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
A technician receives a verbal order from the prescribing physician to change the prosthetic foot category. What must happen before fabrication?
Answer: The verbal order must be followed up with a written order within the payer's required timeframe
Verbal orders must be documented and followed up with a written or electronic signed order within the timeframe specified by the payer to be valid for billing.
Which piece of documentation is used to justify the upgrade from a basic SACH foot to an energy-storing foot for a K3 patient?
Answer: Functional goals statement and documented activity level consistent with K3
A documented functional goals statement aligned with a K3 activity level provides the clinical justification for prescribing an energy-storing foot.
Which of the following is an example of a correctable documentation error versus fraud?
Answer: A date typo is a correctable error; intentionally billing for a higher-cost device is fraud
Unintentional errors such as typographical mistakes are correctable documentation issues, while deliberately billing for services not provided or upcoding constitutes fraud.
A prosthetic facility is undergoing a CMS audit. Which records are auditors most likely to request for a high-cost claim?
Answer: Physician orders, CMN, prior authorization, delivery confirmation, and progress notes
CMS auditors typically request the full documentation chain including orders, CMN, authorization, delivery confirmation, and progress notes to verify claim legitimacy.
Why is it important to document the patient's informed consent before fitting a new prosthetic device?
Answer: It confirms the patient understands risks, benefits, and alternatives, and is a legal and ethical requirement
Informed consent documentation confirms the patient was educated about the device, alternatives, and potential limitations, which is both a legal requirement and an ethical standard of care.
When a prosthetic device is lost or stolen, what documentation action should occur first?
Answer: Document the incident in the patient's record and notify the payer per their guidelines
The incident must be documented in the patient's record and the payer notified according to their specific guidelines before a replacement can be appropriately ordered and billed.
In electronic health records (EHR) used in prosthetics, an audit trail is important because it:
Answer: Tracks who accessed or modified records and when, supporting compliance and fraud prevention
EHR audit trails create an immutable log of all record access and modifications, which is essential for HIPAA compliance and detecting unauthorized changes.