AAPC-CPMA Certified Professional Medical Auditor - Set 1 - Part 1

Correct Answer: I, II, and III

OIG guidance states a properly documented medical record may validate the site of the service, the appropriateness of services provided, the accuracy of the billing, and the identity of the care giver. Household income is not listed. Option a is incorrect because it leaves out the accuracy of the billing, which OIG guidance also lists among the items the medical record may validate. Option c is incorrect because it includes household income, which is not among the items OIG guidance says the record validates, and it drops the site of service. Option d is incorrect because household income does not appear in OIG's list of validation purposes, and this choice also omits the identity of the care giver, which does.

Correct Answer: coder

The Official Guidelines state that a joint effort between the healthcare provider and the coder is essential to achieve complete and accurate documentation, code assignment, and reporting of diagnoses and procedures. Option a is incorrect because the patient is the subject of the record, yet the guidelines do not assign the patient a role in the joint documentation and code reporting effort. Option b is incorrect because a compliance officer is not mentioned in the guidelines as a party to this collaboration, which is described between provider and coder. Option d is incorrect because payers review documentation to validate services and coverage, but the guidelines name the coder, not the payer, as the provider's partner in complete documentation and reporting.

Correct Answer: Verification that the bill is accurate as submitted

OIG guidance says timely, accurate and complete documentation serves clinical patient care first. Its second function arises when a bill is submitted, namely verification that the bill is accurate as submitted. Option a is incorrect because coverage is a payer's contractual matter with enrollees, and the guidance does not describe documentation as the means of determining it. Option b is incorrect because documentation supports the appropriateness of a service the physician provided, but the guidance never presents it as a substitute for orders. Option c is incorrect because denial-rate comparison is a quality improvement method a practice may use, not the second function documentation serves with a submitted bill.

Correct Answer: Communication and continuity of care among healthcare professionals

The Documentation Guidelines list communication and continuity of care among physicians and other healthcare professionals involved in the patient's care as one function the medical record facilitates, alongside claims review, utilization review and research data. Option a is incorrect because the identity of the care giver is something the record may be used to validate, which is different from assigning credentials. Option b is incorrect because the site of service is one item a payer may ask the record to validate; the record verifies it rather than selects it. Option d is incorrect because the guidelines describe the contractual obligation to enrollees as the reason payers may require reasonable documentation, not as something the record itself facilitates.

Correct Answer: The UPIC

The Medicare manual states that when MAC, RAC, SMRC or CERT reviewers identify missing or illegible signatures that raise legitimacy or falsity concerns, they shall consider referring to the appropriate UPIC for further development. Option a is incorrect because CERT is one of the review contractors that identifies the signature concern, so it is a source of the referral and not its destination. Option b is incorrect because RACs perform reviews like the MAC, SMRC and CERT, and Medicare manual guidance gives fraud development to a different contractor. Option c is incorrect because the SMRC is listed among the reviewers who identify the problem signatures, not the contractor that develops suspected fraud further.

Correct Answer: At the time they are rendered

The Medicare manual states that all services provided to beneficiaries are expected to be documented in the medical record at the time they are rendered. Amendments, corrections and delayed entries address occasional exceptions to that expectation. Option b is incorrect because review timing is not the benchmark; the manual ties the documentation expectation to the moment of service, not to when a contractor examines the claim. Option c is incorrect because a signature log is a tool in the authenticity process for questioned records, not the point at which services are expected to be documented. Option d is incorrect because an amendment is itself a later change to an entry; the manual treats it as an exception to timely documentation, not the expectation.

Correct Answer: Consider the log and not deny for missing credentials

Medicare review guidance says reviewers shall consider all submitted signature logs regardless of creation date and shall not deny a claim for a log missing credentials, although they should encourage providers to list credentials. Option a is incorrect because reviewers are told to encourage credentials in the log, yet they shall not deny a claim for a signature log lacking them. Option c is incorrect because medicare guidance directs reviewers to consider all submitted signature logs regardless of the date they were created, so a late creation date is not grounds for rejection. Option d is incorrect because a signature log may be on the page where the initials appear or may be a separate document, so placement is not mandated.

