AAPC-CDEO Certified Documentation Expert Outpatient - Set 3 - Part 2

Correct Answer: Charting by exception

Charting by exception (CBE) contains a list of normal findings. After an assessment, nurses confirm normal findings and write only brief progress notes for abnormal findings or for communication with other team members. Option b is incorrect because is a brief progress note built on Data, Action and Response for one client problem; it is commonly paired with the list-based format, not the list itself. Option c is incorrect because is a safety tool completed after an unexpected occurrence such as a fall or near miss, and it is not part of the medical record. Option d is incorrect because is documented when a client leaves an agency and covers departure, condition, education, instructions and follow-up, not a list of normal findings confirmed after assessment.

Correct Answer: Identifiable date and author, clearly and permanently denoted

The Medicare manual states that the date and author of any amendment, correction or delayed entry should be identifiable, and the addition should be clearly and permanently denoted, so a later entry is transparent. Option a is incorrect because erasing is not a permitted method; errors are never erased, scribbled out, or covered with white-out, and a delayed entry adds information rather than removing it. Option c is incorrect because the Medicare manual requires the date of the addition to be identifiable, so dating it as though written at the time of service would obscure that it was added later. Option d is incorrect because blank lines in paper records are avoided because they let others add to the documentation, so they offer no protection for a delayed entry.

Correct Answer: Assume the entry date from the adjacent dated entries

Documentation must contain enough information to show the date services were ordered or performed. When entries immediately above and below an undated entry are dated, medical reviewers may reasonably assume the date of the entry in question. Option a is incorrect because the guidance only requires enough information to determine the date of service or order, and neighboring dated entries can supply it. Option b is incorrect because an attestation resolves a signature problem, such as an illegible signature, and cannot be used to backdate an entry. Option c is incorrect because referrals follow suspected fraud, such as missing or illegible signatures raising legitimacy concerns, not an ordinary undated entry with dated neighbors.

Correct Answer: Avoid abbreviations

Guidance on incident reports, also called variance reports, states that abbreviations, assumptions, or interpretations should be avoided. Legal documentation guidelines also say abbreviations should be avoided, so the nurse writes out terms in full. Option b is incorrect because guidance directs that assumptions and interpretations be avoided in incident reports, so the narrative should state what occurred rather than a presumed cause. Option c is incorrect because incident reports are not part of the medical record and should not be mentioned there; only the specific event is charted in the record. Option d is incorrect because the date and time of the event are listed among the required elements of an incident report, so omitting the time would leave it incomplete.

Correct Answer: Legible signature and date

Teaching physicians and residents may document their services in the medical record, and all documents must be legibly signed and dated. This applies whether the entry is dictated and transcribed, typed, handwritten, or computer-generated. Option a is incorrect because macro text by itself is insufficient documentation; the note must also describe the patient-specific services provided on that date. Option b is incorrect because handwriting is just one acceptable format; typed, computer-generated, and dictated and transcribed documents are also permitted, so no single format is mandated. Option d is incorrect because dictated and transcribed entries are one of several allowed formats, not a mandatory method, so this cannot be the requirement applying across every format.

Correct Answer: Persons responsible for the beneficiary's care

The Medicare Program Integrity Manual requires that the person(s) responsible for the beneficiary's care, including those providing, ordering or certifying items and services, be identifiable as such in the record for medical review purposes. Option a is incorrect because claim submission is a billing function, and the manual's identifiability requirement addresses the people responsible for the beneficiary's care rather than those who file claims. Option b is incorrect because reviewers are the contractors applying the requirement; the requirement itself concerns who was responsible for care in the record being reviewed. Option c is incorrect because scheduling is not a role the Medicare manual names; the requirement attaches to those responsible for care, including providing, ordering or certifying items and services.

Correct Answer: A system protected against modification

CMS guidance warns that alternate signature methods can be misused or abused, so providers need a system and software protected against modification, along with adequate administrative procedures that correspond to recognized standards and laws. Option b is incorrect because CMS does not require a scribe to sign or date the documentation, and a scribe signature does nothing to protect an electronic system. Option c is incorrect because attestation is a process contractors pursue when the record raises authenticity concerns, not a safeguard that providers build into their electronic systems. Option d is incorrect because stamped signatures are not typically acceptable; CMS permits a rubber stamp only for an author with a physical disability who can provide proof.

