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CPMA Online Practice Exam B

Grading Results:
30 out of 30 are correct. Scroll down to view the rationale (if available) for each question.

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Question 1
Evaluation and Management documentation is often captured in SOAP format, which is
the acronym for:
A. Subjective, Objective, Assessment, Procedure
B. Subjective, Observation, Assessment, Plan
C. Subjection, Objection, Assessment, Plan
D. Subjective, Objective, Assessment, Plan

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Question 2
Failure to have which of the following forms in the medical record will result in payment being
sent to the beneficiary?
A. Patient registration form
B. Assignment of benefits form
C. Confirmation of Receipt of Privacy Notice
D. Release of Information form

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Question 3
Prior to undergoing a specific medical intervention, law requires the provider to obtain an
informed consent for treatment signed by the patient. In addition to the nature or purpose of
the treatment and risks and benefits involved, the informed consent must include which of the
following information?
A. The treating physicians experience in performing the procedure
B. Alternative treatment options and the risks and benefits of alternative treatment options.
C. The cost of the treatment.
D. The length of time for full recovery.

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Question 4
Outpatient physical therapy services cannot be initiated until:
A. an initial plan of care has been established.
B. the afternoon to achieve maximum therapeutic outcome.
C. the patient is mentally prepared for services.
D. primary care provider approves.

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Question 5
When auditing operative reports, the header describing the procedure is:
A. always accurate in describing the procedure that was performed.
B. all that is needed to assign the correct procedure code.
C. may not fully support the procedure documented in the body of the report.
D. the only documentation to be considered during the audit.

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Question 6
During an audit of a paper medical record, the auditor finds a correction was made using white-
out and initialed by the nurse. This method of correction is:
A. acceptable because it was initialed by the person altering the medical record entry.
B. unacceptable because the original content is not readable.
C. unacceptable because a black marker should have been used.
D. acceptable because it provided space to make the correction.

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Question 7
An auditor identifies claims for services provided by a non-physician provider as Incident-to
during the month the physician was on vacation. This would be considered:
A. fraud.
B. abuse.
C. common billing procedure.
D. compliant with False Claim Act.

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Question 8
The penalties for violation of the Stark law include program exclusion for knowing violations and:
A. potential $25,000 CMP for each service.
B. potential $18,000 CMP for each service.
C. potential $15,000CMP for each service.
D. maximum of $25,000 CMP annually.

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Question 9
You audit a provider who performs and bills for an arthroscopic rotator cuff repair, 29827, and for an
arthroscopic debridement, 29822. The payer contract specifies NCCI edit rules will be applied. There is
an NCCI edit against reporting both procedures during the same operative session; in
reviewing the surgeons documentation, you find that the debridement was performed in a
different site supporting the 59 modifier, which is allowed under NCCI. This is an example of:
A. fraud.
B. abuse.
C. proper coding and billing practice.
D. none of the above.

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Question 10
The False Claims Act allows for reduction of penalties to two times the amount of damages (as
opposed to three times) under what condition(s)?
A. The person committing the violation self discloses within 30 days of violation notification.
B. The accused person willfully opts out of the Medicare program.
C. The person fully cooperates with the investigation of the violation.
D. Both a and c

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Question 11
The compliance program guidance (CPG) document identifies four risk areas most likely to
affect a physicians practice. The risk areas include:
A. Coding and billing, malpractice insurance, patient dissatisfaction, increasing health risks.
B. Coding and billing, reasonable and necessary services, documentation, improper inducements.
C. Reasonable and necessary services, patient dissatisfaction, documentation, improper
inducements.
D. Improper inducements, kickbacks, self-referrals and malpractice insurance.

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Question 12
The manager of a small physicians practice who also is the compliance officer, contacts you an
auditor, stating that a coding and billing violation has been identified by the billing department
manager. You advise the compliance officer to document which of the following in the
practices compliance file:
A. date of incident, name of reporting party, name of person responsible for taking action, follow-up
action taken
B. date of incident, identify previous violations, name of individual involved in violation, final outcome.
C. date of incident, nature of violation, name of person responsible for taking action, follow-up action
taken.
D. date of incident, name of reporting party, name of person committing violation, name of per
responsible for taking action.