Correct Answer: Disregard the missing signature and continue the review

Medicare guidance directs the contractor to disregard the missing or illegible signature when no explicit signature requirement exists and authorship need not be established, then continue reviewing the documentation for coverage, coding and billing requirements. Option a is incorrect because a fraud referral belongs to the process for documentation whose legitimacy or falsity is in question, not to a record with an unneeded signature. Option b is incorrect because attestation is pursued only when authenticity concerns arise from the totality of the record, which is a different situation from a signature that is simply unnecessary. Option d is incorrect because denial is a possible outcome only when authenticity concerns about legitimacy or falsity exist, not when the signature is unneeded to identify the author.

Correct Answer: A clinician

Medicare policy states that only a clinician may perform an initial examination, evaluation, re-evaluation and assessment, or establish a diagnosis or plan of care. Assistants may contribute measurements, but the clinician must participate actively and personally. Option b is incorrect because an OTA, like a PTA, may only supply objective measurements or observations that the clinician folds into an evaluation the clinician actively performs. Option c is incorrect because the contractor is the party who may later review the record to judge whether planned services are appropriate; that reviewer does not perform evaluations. Option d is incorrect because a PTA may contribute objective measurements or observations within scope of practice, but the clinician must personally participate and cannot simply adopt those findings.

Correct Answer: authenticated

The content of record standard requires every patient medical record entry to be legible, complete, dated, timed, and authenticated, in written or electronic form, by the person responsible for providing or evaluating the service. Option a is incorrect because describes converting dictation into text, which the content standard does not list as a required attribute of every entry in the record. Option b is incorrect because is not the term the regulation uses; entries must be authenticated by the person responsible for providing or evaluating the service, not countersigned. Option d is incorrect because is not a listed requirement; the standard calls for complete entries rather than condensed ones, so summarizing does not meet the content rule.

Correct Answer: System of coding and indexing

The hospital condition of participation requires a system of coding and indexing medical records. It must allow timely retrieval by diagnosis and procedure, which supports medical care evaluation studies. Option b is incorrect because the regulation assigns it the task of limiting release of information and copies to authorized individuals, which is a privacy safeguard rather than a retrieval tool. Option c is incorrect because it ensures the integrity of authentification and protects the security of record entries, but it does not organize records for retrieval by diagnosis or procedure. Option d is incorrect because staffing under the organization standard supports prompt completion, filing, and retrieval, yet it is not the system that allows retrieval by diagnosis and procedure.

Correct Answer: Supporting medical care evaluation studies

The regulation requires a system of coding and indexing medical records that allows timely retrieval by diagnosis and procedure, in order to support medical care evaluation studies. Option a is incorrect because confidentiality is addressed by a separate required procedure that limits release of information and copies to authorized individuals, not by the coding and indexing system. Option b is incorrect because security of entries is the job of the author identification and record maintenance system, which is a different requirement from coding and indexing. Option c is incorrect because retention is governed by a separate requirement that records be kept in original or legally reproduced form for a set minimum period.

Correct Answer: A terminology exercise for learners

The note states report samples encourage learners to identify correct medical terminology and do not represent AHDI formatting standards. They are teaching tools, so an auditor should not treat their layout as a documentation benchmark. Option b is incorrect because the attached note says report samples do not represent AHDI formatting standards, so the layout cannot serve as an audit benchmark. Option c is incorrect because surgical care policies are hospital rules meant to assure high standards of practice and patient care, not illustrative reports prepared for learners. Option d is incorrect because a roster is a surgical service record listing each practitioner and that practitioner's surgical privileges; it is not a narrative report sample.

