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CMRS (ACAC) practice questions

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Question 1Medical Record Review Fundamentals and Documentation Standards

Which document is completed by the patient at the time of registration to authorize the release of protected health information to an insurer?

  1. An operative report
  2. A progress note
  3. A discharge summary
  4. An authorization for disclosure Correct answer.

Explanation

An authorization for disclosure is a patient-signed document that permits a covered entity to use or disclose protected health information for purposes such as billing. Progress notes, discharge summaries, and operative reports are clinical entries created by providers.

Question 2Medical Record Review Fundamentals and Documentation Standards

In a paper medical record, a late entry must be clearly identified because it:

  1. Eliminates the need for a signature
  2. Allows the author to backdate the entry
  3. Preserves the integrity and chronology of the legal record Correct answer.
  4. Replaces the original entry

Explanation

Late entries are permitted but must be labeled as late, dated with the actual date of entry, and signed so the record's chronology remains accurate. Backdating or altering the original entry compromises record integrity.

Question 3Medical Record Review Fundamentals and Documentation Standards

Which element is essential for a medical record entry to be considered authenticated?

  1. A witness signature from another department
  2. The author's signature or unique identifier Correct answer.
  3. A typed transcription date
  4. A notary stamp

Explanation

Authentication confirms that the entry was made by the person identified as its author, typically through a signature or a unique electronic identifier. Witness signatures, notarization, and transcription dates do not establish authorship.

Question 4Medical Record Review Fundamentals and Documentation Standards

A patient requests a copy of her medical record. Under HIPAA, the covered entity must act on the request within how many days, with a possible one-time extension?

  1. 7 days
  2. 90 days
  3. 30 days Correct answer.
  4. 14 days

Explanation

HIPAA requires covered entities to act on an access request within 30 days, with a single 30-day extension permitted if the entity notifies the patient in writing. Shorter windows do not reflect the federal standard.

Question 5Medical Record Review Fundamentals and Documentation Standards

Which type of documentation records the patient's own account of symptoms and history in the patient's words?

  1. The medication administration record
  2. The chief complaint and history of present illness Correct answer.
  3. The discharge plan
  4. The pathology report

Explanation

The chief complaint and history of present illness capture the patient's reported symptoms and narrative, often in the patient's own words. The other documents reflect clinician actions or laboratory findings.

Question 6Medical Record Review Fundamentals and Documentation Standards

The primary purpose of the medical record as a legal document is to:

  1. Provide a contemporaneous, verifiable account of care Correct answer.
  2. Serve as a marketing tool for the facility
  3. Record only billable services
  4. Replace informed consent discussions

Explanation

The medical record serves as the official legal account of the patient's care and must be accurate, complete, and contemporaneous. It is not a marketing tool, a substitute for consent discussions, or limited to billing data.

Question 7Medical Record Review Fundamentals and Documentation Standards

Which abbreviation is commonly used in documentation to indicate that a medication was given as needed?

  1. BID
  2. QID
  3. NPO
  4. PRN Correct answer.

Explanation

PRN (pro re nata) means the medication is administered as needed based on the patient's condition. NPO means nothing by mouth, while BID and QID refer to twice and four times daily schedules.

Question 8Medical Record Review Fundamentals and Documentation Standards

In an electronic health record, an audit trail primarily serves to:

  1. Track who accessed or modified a record and when Correct answer.
  2. Schedule appointments
  3. Compress imaging files
  4. Encrypt billing transmissions

Explanation

Audit trails log user access and changes with timestamps, supporting security and integrity review. They do not handle file compression, encryption of transmissions, or scheduling.

Question 9Medical Record Review Fundamentals and Documentation Standards

A nurse realizes she documented a vital sign in the wrong patient's chart. What is the appropriate corrective action?

  1. Leave the entry and document the correct value in a separate note
  2. Overwrite the value with correction fluid
  3. Delete the entry without a trace
  4. Add an addendum noting the error and the correct information Correct answer.

Explanation

Errors are corrected through an addendum or amendment that identifies the mistake and provides accurate information while preserving the original entry. Deleting, obscuring, or separating corrections from the record impairs integrity.

Question 10Medical Record Review Fundamentals and Documentation Standards

Which of the following best describes the minimum necessary standard in medical record review?