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Question 13
According to CPT

coding guidelines for inpatient consultation services, which statement is correct?
A. Subsequent consultation is reported with established patient codes.
B. Only one consultation is reported by consultant per day.
C. Only one consultation is reported per hospital admission.
D. If consultation is initiated on day 2 following admission, report subsequent hospital care codes.

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Question 14
Minor procedures as defined by Medicare have a zero or 10-day postop period. Which statement is true
regarding minor and endoscopic procedures?
A. a. An office visit on the same day of the minor or endoscopic procedure is billable if it corresponds
to the procedure being performed.
B. b. There is no preoperative period and an office visit is billable if a significant and separately
identifiable service is performed in addition to the procedure.
C. c. There is a one day preoperative period and modifier 25 is not allowed under any circumstances.
D. d. A hospital visit on the same day of a minor endoscopic procedure can be reported without
modifier 25.

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Question 15
Based on CPT coding guidelines, which of the following scenarios identifies the correct use of modifier
25?
A. A dermatologist sees a patient at the request of his primary care physician with multiple lesions on
the left and right hands. The dermatologists performs a history pertinent to the presenting problem. The
lesions are determined to be actinic keratosis and are cryosurgically removed.
B. A patient came in for a monthly follow up for chronic shoulder pain. Physician reviewed a current
series of shoulder X-rays and discusses the patients impending return to work. The patient was also
complaining of a severe headache. The physician performed a neurological exam and did not find any
evidence of vascular or CNS etiology. He then performed bilateral occipital block for the headache.
C. An OB/GYN sees a patient who is complaining of severe abdominal pain. The physician obtains a
pelvic ultrasound and other diagnostic testing and determines that the patient has a tubal pregnancy. The
OB/GYN decides that laparoscopic surgery will be performed on the same day.
D. A new patient presents for an annual well-woman exam. A complete review of systems is obtained
and an interval past, family, and social history is reviewed and updated. A neck-to-knees exam is
performed, including a pelvic exam, and a Pap smear is taken. Counseling is given on diet and exercise.
Appropriate labs are ordered. The patient also complains of vaginal dryness. Her prescription for oral
contraception is renewed.

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Question 16
An audit of 20 family practice charts for code 20552-20553 reveals that the provider used fluoroscopic
guidance when performing trigger point injections. In reviewing claims data for these charts, it is found
that 76942 was reported with 20552-20553. What should be stated on the audit findings report?
A. Coding is incorrect, code 77002 should be reported for these cases.
B. Coding is correct, radiologic guidance is reported separately.
C. Coding is incorrect, radiologic guidance is included in codes 20552-20553.
D. Coding is incorrect, code 77021 should be reported for these cases.

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Question 17
A provider performs two procedures that NCCI edits state should not be reported together. However if
the NCCI edit does not allow use of NCCI-associated modifiers to bypass it and the documentation
supports and qualifies as an unusual procedure, the physician may report the column one HCPCS/CPT
procedure code of the NCCI edit with which of the following modifiers?
A. 52
B. 59
C. 22
D. 51

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Question 18
An auditor identifies a procedure that has a modifier appended. This is an indication that:
A. the procedure performed was altered, but the definition of the code has not changed.
B. the procedure performed was altered and the definition of the code has changed.
C. the procedure should not be reported if it was altered.
D. a special report should be submitted with the claim

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Question 19
Sarah Smith works for an emergency physician group. She has been given the responsibility to perform a
baseline E/M audit for the physicians in the group. What is the first step she should take to begin this
process?
A. Run a revenue report of all services performed
B. Review all level four and five E/M services.
C. Run a utilization report of E/M services
D. Identify the providers who have been with the group the longest.

