Exam 10: Auditing

Explain the difference between upcoding and downcoding.

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.

Audits performed on a regular basis will confirm that documentation and coding were appropriate for the level of service provided or will identify problems.

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.

What is the difference between a prospective and a retrospective audit?

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.

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.

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.

In what ways are medical necessity for evaluation and management services expressed?

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.

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.

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.

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.

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.

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.

Types of medical records audits include all of the following EXCEPT: A)accreditation audits. B)certification audits. C)external audits. D)internal audits.

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.

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.

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.

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.