  1. Share the entire record with any workforce member who asks
  2. Limit access to the information needed to accomplish the intended purpose Correct answer.
  3. Restrict access only to the billing department
  4. Provide full records to all requesters by default

Explanation

The minimum necessary standard requires limiting uses and disclosures of protected health information to what is reasonably needed for the intended purpose. It applies broadly across the workforce rather than to a single department.

Question 11Medical Record Review Fundamentals and Documentation Standards

A reviewer finds that a physician's order for a medication is missing the route of administration. This is best classified as which type of documentation deficiency?

  1. Incomplete order element Correct answer.
  2. Duplicate documentation
  3. Untimely entry
  4. Illegible signature

Explanation

An order lacking a required element such as route, dose, or frequency is incomplete. The deficiency concerns missing content rather than legibility, timing, or duplication.

Question 12Medical Record Review Fundamentals and Documentation Standards

When a patient is transferred between units, which documentation element most directly supports continuity of care?

  1. The original admission consent form
  2. The cafeteria menu
  3. The visitor log
  4. A transfer summary with current status and plan Correct answer.

Explanation

A transfer summary conveys the patient's current condition, treatments, and plan so the receiving team can continue care safely. Consent forms, menus, and visitor logs do not support clinical handoff.

Question 13Medical Record Review Fundamentals and Documentation Standards

Which statement best reflects the concept of contemporaneous documentation?

  1. Entries are prepared by the billing team
  2. Entries are recorded at or near the time of the event Correct answer.
  3. Entries are completed after discharge
  4. Entries are written at the end of the shift only

Explanation

Contemporaneous documentation is recorded at or close to the time of the event to preserve accuracy. Delaying documentation until shift end, discharge, or billing review increases the risk of error.

Question 14Medical Record Review Fundamentals and Documentation Standards

A valid informed consent form should include which of the following elements?

  1. The cafeteria schedule
  2. Risks, benefits, and alternatives discussed Correct answer.
  3. The patient's billing estimate
  4. The nurse's home address

Explanation

Informed consent documents that the patient was informed of risks, benefits, and alternatives and agreed to the procedure. Billing estimates and unrelated logistical details are not elements of clinical informed consent.

Question 15Medical Record Review Fundamentals and Documentation Standards

Which of the following is the best example of objective data in a progress note?

  1. The patient describes fatigue
  2. The patient feels anxious
  3. Blood pressure of 148/92 mmHg Correct answer.
  4. The patient reports a headache

Explanation

Objective data are measurable findings observed or recorded by the clinician, such as a blood pressure reading. Reports of feelings, headaches, and fatigue are subjective data provided by the patient.

Question 16Medical Record Review Fundamentals and Documentation Standards

A medical record reviewer notices that a discharge summary was finalized two days after discharge. This finding is best described as:

  1. An authentication failure
  2. A privacy breach
  3. A coding error
  4. A timeliness concern Correct answer.

Explanation

Timeliness standards address how promptly documentation is completed relative to the event; a delayed discharge summary raises a timeliness concern. It is not inherently an authentication, privacy, or coding problem.

Question 17Medical Record Review Fundamentals and Documentation Standards

Which action best preserves the legal integrity of a paper record when a correction is needed?

  1. Erase the error completely
  2. Rewrite the entire page
  3. Tear out the page and start over
  4. Draw a single line through the error, initial it, and write the correction Correct answer.

Explanation

Standard practice is to draw a single line through the error so it remains legible, then initial and date the correction. Erasing, rewriting, or removing pages destroys the record's integrity.

Question 18Medical Record Review Fundamentals and Documentation Standards

Which document typically records the patient's resuscitation preferences and goals of care?

  1. A radiology order
  2. A pathology report
  3. A pharmacy label
  4. An advance directive Correct answer.

Explanation

Advance directives document the patient's wishes regarding life-sustaining treatment and goals of care. Pathology reports, radiology orders, and pharmacy labels serve clinical or operational purposes unrelated to preferences.

Question 19Medical Record Review Fundamentals and Documentation Standards

When reviewing a record for completeness, which element confirms that a verbal order was properly documented?

  1. The order appears only in the nursing notes
  2. The order was entered after discharge
  3. The order was given anonymously
  4. The order is read back, recorded, and signed by the prescriber within policy timeframes Correct answer.

