Exam Preview for 1097: CMS Documentation Guidelines: The Who, What

CMS Documentation Guidelines: The Who, What and Why

Please note: exam questions are subject to change.

1. : ____________ is required for coverage and payment of a therapy claim: An order A physician’s certification A billing record None of the above
2. Which of the following is NOT required documentation: Evaluation/plan of care Certification/re-certification Exercise flow sheet Discharge note
3. Documentation should demonstrate that the patient has potential to make significant, functional _____________: Improvement Short term goals Home programs Activities
4. An excellent example of a documented “Reason for Referral” on an evaluation is: “Decline in function” “Admit from hospital” “See current diagnosis” None of the above
5. “Patient’s status just prior to the onset of the treating condition requiring therapy” defines: Physician’s referral Objective tests and measures Prior level of function Reason for referral
6. Which of the following activity is NOT recognized as medically necessary for therapy reimbursement? Bathing Playing the piano Self-feeding Toilet transfers
7. Which of the following are minimum requirements to be included in Treatment notes? Date of treatment Total treatment time in minutes Signature of the professional providing the services All of the above
8. _____________ are required in progress report format covering the reporting period from the last progress report to the date of discharge: Discharge notes Exercise flow sheets Maintenance programs Certifications
9. Which level of the Medicare appeals process is conducted by a Qualified Independent Contractor (QIC)? Administrative Law Judge hearing Reconsideration Judicial review All of the above
10. How can we proactively combat denials? Internal audits of medical records by therapists Audits of therapy documentation by rehab managers A and B above None of the above