Correct Answer: The surgeon

The regulation requires an operative report describing techniques, findings, and tissues removed or altered to be written or dictated immediately following surgery and signed by the surgeon. Option a is incorrect because the anesthesia provider is listed on the sample report as a participant, but the regulation assigns signature of the operative report to another professional. Option b is incorrect because an assistant may appear in the report header, yet the regulation does not name that role as the one who signs the operative report. Option d is incorrect because the regulation mentions the operating room register and equipment, but it gives no signing duty for the operative report to this role.

Correct Answer: An assessment of the patient after registration

Under the Medicare hospital conditions of participation, an assessment completed and documented after registration replaces the history and physical and its update when medical staff policy identifies specific outpatient surgical or procedural patients as exempt. Option a is incorrect because the update applies when the history and physical was completed within 30 days before admission; the assessment stands in lieu of both that examination and its update. Option c is incorrect because that is the standard comprehensive requirement, which the staff policy exempts these specific outpatient patients from, so it is not the substitute. Option d is incorrect because the regulation lists the register as a separate surgical requirement, and it is not described as taking the place of the pre-procedure examination.

Correct Answer: An updated examination of the patient

When the medical history and physical examination are completed within 30 days before admission or registration, the hospital rule requires an updated examination, including any changes in the patient's condition, completed and documented within 24 hours after admission or registration. Option a is incorrect because the consent form must already be in the patient's chart before surgery, except in emergencies, so it has no 24-hour post-admission deadline. Option b is incorrect because the register is a running record that must be complete and up-to-date; the rule ties it to no timing based on the history and physical. Option d is incorrect because the operative report describes techniques, findings, and tissues removed or altered, and is written or dictated immediately following surgery, not within 24 hours after admission.

Correct Answer: Original Medicare fee-for-service beneficiary

The ABN is given to beneficiaries enrolled in the Medicare fee-for-service program. Its Quick Glance Guide lists the Original Medicare FFS beneficiary as the recipient of the notice. Option a is incorrect because the guidance states the ABN is not used for items or services provided under the Medicare Advantage Program. Option b is incorrect because Part A skilled nursing facility items and services call for the separate SNF ABN, while this notice covers only Part B services there. Option c is incorrect because prescription drugs under the Medicare Prescription Drug Program are expressly excluded from ABN use, so that enrollee is not the intended recipient.

Correct Answer: Teaching physician presence during the key portion

Under the general rule, when a resident participates in a service in a teaching setting, payment is made only if a teaching physician is present during the key portion of the service. The excerpt shows only a later note review. Option a is incorrect because that location is not a payment condition; the rule mentions it only to allow presence by audio/video real-time technology at such sites. Option c is incorrect because the documentation already shows this, and the rule treats resident participation as the circumstance that triggers the presence requirement, not as a missing element. Option d is incorrect because the rule offers this only as an additional way to show presence, and only at residency training sites outside a metropolitan statistical area.

Correct Answer: It is formed by legally separate covered entities under common ownership or control

Legally separate covered entities affiliated by common ownership or control may designate themselves as a single covered entity, which is an affiliated covered entity. A hybrid entity is a single legal entity. Option a is incorrect because written designation of health care components is the step that creates hybrid status, and a covered entity that skips it remains subject to the Privacy Rule in its entirety. Option b is incorrect because limiting most requirements to the designated health care components is the main effect of the election, so this is a genuine feature of a hybrid entity. Option c is incorrect because this describes the starting point of a hybrid entity: one legal entity that carries out covered functions as well as non-covered functions, and elects hybrid status.

Correct Answer: Ban on retaliatory acts and waiver of individual rights

Under the Fully-Insured Group Health Plan Exception, a plan with only enrollment data and summary health information must comply only with the ban on retaliatory acts and waiver of individual rights, plus certain plan document documentation. Option a is incorrect because this retention rule covers covered entities in general; the exception limits this plan to documentation tied to amended plan documents instead. Option c is incorrect because the notice duty falls on health plans generally, yet the exception does not name it as one of the obligations that remain. Option d is incorrect because complaint procedures belong to the general covered entity duties, and the exception does not list them among the few obligations this plan keeps.