CMS Patient Assessment & Documentation 2 — Questions and Answers
Question 1: A Medicare patient's physician documents 'moderate complexity medical decision making' during an office visit. Which CPT E/M level does this MOST likely support?
- 99213
- 99214 (Correct answer)
- 99215
- 99212
Correct answer: 99214
CPT 99214 corresponds to an established patient office visit with moderate complexity medical decision making.
Question 2: Which document serves as the legal authorization for a provider to access a Medicare beneficiary's medical records for care coordination?
- Advance Beneficiary Notice (ABN)
- HIPAA-compliant authorization form (Correct answer)
- Certificate of Medical Necessity (CMN)
- Medicare Secondary Payer questionnaire
Correct answer: HIPAA-compliant authorization form
A HIPAA-compliant authorization form is required to release a beneficiary's protected health information to another party.
Question 3: When documenting a Medicare patient's functional status for home health eligibility, which scale is most commonly used to assess activities of daily living (ADLs)?
- Glasgow Coma Scale
- Katz Index of Independence (Correct answer)
- AUDIT-C Score
- PHQ-9 Depression Scale
Correct answer: Katz Index of Independence
The Katz Index of Independence assesses a patient's ability to perform six ADLs and is widely used for home health eligibility documentation.
Question 4: A Medicare patient is admitted to a skilled nursing facility (SNF). Which assessment instrument must be completed to determine the patient's care needs and Medicare payment level?
- OASIS-E
- Minimum Data Set (MDS) (Correct answer)
- IRF-PAI
- LCDS
Correct answer: Minimum Data Set (MDS)
The Minimum Data Set (MDS) is the standardized assessment tool required for all SNF Medicare patients to determine care planning and payment under PDPM.
Question 5: Which element is NOT required in a physician's order for Medicare Part B durable medical equipment (DME)?
- Patient's diagnosis
- Detailed description of the item
- Patient's Medicare ID number (Correct answer)
- Treating physician's NPI
Correct answer: Patient's Medicare ID number
A Medicare Part B DME order requires the diagnosis, item description, and physician's NPI, but the Medicare ID number is not a required element of the order itself.
Question 6: What is the purpose of the OASIS-E assessment in Medicare home health documentation?
- To determine SNF payment levels under PDPM
- To assess patient outcomes and drive Home Health Resource Groups (HHRGs) for payment (Correct answer)
- To authorize inpatient rehabilitation stays
- To calculate hospice cap amounts
Correct answer: To assess patient outcomes and drive Home Health Resource Groups (HHRGs) for payment
OASIS-E collects standardized patient data used to measure outcomes, guide care planning, and calculate payment under the Home Health Patient-Driven Groupings Model.
Question 7: A Medicare specialist reviews a patient's chart and finds the physician documented 'patient stable, no changes' without any subjective complaints, exam findings, or assessment. What is the documentation deficiency?
- Missing advance directive reference
- Insufficient E/M documentation to support medical necessity (Correct answer)
- Absent care coordination note
- No prior authorization reference
Correct answer: Insufficient E/M documentation to support medical necessity
E/M documentation must include history, examination, and medical decision making (or time) to support medical necessity; a brief note without these elements is insufficient.
CMS Patient Assessment & Documentation 2
A Medicare patient's physician documents 'moderate complexity medical decision making' during an office visit.
Which CPT E/M level does this MOST likely support?