chart supports a lower level of service than that coded, the error would be called:

A) upcoding.
B) downcoding.
C) bundling.
D) unbundling.

Question 15

Documentation of a review of systems (ROS) is required in all types of histories EXCEPT:

A) problem focused.
B) expanded problem focused.
C) comprehensive.
D) detailed.

Question 16

Medical necessity of E/M services is based on all of the following factors EXCEPT the:

A) acuity and severity of the problems addressed.
B) complexity of documented comorbidities.
C) physical scope encompassed by the problems.
D) procedures performed to address the problem.

Question 17

An internal audit may be performed by a:

A) practice employee.
B) private payer.
C) government investigator.
D) all of the above.

Question 18

An independent audit should be performed a minimum of:

A) once a month.
B) once a quarter.
C) twice a year.
D) once a year.

Question 19

If documentation in the patient chart supports a higher level of service than that coded, the error would be called:

A) upcoding.
B) downcoding.
C) bundling.
D) unbundling.

Question 20

Which of the following is a disadvantage of a prospective internal audit?

A) It delays insurance payment.
B) It decreases the workload of the medical office specialist.
C) It ensures compliance.
D) It increases the risk of errors.

Question 21

If a patient states that the pain he or she is experiencing is in the right arm, the element he or she would be describing is the:

A) location.
B) severity.
C) context.
D) quality.

Question 22

If a patient complains of a dull ache in the left ear over the past 24 hours, he or she would be describing:

A) one HPI element.
B) two HPI elements.
C) three HPI elements.
D) four HPI elements.

Question 23

In a patient's chart, a diagnosis:

A) must be explicitly stated.
B) can be stated or implied.
C) must be part of the HPI.
D) must be coded.

Question 24

If a medical record note documents that the patient is status post-thyroid resection 10 years ago, this would be an example of the patient's:

A) past history.
B) family history.
C) social history.
D) HPI.

Question 25

If a patient states that the present illness started 3 days ago, the element he or she would be describing is the:

A) quality.
B) severity.
C) duration.
D) timing.

Question 26

In documenting a medical examination, all of the following are recognized organ systems EXCEPT the:

A) eyes.
B) ears, nose, mouth, and throat.
C) head, including face.
D) skin.

Question 27

If a patient states that the pain he or she is experiencing is burning, the element he or she would be describing is the:

A) associated signs and symptoms.
B) severity.
C) context.
D) quality.

Question 28

HPI types include:

A) brief or extended.
B) brief or detailed.
C) brief or comprehensive.
D) brief or complicated.

Question 29

A medical chart that reports an exam involving at least nine organ systems or body areas would be documentation of a(n):

A) problem-focused exam.
B) expanded problem-focused exam.
C) detailed exam.
D) comprehensive exam.

Question 30

All of the following are types of ROS EXCEPT:

A) problem pertinent.
B) extended.
C) comprehensive.
D) complete.

Question 31

Documentation of an extended HPI includes at least:

A) one HPI element.
B) two HPI elements.
C) three HPI elements.
D) four HPI elements.

Question 32

In documenting a medical examination, all of the following are recognized body areas EXCEPT the:

A) neck.
B) abdomen.
C) back.
D) skin.

Question 33

An examination that involves one or more organ systems or body areas is called a:

A) general multisystem exam.
B) general organ system exam.
C) single organ system exam.
D) multibody-area exam.

Question 34

A multisystem evaluation that includes at least six organ systems or body areas, and for each system/area selected, performance and documentation of at least two elements would be considered a(n):

A) problem-focused exam.
B) expanded problem-focused exam.
C) detailed exam.
D) comprehensive exam.

Question 35

In documentation of a medical exam, the terms musculoskeletal, respiratory, and gastrointestinal would refer to:

A) body areas.
B) body organs.
C) organ systems.
D) tissue systems.

Question 36

If a physician documents that an exam included the measurement of a patient's blood pressure, the system examined would be the:

A) cardiovascular system.
B) respiratory system.
C) neurological system.
D) musculoskeletal system.

Question 37

If a PFSH includes a review of the patient's past, family, and social history, it would be considered:

A) pertinent.
B) complete.
C) comprehensive.
D) detailed.

Question 38

If a physician examines the system directly related to the problem plus two to nine additional systems, the ROS would be considered:

A) problem pertinent.
B) extended.
C) complete.
D) none of the above.

Question 39

If a medical record note documents that the patient has smoked two packs of cigarettes every day for the past 10 years, it would be an example of the patient's:

A) past history.
B) family history.
C) social history.
D) HPI.

Question 40

Elements of medical decision making include all of the following EXCEPT:

A) number of diagnoses or management options.
B) number of procedures or services provided.
C) amount and/or complexity of data to be reviewed.
D) risk of significant complications, morbidity, and/or mortality.

Question 41

Which of following questions should be asked and answered yes before coding as a consultation?

A) Does the documentation of the service clearly demonstrate who made the request and the nature of the opinion requested?
B) Has the provider provided a written report of his or her opinion/advice to the referring physician?
C) Although the referring physician may have asked for a "consultation," should the E/M service truly be reported as a consultation?
D) all of the above.

