ABFAS Documentation and Record Keeping 3 — Questions and Answers
Question 1: Which element is essential in the documentation of informed consent for an elective foot and ankle procedure?
- Surgeon's board certification number
- Discussion of material risks, benefits, and alternatives (Correct answer)
- Cost estimate for the procedure
- Insurance pre-authorization number
Correct answer: Discussion of material risks, benefits, and alternatives
Informed consent documentation must capture that the patient was advised of material risks, expected benefits, and reasonable alternatives before agreeing to the procedure.
Question 2: When amending a paper medical record, what is the correct method for correcting an error?
- Use correction fluid (white-out) to cover the error
- Draw a single line through the error, write the correction, and initial with date (Correct answer)
- Remove and replace the page containing the error
- Highlight the error in yellow for future reference
Correct answer: Draw a single line through the error, write the correction, and initial with date
A single strikethrough preserving the original entry, followed by the correction, initials, and date, maintains record integrity and legal defensibility.
Question 3: Under CMS guidelines, what is the required retention period for Medicare patient medical records?
- 3 years from date of service
- 5 years from date of service (Correct answer)
- 7 years from date of service
- 10 years from date of service
Correct answer: 5 years from date of service
CMS requires Medicare records to be retained for a minimum of 5 years from the date of service, though state law may require longer retention.
Question 4: In podiatric surgery, documentation of the 'laterality' confirmation is critical to prevent which type of adverse event?
- Retained surgical instrument
- Wrong-site surgery (Correct answer)
- Anaphylactic reaction
- Postoperative infection
Correct answer: Wrong-site surgery
Laterality documentation—confirming left versus right foot—directly prevents wrong-site surgery, which is a never event.
Question 5: Which CPT code modifier must be appended to document that a bilateral procedure was performed on foot and ankle structures?
- -50 (Correct answer)
- -51
- -59
- -22
Correct answer: -50
Modifier -50 is appended to CPT codes to indicate that an identical procedure was performed bilaterally in the same operative session.
Question 6: A podiatric surgeon uses a template-generated note without reviewing its accuracy. Under OIG guidelines, this practice is known as:
- Downcoding
- Cloning (Correct answer)
- Unbundling
- Upcoding
Correct answer: Cloning
Cloning refers to copying forward template or prior-visit notes without individualization, which the OIG identifies as a fraudulent documentation practice.
Question 7: Which section of the SOAP note format is used to record the podiatric surgeon's interpretation of x-ray findings?
- Subjective
- Objective
- Assessment (Correct answer)
- Plan
Correct answer: Assessment
The Assessment section contains the clinician's interpretation and diagnostic conclusions, including analysis of imaging studies.
ABFAS Documentation and Record Keeping 3
Which element is essential in the documentation of informed consent for an elective foot and ankle procedure?