Explanation

Verbal orders require a read-back for verification, documentation by the receiving clinician, and prescriber authentication within the timeframe set by policy. Anonymous, note-only, or post-discharge entries do not meet these requirements.

Question 20Medical Record Review Fundamentals and Documentation Standards

Which of the following best describes the purpose of a problem list in the medical record?

  1. To list the patient's visitors
  2. To record every medication dose administered
  3. To document billing codes only
  4. To provide a concise summary of the patient's active and significant conditions Correct answer.

Explanation

The problem list summarizes active and significant conditions to support continuity and clinical decision-making. It is not a medication log, visitor record, or billing-only document.

Question 21Medical Record Review Fundamentals and Documentation Standards

A reviewer identifies that a required history and physical examination was performed but never documented. What is the most appropriate classification?

  1. Duplicate documentation
  2. Missing documentation Correct answer.
  3. Unauthorized documentation
  4. Illegible documentation

Explanation

When required care occurred but was not recorded, the deficiency is missing documentation. Illegibility, duplication, and authorization concern the quality or permission of existing entries, not their absence.

Question 22Medical Record Review Fundamentals and Documentation Standards

Under HIPAA, which of the following is a permitted disclosure of protected health information without patient authorization?

  1. Disclosure to a patient's employer for marketing
  2. Disclosure for treatment purposes Correct answer.
  3. Disclosure to a neighbor who asks
  4. Disclosure to a news outlet for publicity

Explanation

HIPAA permits disclosures for treatment, payment, and health care operations without authorization. Marketing, publicity, and disclosures to curious third parties require authorization or are otherwise prohibited.

Question 23Medical Record Review Fundamentals and Documentation Standards

A clinician documents an assessment that contradicts the objective findings recorded earlier in the same note. From a review standpoint, this represents:

  1. An internal inconsistency requiring clarification Correct answer.
  2. A valid addendum
  3. A privacy violation
  4. A routine variation needing no review

Explanation

Internal inconsistencies between the assessment and objective data can affect patient safety and record reliability, so they warrant clarification. Routine variation does not excuse contradictory content, and this is not an addendum or privacy issue.

Question 24Medical Record Review Fundamentals and Documentation Standards

Which scenario best illustrates a potential over-documentation (cloning) concern in an electronic record?

  1. A nurse corrects a dosage error with an addendum
  2. Identical review-of-systems text appears across multiple visits with differing complaints Correct answer.
  3. A physician signs a verbal order after read-back
  4. A clinician adds a late entry for a missed vital sign

Explanation

Cloning is suspected when identical text appears across encounters despite differing patient presentations, suggesting content was copied rather than individually documented. Late entries, addenda, and verbal order authentication are legitimate practices.

Question 25Medical Record Review Fundamentals and Documentation Standards

A patient requests an amendment to correct inaccurate information in the record. Under HIPAA, the covered entity must:

  1. Forward the request to the patient's employer
  2. Refuse all amendment requests automatically
  3. Immediately delete the disputed entry
  4. Act on the amendment request within a defined timeframe and document the decision Correct answer.

Explanation

HIPAA gives patients the right to request amendment, and the covered entity must respond within the regulatory timeframe, either making the amendment or providing a written denial with appeal rights. Deleting entries or automatic refusal is not permitted.

Question 26Medical Record Review Fundamentals and Documentation Standards

Which element of a medical record entry establishes who is accountable for the information documented?

  1. The patient's medical record number
  2. The department where care was delivered
  3. The author's signature or authenticated identifier Correct answer.
  4. The date and time the entry was made

Explanation

Accountability in documentation is established through authentication, meaning the entry carries the signature, initials, or electronic identifier of the person who made it. This identifies the responsible author and supports legal and professional accountability.

Question 27Medical Record Review Fundamentals and Documentation Standards

A patient's chart lists a penicillin allergy in the allergy section, but the current progress note documents administration of amoxicillin with no reaction noted. What is the most appropriate reviewer action?

  1. Remove the allergy entry since the medication was tolerated
  2. Assume the note refers to a different patient encounter
  3. Ignore the discrepancy because no adverse reaction occurred
  4. Flag the inconsistency for clinical review and clarification Correct answer.