Question 42

An audit done within a medical practice to make sure it is compliant is an external audit.

Question 43

If a patient presents with one self-limited or minor problem, the level of risk involved with the medical decision making would be considered:

A) minimal.
B) low.
C) moderate.
D) high.

Question 44

The risk of significant complication, morbidity, and/or mortality is based on the risks of:

A) the presenting problems.
B) the diagnostic procedures.
C) the possible management options.
D) all of the above.

Question 45

To consider time as the key factor in determining the level of E/M services, the counseling and/or coordination of care must make up more than:

A) 10% of the encounter.
B) 25% of the encounter.
C) 50% of the encounter.
D) 75% of the encounter.

Question 46

Physician services that are more intense than the work of other E/M services and that involve frequent personal assessment by the physician would be coded as:

A) consultation.
B) critical care.
C) subsequent care.
D) initial hospital care.

Question 47

If a physician who ordered a test personally reviews the results to supplement information from the physician who prepared the test report, the work would add to the level of the:

A) number of diagnoses or management options.
B) amount and/or complexity of data to be reviewed.
C) risk of significant complications, morbidity, and/or mortality.
D) all of the above.

Question 48

Medicare can deny or downcode an E/M service if it feels that the service provided exceeds the patient's documented needs.

Question 49

An internal audit will NOT be able to help a practice discover lost revenue.

Question 50

All third-party payers follow the same rules and policies for submitting a clean claim.

Question 51

A medical office specialist can find clinical examples for documenting medical necessity in the:

A) CPT Index.
B) CPT Appendix A.
C) CPT Appendix C.
D) CPT Guidelines.

Question 52

If a patient presents with an acute or chronic illness that poses a threat to life or body function and requires emergency surgery, the level of risk involved with the medical decision making would be considered:

A) minimal.
B) low.
C) moderate.
D) high.

Question 53

If a medical office specialist does NOT agree with the payment determination made by an insurance company, the decision can be appealed.

Question 54

A retrospective audit is conducted before sending claims to an insurance company.

Question 55

If the level of risk of mortality is very high, the medical decision making would be considered:

A) minimal.
B) low.
C) moderate.
D) high.

Question 56

An audit tool utilizes number counts in different categories to determine if the correct E/M code was used in billing an insurance carrier.

Question 57

If a CPT code stated on a claim form represents a lower level of service than is documented in the medical record, the procedure has been downcoded.

Question 58

A prospective audit would typically be done on claims that require an attachment or more information.

Question 59

If a medical office assistant is NOT sure about which E/M code to use, he or she should:

A) not code the procedure.
B) use the lowest possible code level.
C) use an intermediate level code for the service.
D) ask for help.

Question 60

An example of an E/M code that requires three key components documented and a comprehensive history and comprehensive exam is:

A) a new patient office visit.
B) an established patient office visit.
C) critical care services.
D) subsequent in-hospital care.

Question 61

If a patient complains of an aching pain in the chest, the complaint would be considered part of the PFSH.

Question 62

In general, medical decision making with respect to a diagnosed problem is harder than that for an identified but undiagnosed problem.

Question 63

If a physician considers findings from discussions with family members in his or her medical decision making, documentation in the chart can simply state "additional history obtained from family" without providing additional detail.

Question 64

When documentation does NOT support the level of service provided, and a lower-level code should have been selected, this practice is known as ________.

Question 65

Time is considered the controlling factor for determining the level of E/M service if counseling with the patient or family members constitutes more than 50% of the encounter.

Question 66

A brief statement or notation indicating "negative" or "normal" is sufficient to document normal findings related to unaffected area(s) or asymptomatic organ system(s).

Question 67

An ROS is considered part of the physical examination.

Question 68

A physician's review of laboratory reports and previous medical records would impact the level of medical ________.

Question 69

The key elements in determining the level of E/M services include the extent of the history, physical exam, and medical decision making.

Question 70

If a physician documents that a patient had breast cancer 4 years ago, he or she would be documenting the patient's ________ history.

Question 71

For a presenting problem without an established diagnosis, the clinical impression may be stated as a "possible" or "rule-out" diagnosis.

Question 72

An extended HPI will include one to three documented HPI elements.

Question 73

An audit done by a practice before submitting a claim to an insurance company would be referred to as a(n) ________ audit.

Question 74

An inventory of body systems obtained by asking the patient a series of questions is called a(n) ________.

Question 75

If a physician documents that a patient's maternal grandmother died of breast cancer, he or she would be documenting the patient's ________ history.

Question 76

The two types of HPI are ________ and ________.

Question 77

An independent medical record review completed after payment is received from an insurance carrier is a(n) ________ audit.

Question 78

The extent of information that the physician gathers for a medical history is based on rules set up by Medicare.

Question 79

Audits performed on a regular basis will confirm that documentation and coding were appropriate for the level of service provided or will identify problems.

Question 80

When documentation supports a higher level of service than the code assigned, this practice is known as ________.