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Question 20
An audit performed on one provider would be considered a:
A. Retrospective audit
B. Focused audit
C. Random audit
D. Perspective audit

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Question 21
When performing a retrospective audit, the auditor will need to have which of the following materials?
A. Coding manuals, medical record, audit form, CMS 1500 form, billing policies, release of
information form.
B. Medical record, audit form, coding manuals, EOB or Medicare RA, payer policies and CMS-1500
form.
C. Release of information form, coding manuals, audit form, medical record, EOB or Medicare RA.
D. Coding manuals, audit form, CMS 1500 form, assignment of benefits, payer policies, medical
record.

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Question 22
The OIG is investigating a medical practice. You have been hired by an attorney to audit medical charts
to validate the coding of office services. The OIG requests the auditor to pull medical records with a
confidence level of 95 percent based on and Excel file given to the auditor. Based on this request, how
many charts need to be pulled?
Confidence Level
Precision 80% 90% 95% 99%
1% 7254 13596 19763 32064
2% 2089 3432 4856 8349
5% 338 684 752 1356
10% 82 139 165 339
15% 38 64 79 154
25% 14 23 32 57
A. 3432
B. 4856
C. 752
D. 19763

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Question 23
A sample is gathered of the CPT/HCPCS codes that have the highest dollar charges. This would be
considered which type of sampling?
A. Non-statistical
B. Numerical
C. Judgmenta
D. Proportional

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Question 24
Using RAT-STATS to create a Discovery Sample for a CIA Claims Review serves what purpose?
A. Identify the estimated dollar difference between billed and paid claims.
B. Identify the financial error rate of the selected sample
C. Estimate the net underpayment.
D. Estimate the net overpayment.

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Question 25
A provider receives denials from a private payer for E/M services performed on the same date as a minor
procedure. You review documentation for 25 records and the payer contract which states the provider
must follow CMS coding guidelines. You determine that 20 of the records have appropriate
documentation to support both E/M and the procedure and were coded correctly when the claim was
originally submitted. You submit an appeal for the 20 dates of service that are supported by
documentation. To support you findings, you will include in the appeal a letter reporting your findings,
claim forms, copies of documentation, EOB copies and:
A. CPT description for modifier 25 use.
B. NCCI policy manual for modifier 25.
C. CPT Assistant article
D. NCCI Edits for major procedures.

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Question 26
Nancy prepares to begin a focused audit for Dr. Jacobsen, a general surgeon.The resources
that she will gather in addition to the CPT

, HCPCS Level II and ICD-9-CM codebooks, that will


be needed to accurately complete the audit will be:
A. Medical terminology book, surgical package definitions, global days, surgery audit tool, OSHA
compliance documents.
B. A generic audit tool and CPT, HCPCS Level II and ICD-9-CM codebooks is all that is needed.
C. NCCI edits, medical terminology book, E/M Documentation Guidelines
D. Medical terminology book, surgical package definition, global days, surgery audit tool, insurance
carrier rules and NCCI edits.

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Question 27
In reviewing claims for an ENT provider, you identify that he is consistently billing Medicaid for
four units of 69641. Which of the following resources would support your findings that this
provider is billing too many units?
A. NCCI Edits
B. Medically Unlikely Edits
C. CPT Assistant
D. Medical Necessity Edits

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Question 28
An annual audit is the minimum requirement an IRO must conduct under which of the following
agreements?
A. Compliance Information Agreement
B. Corporate Integrity Agreement
C. Collaborative Information Agreement
D. Compliance Integrity Agreement

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Question 29
When conducting a compliance audit your findings identify that one of the providers is signing
chart entries in the EMR three days after seeing patients. What steps should be taken to
address this finding?
A. Review audit findings with all providers in the group practice.
B. Prepare a summary of findings that include number or percentages of compliant vs. non-compliant
charting; discuss with the provider, including recommendations for improvement; re-audit according to
criteria established by the practice.
C. Review the CMS 1995 and 1997 Documentation Guidelines, and discuss proper documentation
with each provider.
D. Provide ongoing training, based on the findings identified; re-audit according to criteria established
by the practice.

