Documentation & Clinical Communication Flashcards
7 cards from real MTM 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 & Clinical Communication flashcards as text
A pharmacist completes an MTM encounter and must choose between CPT codes 99605 and 99607. The distinction between these codes is based on:
Answer: Whether the patient is new (99605) or established (99606/99607) and the duration of the encounter
99605 is for new MTM patients (up to 15 min), 99606 for established patients (up to 15 min additional), and 99607 for each additional 15 minutes beyond the initial service.
Which of the following BEST describes the role of a 'clinical decision support alert' in MTM EHR documentation?
Answer: It flags potential drug-related problems and prompts the pharmacist to document a clinical response
Clinical decision support alerts identify potential DRPs and prompt the pharmacist to evaluate and document a clinical response, supporting but not replacing professional judgment.
When documenting a patient's social determinants of health (SDOH) that affect medication adherence during MTM, this information is MOST appropriately placed in which section of the clinical note?
Answer: Subjective
SDOH factors reported by or identified through direct patient interaction are subjective findings that inform the pharmacist's overall assessment and plan.
A pharmacist is preparing a written recommendation letter to a specialist physician after identifying an issue outside the primary care provider's scope. The letter should:
Answer: Identify the specific clinical concern, the relevant medication, and a clear recommended action
Specialist communication letters must clearly articulate the clinical concern, the implicated medication(s), and actionable recommendations to facilitate timely specialist response.
During MTM documentation, 'medication nonadherence' as a drug-related problem should be classified as which type of DRP using the Cipolle-Strand-Morley framework?
Answer: Compliance problem
In the Cipolle-Strand-Morley DRP framework, medication nonadherence is classified under 'Compliance' (also termed 'Adherence'), reflecting the patient's inability or unwillingness to take medication as intended.
A pharmacist documents a 'Needs Additional Drug Therapy' DRP in an MTM note. This is MOST likely because:
Answer: A medical condition is present that requires pharmacotherapy but none has been prescribed
'Needs Additional Drug Therapy' is documented when a patient has an untreated medical condition that warrants pharmacotherapy not currently prescribed.
Following an MTM session, a pharmacist must transmit the CMR written summary to the patient within how many calendar days, per CMS guidelines?
Answer: 30 days
CMS requires that the CMR written summary be provided to the patient within 14 calendar days of the comprehensive medication review encounter.