Deck 10: Auditing

Question 1

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.

Answer 1

the coder's skill and knowledge.

Question 2

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

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

Answer 2

certification audits.

Question 3

If Medicare determines that an evaluation and management (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.

Answer 3

deny payment.

Question 4

An internal audit can be conducted:

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

Question 5

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 6

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.

Question 7

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 8

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 9

An internal audit would determine:

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

Question 10

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 11

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 12

The most widely used CPT codes are:

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

Question 13

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 14

The most extensive type of history is:

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

Question 15

Medical necessity of evaluation and management (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 16

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 17

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 18

An internal prospective audit would most likely be performed on:

A)all claims.
B)workers' compensation claims.
C)all evaluation and management (E/M) claims.
D)all Medicare claims.

Question 19

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 20

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.

Question 21

Documentation of an extended history of present illness (HPI) includes at least:

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

Question 22

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 23

A 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 24

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 25

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 26

If a chart 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)history of present illness (HPI).

Question 27

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

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

Question 28

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 history of present illness (HPI) element.
B)two HPI elements.
C)three HPI elements.
D)four HPI elements.

Question 29

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 30

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 31

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 32

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 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

An examination that documents a limited examination of the affected body area or organ system and any other symptomatic or related body areas would be considered a(n):

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

Question 35

If a chart 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)history of present illness (HPI).

Question 36

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

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

Question 37

History of present illness (HPI) types include:

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

Question 38

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 39

In a patient's chart, a diagnosis:

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

Question 40

All of the following are types of review of systems (ROS) EXCEPT:

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

Question 41

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 42

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

Question 43

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 44

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 45

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

Question 46

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

Question 47

An example of an evaluation and management (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 48

Clearinghouses charge providers based on which type of payment system?

A)A percentage of each claim's dollar value
B)A flat fee per claim
C)Per diem
D)Per membership per month

Question 49

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

Question 50

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

Question 51

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

Question 52

If a medical office assistant is NOT sure about which evaluation and management (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 53

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

Question 54

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

Question 55

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 56

Physician services that are more intense than the work of other evaluation and management (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 57

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

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

Question 58

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 59

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 60

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 61

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 62

A review of systems (ROS) is considered part of the physical examination.

Question 63

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

Question 64

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

Question 65

Time is considered the controlling factor for determining the level of evaluation and management (E/M) service if counseling with the patient or family members constitutes at least 50% of the encounter.

Question 66

The two types of history of present illness (HPI) are __________ and __________ .

Question 67

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 68

If a patient complains of an aching pain in the chest, the complaint would be considered part of the past, family, and social history (PFSH).

Question 69

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

Question 70

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 71

An extended history of present illness (HPI) will include one to three documented HPI elements.

Question 72

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

Question 73

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

Question 74

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

Question 75

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

Question 76

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

Question 77

If a patient presents with a minimal problem and the physician performs a limited exam of the affected body area only, the exam would be reported as problem focused.

Question 78

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 79

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

Question 80

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