Explanation

Discrepancies between documented allergies and administered medications are safety-relevant and should be flagged for clarification by the responsible clinician. The reviewer documents the finding rather than altering the record or dismissing it.

Question 28Medical Record Review Fundamentals and Documentation Standards

Which documentation practice best supports the principle that a medical record entry should reflect the care actually provided at the time it occurred?

  1. Entering notes immediately or shortly after the event Correct answer.
  2. Summarizing several days of care in one late entry
  3. Documenting at the end of the shift from memory
  4. Backdating entries to match the time of care

Explanation

Timely documentation, completed at or near the time of the event, produces the most accurate and credible record. Late reconstruction from memory increases the risk of error and undermines the record's reliability.

Question 29Medical Record Review Fundamentals and Documentation Standards

A reviewer is assessing whether a progress note supports the billed level of service. Which characteristic of the note is most important for that determination?

  1. The length of the note in lines of text
  2. The documented elements of history, examination, and medical decision-making Correct answer.
  3. The number of attachments referenced in the note
  4. The presence of copied text from a prior note

Explanation

Support for a service level depends on whether the note documents the required components, such as history, examination, and medical decision-making. Volume or duplication of text does not establish that the documented work was performed.

Question 30Medical Record Review Fundamentals and Documentation Standards

A reviewer compares a series of outpatient notes and finds that the review of systems, physical examination findings, and assessment text are identical across every visit for six months, including visits for unrelated complaints. Which conclusion is best supported?

  1. The identical text confirms efficient standardized documentation
  2. The notes are acceptable because each was signed by the author
  3. The documentation pattern suggests cloned content requiring integrity review Correct answer.
  4. The pattern proves the clinician performed the same examination each visit

Explanation

Identical narrative across visits with unrelated complaints suggests content was copied forward rather than reflecting each encounter. This raises a documentation integrity concern that warrants review, because cloned text may not represent the care actually delivered.

Question 31Coding and Reimbursement Compliance Review

A payer's published policy states that a service is covered only when the patient's diagnosis appears on a specific list. What type of coverage policy is this?

  1. A diagnosis-based medical necessity policy Correct answer.
  2. A global surgical package policy
  3. A credentialing policy
  4. A coordination of benefits policy

Explanation

Diagnosis-based medical necessity policies tie coverage to a defined list of ICD-10-CM codes, so a code not on the list is denied as not medically necessary. Global surgical packaging, coordination of benefits, and credentialing address different reimbursement and enrollment issues.

Question 32Coding and Reimbursement Compliance Review

A coder assigns a CPT code for a procedure and a separate HCPCS Level II code for the same encounter. Which coding system is used for the procedure itself?

  1. ICD-10-CM
  2. HCPCS Level II
  3. CPT Correct answer.
  4. ICD-10-PCS

Explanation

CPT describes professional medical services and procedures, while HCPCS Level II covers supplies, drugs, and equipment not represented in CPT. ICD-10-CM is diagnosis coding, and ICD-10-PCS is used for inpatient facility procedure reporting.

Question 33Coding and Reimbursement Compliance Review

A payer denies a claim with a remark code indicating the service is included in another service already paid on the same date. What is this denial concept called?

  1. Bundling Correct answer.
  2. Sequential filing
  3. Balancing
  4. Downcoding

Explanation

Bundling means component services are considered part of a more comprehensive service and are not separately payable. Downcoding reduces a code's level rather than combining services, and the other terms do not describe inclusion of one service in another.

Question 34Coding and Reimbursement Compliance Review

Under the Medicare physician fee schedule, what does the conversion factor represent?

  1. The annual update to the diagnosis code set
  2. The percentage of charges a payer allows on a claim
  3. A dollar multiplier applied to the total relative value units to produce payment Correct answer.
  4. The number of visits permitted per beneficiary per year

Explanation

Payment under the fee schedule equals the sum of work, practice expense, and malpractice relative value units multiplied by the conversion factor. The conversion factor is a dollar amount, not a percentage allowance or a utilization limit.

Question 35Coding and Reimbursement Compliance Review

A patient's Medicare Advantage plan pays a claim, and the patient also has employer group coverage. Which process determines which plan pays first?