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Question 30
Audit findings are of little value unless the findings are shared with the provider to:
A. Offer recommendations for improvement
B. Illustrate compliant documentation
C. Address problem areas.
D. All of the above
Rationale 1: The acronym SOAP refers to:
Subjective; where the patient provides information about his or her symptoms and what, if anything,
he or she has done to relieve the symptoms.
Objective; indicates the physical exam findings of the provider.
Assessment; the providers assessment of the patients condition, and where the provider indicates
either a definitive or working diagnosis. In absence of a diagnosis, signs and symptoms may be
documented until further testing can be performed.
Plan; the providers plan is documented in direct relation to the assessment above. In cases where a
definitive diagnosis has not been reached, the documentation should reflect tests that are being ordered,
with an indication of the providers thought process.

Rationale 2: The assignment of benefits form is an authorization form signed by the patient
that allows their insurance carrier to pay the provider directly. Without this, the payment will go
to the beneficiary and the provider will be required to collect payment from the beneficiary.

Rationale 3: Prior to a patient undergoing a specific medical intervention, state law requires that the
provider obtain an informed consent for treatment. A signed consent form indicates that the provider
communicated with the patient to explain the treatment plan ahead of time, so that the patient is legally
able to make his or her own decisions as to whether to proceed with the treatment. The communication
should include: Patients diagnosis if known, nature and purpose of treatment, risks and benefits of
treatment, alternative treatment options and their benefits and risks, as well as risks and benefits of not
receiving any treatment.
Rationale 4: Therapy cannot start until the initial plan of care is established. A plan of care
should be established for each type of therapy.
Rationale 5: An Operative report may indicate a specific procedure in the header, but the details in the
body of the note do not always support that procedure, or indicate additional procedures not reported in
the title/header. For this reason, it is very important to read the entire note slowly and carefully.
Rationale 6: When correcting a paper medical record, a single line strike through should be
used so the original content is still readable. The person altering the medical record must sign
and date the revision, amendment, or addenda.
Rationale 7: Relative to healthcare services, examples of fraud include submitting claims for
physician services performed by non-physician provider (NPP) without regard to Incident-to
guidelines.
Rationale 8: Penalties for violation of Stark Law are civil penalties which include overpayment/refund
obligation, False Claims Act liability, civil monetary penalties and program exclusion, potential for $15,000
CMP for each service and civil assessment for up to three times the amount claimed.

Rationale 9: Because the payer contract specifies NCCI edit rules will be applied, and due to
the surgeons documentation identifying the area of debridement allowing the use of modifier
59, this service was reported correctly.
Rationale 10: The FCA allows for reduced penalties (mitigation) if the person committing the violation
self-discloses. 3729 a.2 states that the court may assess not less than two times the amount of
damages (as opposed to three times), which the government sustains because of the act of that person,
if: (A) The person responsible furnishes officials of the United States responsible for investigating false
claims violations with all information known to such person about the violation within 30 days after the
date on which the defendant first obtained the information; (B) such person fully cooperates with the
investigation of such violation; and (C) at the time such person furnishes the information about the
violation, no criminal prosecution, civil action, or administrative action has commenced under this title
with respect to such violation, and the person did not have actual knowledge of the existence of an
investigation into such violation.
Rationale 11: Potential areas for individual and small group practices indicated by the OIG include
coding and billing, reasonable and necessary services, documentation, and improper inducements,
Kickbacks and self-referrals.

Rationale 12: Compliance guidance indicates that whenever non-compliance is identified by the
compliance staff, corrective action must be taken, although there can be varying degrees of disciplinary
action. Any finding of non-compliant conduct must be documented in the compliance files and should
include date of incident, name of the reporting party, name of the person responsible for taking action,
the follow-up action taken.

