CMS Patient Assessment & Documentation 2

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?

Accepted Answer

99214

Answer

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?

Accepted Answer

HIPAA-compliant authorization form

Answer

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)?

Accepted Answer

Katz Index of Independence

Answer

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?

Accepted Answer

Minimum Data Set (MDS)

Answer

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)?

Accepted Answer

Patient's Medicare ID number

Answer

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.

(CMS) Certified Medicare Specialist Practice Test

(CMS) Certified Medicare Specialist Practice Test

CMS Patient Assessment & Documentation 2