Correct Answer: Proof of inability to sign due to disability

Stamped signatures are not typically acceptable. CMS permits a rubber stamp under the Rehabilitation Act only for an author with a physical disability who can provide the contractor proof of the inability to sign. Option a is incorrect because a signature log identifies a signer whose handwriting is illegible; the guidance does not make it the condition for a disability-based stamp exception. Option b is incorrect because an attestation addresses a missing required signature on a medical record; it does not replace the proof the contractor needs for stamp use. Option c is incorrect because CMS does not require a scribe to sign or date documentation, so a scribe's signature does not establish the stamp exception.

Correct Answer: Must list the author's credentials

Credentials in a signature log are encouraged but not required. Reviewers shall not deny a claim for a signature log that is missing credentials, so a credentials requirement is not a feature of the log. Option a is incorrect because reviewers consider all submitted logs regardless of creation date, and an organization without a log may create one whenever needed. Option c is incorrect because the guidance allows a log to appear on the page where the initials are used or to be submitted as its own document. Option d is incorrect because the guidance describes a signature log as listing the typed or printed name of the author associated with initials or an illegible signature.

Correct Answer: A tool that assists in documenting a progress note

CMS defines a template as a tool, instrument or interface that assists in documenting a progress note. Templates may be paper or electronic, ranging from simple electronic documents to graphical interfaces with clinical decision support prompts. Option b is incorrect because CMS states that certificates of medical necessity, supplier prepared statements and attestations alone do not provide sufficient documentation of medical necessity, even when signed by the ordering physician. Option c is incorrect because that describes a documentation macro, which may be a computer or dictation command, whereas a template is a paper or electronic tool assisting the note. Option d is incorrect because CMS does not endorse or approve particular templates except the clinical templates it publishes, and a physician or LCMP may choose any template.

Correct Answer: Insufficient by themselves to document medical necessity

CMS states that Certificates of Medical Necessity, DME Information Forms, supplier prepared statements and physician attestations by themselves do not provide sufficient documentation of medical necessity, even if signed by the ordering physician. Option a is incorrect because CMS states that these items do not provide sufficient documentation of medical necessity by themselves, even when the ordering physician has signed them. Option b is incorrect because a supplier prepared statement is one of the items CMS names as inadequate alone, so supplier authorship adds no support for medical necessity. Option d is incorrect because CMS allows templates to facilitate record-keeping but notes that limited templates often fail to capture detail, so a template does not turn these items into proof.

Correct Answer: A signed order listing the specific test

CMS lists three acceptable forms of diagnostic lab test order documentation. One is a signed order or signed prescription listing the specific test. The others pair an unsigned order with an authenticated medical record, or rely on that record alone. Option a is incorrect because unsigned physician orders or unsigned requisitions alone do not support physician intent to order, so this would not meet the requirement. Option b is incorrect because documentation of accurate order processing and claim submission is something the claim submitter must keep, but it is not one of the accepted order types. Option c is incorrect because CMS says to include a signature log when a handwritten signature is illegible; it is not listed among the documents that satisfy the order requirement.

Correct Answer: An authenticated medical record supporting intent to order

An unsigned order listing the specific tests must be followed by an authenticated medical record supporting intent to order. Unsigned orders or requisitions alone do not support physician intent to order. Option b is incorrect because a further unsigned requisition is still an unsigned order, and unsigned orders or requisitions alone do not support intent to order. Option c is incorrect because the claim shows order processing and billing, which the submitting entity must keep, but it does not show the treating provider's intent to order. Option d is incorrect because a protocol copy is required when a standing order or protocol is used, but it does not authenticate intent for an unsigned requisition.