  1. Retrospective audit
  2. Medical necessity review
  3. Coordination of benefits Correct answer.
  4. Credentialing verification

Explanation

Coordination of benefits rules establish the order of payment when a patient is covered by more than one plan. Medical necessity review and audits address whether and how much a single plan should pay, not the order among plans.

Question 36Coding and Reimbursement Compliance Review

An auditor finds that a provider documented a comprehensive visit but billed a lower-level code. What compliance risk does this undercoding create?

  1. It is permitted only for Medicare claims
  2. It may constitute a false claim if done intentionally to obtain payment Correct answer.
  3. It is always treated as fraud regardless of intent
  4. It has no compliance implications because it lowers cost

Explanation

Intentionally submitting a code that does not reflect the service provided can be a false claim even when the error favors the payer, because the claim is still inaccurate. Under-coding is not automatically fraud, since intent matters, and it is not restricted to any single payer.

Question 37Coding and Reimbursement Compliance Review

A payer requests medical records to verify that documentation supports the codes billed. What is this review called?

  1. A preauthorization
  2. An audit Correct answer.
  3. A grievance
  4. An appeal

Explanation

An audit compares submitted claims against supporting documentation to confirm accuracy. Preauthorization occurs before service delivery, while grievances and appeals are dispute processes rather than documentation verification.

Question 38Coding and Reimbursement Compliance Review

Which document typically defines the contractual terms under which a provider agrees to accept a payer's payment as payment in full?

  1. The remittance advice
  2. The superbill
  3. The advance beneficiary notice
  4. The participating provider agreement Correct answer.

Explanation

A participating provider agreement sets the terms of network participation, including acceptance of the allowed amount. Remittance advices, superbills, and advance beneficiary notices are operational or disclosure documents, not contracts.

Question 39Coding and Reimbursement Compliance Review

A coder bills a modifier that indicates a procedure was performed on a distinct body site during the same operative session. Which modifier category does this describe?

  1. A modifier indicating a distinct anatomic site Correct answer.
  2. A modifier indicating a decision for surgery
  3. A modifier indicating a bilateral procedure
  4. A modifier indicating reduced services

Explanation

Distinct-site modifiers explain that a service was performed at a separate anatomic location so it is not bundled. Modifiers for reduced services, surgical decisions, and bilateral procedures convey different circumstances.

Question 40Coding and Reimbursement Compliance Review

A laboratory performs a test that is not on the payer's covered list but is medically appropriate. What is the most appropriate first step before billing the patient?

  1. Change the diagnosis to one that is covered
  2. Bill the patient without any notice
  3. Submit the claim repeatedly until it pays
  4. Obtain an advance beneficiary notice and document the patient's acknowledgment Correct answer.

Explanation

When a service may be denied as not covered, an advance beneficiary notice shifts financial responsibility to the patient only if properly issued and acknowledged. Altering the diagnosis to obtain payment is misrepresentation, and billing the patient without notice may violate notice requirements.

Question 41Coding and Reimbursement Compliance Review

A provider bills a global surgical code, and a payer denies the post-operative visit on the same claim. What is the most likely reason?

  1. The visit was performed by a different specialty
  2. The visit occurred after the global period ended
  3. The visit is included in the global surgical package Correct answer.
  4. The visit lacked a diagnosis code

Explanation

Global surgical codes include routine pre-operative, intra-operative, and post-operative care, so routine visits during the global period are not separately payable. A visit after the global period, or an unrelated service, would generally be separately billable.

Question 42Coding and Reimbursement Compliance Review

An auditor compares the number of units billed for a timed therapy service against the documented treatment minutes. Which coding principle is being tested?

  1. Modifier sequencing
  2. Place-of-service accuracy
  3. Diagnosis sequencing
  4. Unit reporting based on documented time Correct answer.

Explanation

Timed services are billed in units that correspond to the documented minutes of treatment, so unit-to-time matching is the principle under review. Place of service, diagnosis sequencing, and modifier order concern different aspects of the claim.

Question 43Coding and Reimbursement Compliance Review

A payer's edit pairs two codes that should not be billed together because one is a component of the other. What is the accepted way to override the edit when documentation supports separate services?

