AAPC-CPMA Certified Professional Medical Auditor - Set 3 - Part 3

Correct Answer: The brief "normal" notation suffices for unaffected systems

Documentation guidelines state that a brief statement or notation of "negative" or "normal" is sufficient for normal findings in unaffected areas or asymptomatic organ systems. Specific detail is needed for the affected area and for abnormal findings. Option a is incorrect because the brief-notation rule applies to normal findings for unaffected areas generally, and is not restricted to one examination type such as general multi-system. Option b is incorrect because the guidelines allow findings on unaffected or asymptomatic systems to be recorded, and a brief notation is accepted for normal ones. Option d is incorrect because elaboration is called for with abnormal or unexpected findings in unaffected areas, while a brief "normal" or "negative" notation is sufficient for normal findings.

Correct Answer: Detailed

A Detailed multi-system examination may be met by at least twelve bulleted elements in two or more organ systems or body areas. Fourteen elements across two systems meet that alternative but not the Comprehensive requirement. Option a is incorrect because is a lower tier calling for at least six elements, so fourteen elements in two systems already satisfy something higher. Option c is incorrect because covers only one to five bulleted elements, and a note with fourteen elements falls outside that range. Option d is incorrect because requires at least nine organ systems or body areas, with at least two elements documented in each; two systems fall well short.

Correct Answer: Enforcement action summaries

OIG posts summaries and press release links when a matter is settled or resolved. They help in designing risk assessments and setting compliance priorities, and they serve as case examples in training materials and presentations. Option a is incorrect because a CIA outlines obligations an entity accepts in a settlement and informs compliance program structure; it is not a posted set of case examples. Option b is incorrect because they are legal opinions on a requesting party's existing or proposed arrangement, specific to the certified facts, and are not collections of resolved misconduct cases for training. Option c is incorrect because these address industry-wide health care fraud trends drawn from investigative sources, rather than posting summaries of individual matters that have been settled or resolved.

Correct Answer: A certification that the estimate will be submitted within 90 days

The SDP submission must contain a damages estimate for each affected Federal health care program, or a certification that the estimate will be completed and submitted to OIG within 90 days of the date of submission. Option a is incorrect because netting for underpayments is prohibited because the SDP does not extend the time to resubmit claims to Federal health care programs. Option b is incorrect because the submission content rules allow no open-ended deferral; they require either an estimate or a certification tied to a 90-day deadline. Option d is incorrect because the guidance places the review and estimate on the disclosing party, while OIG only verifies the disclosing party's calculation afterward.

Correct Answer: Section I, Conventions and general guidelines

The outpatient guidelines state that Section I, covering Conventions, general coding guidelines and chapter-specific guidelines, should also be applied for outpatient services and office visits, because the conventions and general guidelines apply to all settings. Option a is incorrect because these were developed for inpatient reporting and do not apply to outpatients, who instead have a separate uncertain diagnosis rule that bars coding of such terms. Option c is incorrect because outpatient reporting uses the term first-listed diagnosis in lieu of principal diagnosis, so principal diagnosis selection rules belong to inpatient coding. Option d is incorrect because the guidelines state that this definition does not apply to hospital-based outpatient services and provider-based office visits, so it cannot be the shared portion.

Correct Answer: Medical necessity and appropriateness of services

Documentation guidelines state that payers may request information to validate the site of service, the medical necessity and appropriateness of diagnostic and/or therapeutic services provided, and that services have been accurately reported. Option a is incorrect because a fee schedule belongs to the contract between payer and provider, and the guidelines do not name it as something documentation must validate. Option b is incorrect because Medicare therapy coverage does not turn on potential for improvement but on the need for skilled care, so it is not a validation target here. Option d is incorrect because enrollment status is not among the items the documentation guidelines list for validation; payers ask for site of service, medical necessity and accurate reporting.

Correct Answer: The "other specified" code

In the Alphabetic Index, NEC, "Not elsewhere classifiable," represents "other specified." When no specific code exists for a condition, the entry directs the coder to the "other specified" code in the Tabular List. Option b is incorrect because the abbreviation NOS is the equivalent of unspecified, so that term points to an unspecified code and does not signal a specific entity lacking its own code. Option c is incorrect because an Excludes1 note means "NOT CODED HERE!" and marks conditions that cannot be reported together, which is a different convention from NEC. Option d is incorrect because a placeholder X fills empty characters when a code requiring a 7th character is shorter than 6 characters; it has no connection to NEC.

Correct Answer: Extended ROS

An extended ROS inquires about the system directly related to the problem identified in the HPI and a limited number of additional systems, with positive responses and pertinent negatives documented for two to nine systems. Option a is incorrect because constitutional symptoms, such as fever and weight loss, are one of the recognized body systems, not a level of ROS. Option b is incorrect because it inquires only about the system directly related to the problem identified in the HPI, with no additional systems reviewed. Option c is incorrect because it goes beyond a limited number of systems, requiring review of at least ten organ systems in addition to the system tied to the problem.

Correct Answer: Back, including spine

The CMS Documentation Guidelines recognize these body areas for examination: head, neck, chest, abdomen, genitalia/groin/buttocks, back including spine, and each extremity. Back, including spine, is the only listed body area among the options. Option a is incorrect because eyes are listed among the recognized organ systems, not the body areas, so the term belongs to a different category of the examination guidelines. Option c is incorrect because this is one of the recognized organ systems; the body area list covers regions such as the head, neck and abdomen instead. Option d is incorrect because constitutional, with examples such as vital signs and general appearance, is an organ system in the guidelines and does not appear as a body area.

Correct Answer: A "rule out" (R/O) diagnosis

The Documentation Guidelines state that without an established diagnosis, the assessment or clinical impression may be given as differential diagnoses or as a "possible", "probable" or "rule out" (R/O) diagnosis. Option a is incorrect because describes the record of a problem that already has an established diagnosis, where status such as improved, well controlled or resolved is noted. Option b is incorrect because the guidelines ask for this when a referral or consultation is made, so it records who was asked rather than what the assessment is. Option c is incorrect because patient instructions are a form of treatment, documented as part of management options, and they do not express an assessment or clinical impression.