Practice Test Geeks(CMS) Certified Medicare Specialist Practice Test
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Patient Assessment & Documentation Flashcards

7 cards from real CMS practice questions. Tap to flip, then mark Knew It or Still Learning — missed cards come back until you master them.

Read the first 7 Patient Assessment & Documentation flashcards as text

  1. Which Medicare-specific form is used to certify a patient's eligibility for hospice and must be signed by the attending physician and hospice medical director?

    Answer: Hospice Election Statement with physician certification

    Hospice enrollment requires a written election statement and a physician certification that the patient has a terminal prognosis of 6 months or less if the illness runs its normal course.

  2. A Medicare patient's documentation includes the phrase 'patient denies chest pain, shortness of breath, and palpitations.' In E/M coding, this constitutes which element?

    Answer: Review of Systems (ROS)

    Review of Systems (ROS) is an inventory of body systems obtained by questioning the patient to identify signs or symptoms; denial of symptoms constitutes a negative ROS.

  3. Under Medicare's Chronic Care Management (CCM) program, which documentation requirement must be met before billing 99490?

    Answer: Comprehensive care plan must be established and in the medical record

    Billing CCM code 99490 requires a comprehensive care plan addressing all health conditions, documented in the medical record and shared with the patient.

  4. When a Medicare inpatient is transferred to another acute care hospital, which document must accompany the patient to ensure continuity of care under CMS Conditions of Participation?

    Answer: A medical summary or transfer documentation including active diagnoses, medications, and care plan

    CMS Conditions of Participation require that a medical summary or copy of relevant records — including diagnoses, medications, and care plan — accompany a transferred patient.

  5. A Medicare patient's chart shows a principal diagnosis listed after the admission note but before discharge. According to UHDDS guidelines, how is the principal diagnosis defined?

    Answer: The condition established after study to be chiefly responsible for occasioning the admission

    The Uniform Hospital Discharge Data Set (UHDDS) defines the principal diagnosis as the condition established after study to be chiefly responsible for the patient's admission.

  6. Which Medicare quality initiative requires hospitals to document and publicly report patient experience scores, including communication with doctors and nurses?

    Answer: HCAHPS (Hospital Consumer Assessment of Healthcare Providers and Systems)

    HCAHPS is the standardized, publicly reported survey measuring patients' perspectives of hospital care, including communication, responsiveness, and overall rating.

  7. A Medicare specialist documents a patient's medication reconciliation at a Transitional Care Management (TCM) visit. Which code set covers TCM services billed within 30 days of discharge?

    Answer: 99495 or 99496

    TCM services are billed using CPT 99495 (moderate complexity, 14-day follow-up) or 99496 (high complexity, 7-day follow-up) within 30 days post-discharge.