Correct Answer: Internal audit results

OIG guidance on retention of records says the primary compliance documents a practice would want to retain are those relating to educational activities, internal investigations and internal audit results, so internal audit results is correct. Option a is incorrect because the practice may obtain copies of these to keep its standards and procedures current, but OIG guidance does not name them among the primary compliance documents to retain. Option b is incorrect because another entity's policies and procedures can serve as a template for the practice's own version, which makes them a drafting aid rather than a primary retained compliance record. Option d is incorrect because these belong to the medical record and help support medical necessity; they are patient care documents, not the compliance records OIG singles out for retention.

Correct Answer: Reviewer cannot confirm services, level billed or necessity

CERT reviewers assign an insufficient documentation error when the submitted records do not let them determine whether services were provided, were provided at the level billed, or were medically necessary. Option b is incorrect because the billing provider is expected to collect supporting documentation from referring offices and other record locations, because its payment is the one under CERT review. Option c is incorrect because CERT requests records by fax, letter, or phone call, so responding to a phone request is the normal process and not an error. Option d is incorrect because CMS guidance tells staff to send records that support payment, including earlier-dated items such as a signed note from a prior visit, so this helps rather than harms.

Correct Answer: Revocation of Medicare enrollment

Failure to comply with document maintenance and access requirements may result in revocation of Medicare enrollment. A hospital employer's refusal to provide access is not a valid excuse, and even one missing record may be an instance of non-compliance. Option a is incorrect because CMS guidance calls the hospital's refusal of access an invalid excuse, so the request stands and the physician remains responsible for producing the record. Option c is incorrect because CERT is a program that samples claims to measure improper payments; it is not a penalty imposed for failing to give record access. Option d is incorrect because the maintenance and access requirements apply to the physician who orders or refers services, even when an employer holds the records; responsibility is not shifted.

Correct Answer: A contact person or office

The administrative requirements standard on personnel designations requires a covered entity to designate a contact person or office responsible for receiving complaints and able to provide further information about matters covered by the notice of privacy practices. Option a is incorrect because a plan sponsor is the party to which a group health plan may disclose protected health information, not a complaint-handling designee. Option b is incorrect because the Secretary specifies the technology or methodology that renders protected health information unusable or unreadable, not the entity's internal complaint contact. Option c is incorrect because the privacy official is designated to develop and implement the entity's policies and procedures, which is a separate duty from receiving complaints.

Correct Answer: The individual will not be retaliated against

The Complaints element of a notice of privacy practices requires a statement that individuals may complain to the covered entity and the Secretary, a brief filing description, and a statement that the individual will not be retaliated against. Option a is incorrect because the complaint element does not impose a deadline; it gives a brief description of the filing process and a non-retaliation statement instead. Option b is incorrect because the required complaint content covers the right to complain, a brief description of how to file with the covered entity, and non-retaliation, with no fee mentioned. Option d is incorrect because the notice says individuals may complain to the covered entity and to the Secretary, and it does not require the Secretary to be contacted first.

Correct Answer: Underpayment of investors under private ownership

OIG guidance links fee-for-service to overutilization, capitation to stinting on care and discriminating against costly patients, and performance-based payment to gaming of data. It lists no risk of investor underpayment as a payment methodology risk. Option a is incorrect because capitated payment is described in the guidance as raising the risk that care is withheld, which is called stinting. Option b is incorrect because OIG guidance names overutilization as a heightened risk when an insurer pays on a volume-sensitive or fee-for-service basis. Option c is incorrect because payments that take quality or other performance measures into account are tied in the guidance to gaming of data to qualify for payment.

Correct Answer: fee-for-service

Health care institutions were traditionally paid under the fee-for-service model, in which the hospital bills the individual's insurance program for the cost of care. Pay for Performance later emerged as part of a national strategy to reduce costs. Option b is incorrect because it names an entity that participates in a qualifying model with certified EHR use and financial risk, not a reimbursement model. Option c is incorrect because it is the newer value-based model that ties higher payment to outcomes, best practices, and client satisfaction rather than to billing for services. Option d is incorrect because it is a defined model type, such as the shared savings program, and is not described as the traditional way institutions were paid.