Rationale 13: CPT coding guidelines state that only one consultation should be reported by a
consultant per admission. Subsequent services during the same admission are reported using
subsequent hospital care codes.

Rationale 14: A minor procedure is defined by Medicare as a service that has 0- or 10-day postoperative
period. Payment for minor procedures includes same-day services (either preoperative or postoperative
care), intraoperative care, and care within the defined global period. If a separately identifiable
evaluation and management service is performed, it should be reported with modifier 25.

Rationale 15: When a patient comes in for regular follow-up care and also complains of another
condition in which the provider performs an exam that is related to that new condition along and
performs a procedure, the E/M code is reported with modifier 25.
Rationale 16: The parenthetical note for codes 20522-20553 states that if imaging guidance is
performed it can be reported separately with 76942 (ultrasonic), 77002 (fluoroscopic) 77021 (magnetic
resonance). Documentation stated fluoroscopic guidance was use which would be reported with 77002.
Rationale 17: Applying modifier 22 must be done judiciously. Documentation must clearly indicate the
reason for increase in the service. An example would be when an endoscopic procedure is converted to
an open procedure. To be reimbursed for attempting the endoscopic procedure, modifier 22 can be
appended to the open procedure codeif the endoscopic service is significant. Just because modifier 22
is appended, does not mean additional payment will be approved. The payer will review the
documentation to make sure additional payment is appropriate. An auditor should look for indications
of modifier 22 overuse, i.e. high number of denials for services reported with modifier 22 or continual
use of modifier 22 with the same procedure code.

Rationale 18: A modifier provides the means to report or indicate that a service or procedure that has
been performed has been altered by some specific circumstance but the definition of the code has not
changed. Refer to CPT Appendix A Modifiers.

Rationale 19: Running a utilization report is the first step in beginning a baseline audit. This report
identifies the providers with the highest utilization of a service or procedure and provides a basis for a
focused audit, which in this scenario, is the E/M services of the physician group.

Rationale 20: A focused audit is one that looks at one item, one type of service, or one provider.

Rationale21: When performing a retrospective audit the auditor will need to have the patients medical
record, the appropriate audit form, coding manuals, EOB or Medicare RA, payer policies and the CMS
1500 claim form.
Rationale 22: Created in RAT-STATS, the number of charts to pull is 752 based on a 5% error rate and
95% confidence level.

Rationale 23: A proportional sample is based on high frequency items, or those that are considered proportionally
significant.

Rationale 24: RAT-STATS is statistical software program used to perform a sample size estimate and to
generate a random number printout that supports is sampling methodology. RAT-STATS is one of the
best methods to determine outliers and is provided by the OIG free of charge

Rationale 25: Because the providers payer contract requires adherence to CMS coding guidelines, it
would be appropriate to submit NCCI policy manual documentation for modifier 25 to support your
appeal in addition to claim forms, copies of documentation and EOBs.

Rationale 26: In addition to the CPT, HCPCS Level II and ICD-9-CM codebooks, a medical
terminology book, definition of surgical package including global days for procedures, an audit
tool specifically designed to review surgeries, the providers insurance carrier rules and NCCI
edits will be required to perform a reliable audit.

Rationale 27: Medical Unlikely Edits (MUE) file would support your findings that the provider is
billing too many units for this procedure

Rationale 28: Most CIAs (Corporate Integrity Agreements) require an annual audit and will
define the specific number of claims to analyze, how to sample, and the issues to evaluate.
Rationale 29: Communication of audit findings usually occurs in two phases: 1) the written
communication via the audit report including a summary of findings, and 2) the oral communication to
address questions or concerns with the reported findings, conclusions, and recommendations. Re-
auditing will identify if recommendations have been implemented by the provider.

Rationale 30: Effective communication of audit results is the most critical step in the audit
process. Effective communication will address the problem areas uncovered in the audit,
demonstrate compliant documentation and providing recommendations for improvement.