  1. Split the services across two claim forms
  2. Resubmit the claim without changes
  3. Append an appropriate modifier with supporting documentation Correct answer.
  4. Bill both codes at full value on separate dates

Explanation

An appropriate modifier, supported by documentation, signals that the services were distinct and separately reportable. Resubmitting, splitting claims, or altering dates does not establish that the services were separate and may create billing errors.

Question 44Coding and Reimbursement Compliance Review

A compliance reviewer finds that a provider's documentation supports a higher-level evaluation and management code than the one billed. What is the recommended corrective action?

  1. Leave the claim as billed to avoid scrutiny
  2. Bill the higher code on a future claim to balance
  3. Correct the claim and monitor for patterns of undercoding Correct answer.
  4. Report the patient to the payer

Explanation

Claims should reflect the service documented, so correcting the claim and monitoring for patterns addresses accuracy. Deliberately offsetting undercoding on other claims is improper, and the patient is not responsible for coding errors.

Question 45Coding and Reimbursement Compliance Review

A payer issues a denial stating that a prior authorization was required but not obtained. What is the most appropriate first response?

  1. Resubmit the identical claim
  2. Review the plan's authorization requirements and determine whether an appeal or retro-authorization is available Correct answer.
  3. Change the date of service to avoid the requirement
  4. Bill the patient the full charge immediately

Explanation

The first step is to verify whether authorization was required and whether the plan permits retroactive review or appeal. Immediately billing the patient or altering the claim may violate plan rules and is not an appropriate resolution.

Question 46Coding and Reimbursement Compliance Review

A practice discovers that a coder has been assigning a higher-level code than documentation supports across many claims. What compliance exposure does this create?

  1. No exposure because the payer processed the claims
  2. Exposure only if the patient complains
  3. Potential overpayment liability and false claims exposure Correct answer.
  4. Exposure limited to a single claim

Explanation

Upcoding that results in overpayment can create refund obligations and, if knowing, false claims liability across all affected claims. Payer processing does not eliminate the obligation, and exposure is not limited to a single claim or to patient complaints.

Question 47Coding and Reimbursement Compliance Review

A payer recoups payment after an audit finds documentation did not support the level of service billed. What is the provider's most appropriate action?

  1. Appeal every recoupment regardless of merit
  2. Stop billing that service entirely
  3. Perform a root-cause review and correct the underlying documentation and coding process Correct answer.
  4. Bill the patient for the recouped amount without review

Explanation

A recoupment based on unsupported documentation calls for identifying the cause and correcting processes to prevent recurrence. Meritless appeals, ceasing all related billing, or shifting the loss to the patient do not address the underlying problem.

Question 48Coding and Reimbursement Compliance Review

A provider performs a service in a hospital outpatient department and bills with the place-of-service code for the physician office. What is the likely consequence?

  1. The claim will be automatically paid at a higher rate
  2. The diagnosis code will be rejected
  3. No consequence because place of service is informational only
  4. Payment may be incorrect because the place of service affects the payment amount Correct answer.

Explanation

Place of service affects facility versus non-facility payment and can change the allowed amount, so an incorrect code can produce incorrect payment. It is not merely informational, and it does not affect diagnosis code validity.

Question 49Coding and Reimbursement Compliance Review

A payer's policy requires that a specific diagnosis be listed as the principal diagnosis for a procedure to be covered. A coder lists it as a secondary diagnosis. What is the likely outcome?

  1. The claim will pay because the code appears somewhere on the claim
  2. The claim will be returned for a missing modifier
  3. The claim may be denied for failing to meet the diagnosis requirement Correct answer.
  4. The claim will pay at a reduced rate automatically

Explanation

When a policy ties coverage to the principal diagnosis, listing the required code as secondary does not satisfy the requirement and can cause denial. Payer edits typically evaluate the principal diagnosis position, not merely presence on the claim.

Question 50Coding and Reimbursement Compliance Review

A compliance plan requires periodic internal audits of coding accuracy. Which sampling approach best supports a defensible audit?

  1. A statistically valid random sample of claims stratified by provider or service type Correct answer.
  2. Only claims that were previously denied
  3. Only the claims the practice believes are correct
  4. A single claim chosen by the coder

Explanation

A statistically valid, stratified random sample supports reliable estimates of error rates and defensible extrapolation. Selecting only favorable, self-chosen, or previously denied claims introduces bias and weakens the audit's conclusions.