Documentation & Record Keeping Flashcards
7 cards from real CPT practice questions. Tap to flip, then mark Knew It or Still Learning — missed cards come back until you master them.
Read the first 7 Documentation & Record Keeping flashcards as text
Which section of a prosthetic patient record documents the patient's residual limb measurements and shape?
Answer: Evaluation/assessment
The evaluation or assessment section captures objective data including residual limb measurements, shape, skin condition, and volume.
A patient requests a copy of their prosthetic records. Under HIPAA, the facility must provide access within:
Answer: 30 days
HIPAA requires covered entities to provide patients with access to their health records within 30 days of the request, with one 30-day extension if needed.
An ABC-accredited prosthetic facility must maintain documentation proving that its technicians meet which requirement?
Answer: Possess current and appropriate credentials or supervised training hours
ABC accreditation standards require facilities to document that staff possess current credentials or are completing supervised training as applicable.
In which document would a technician record that a patient's prosthetic liner was replaced during a routine visit?
Answer: Patient progress note or service record
Routine supply replacements and services are recorded in the patient's progress notes or service record to maintain a complete treatment history.
When submitting a claim for a myoelectric upper-limb prosthesis, the supporting documentation must include:
Answer: Physician's order, functional assessment, and fitting notes
Complex devices like myoelectric prostheses require comprehensive documentation including a physician's order, documented functional need, and clinical fitting records.
If a Medicare audit reveals that delivery receipts are missing from patient files, the likely consequence is:
Answer: Recoupment of payments for those claims
Missing delivery receipts are a primary cause of Medicare claim recoupment because they are required proof that the beneficiary received the device.
What is the significance of documenting a patient's ambulatory status as 'household ambulator' in a prosthetic record?
Answer: It correlates to a K-level that determines appropriate device selection and coverage
Ambulatory status descriptions correspond to Medicare K-levels, which directly determine which prosthetic components are medically justified and covered.