Documentation & Record Keeping Flashcards
7 cards from real CPT 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 & Record Keeping flashcards as text
When a prosthetist modifies a patient's socket due to skin breakdown, which document must be updated to reflect the change?
Answer: The patient's clinical progress notes
Clinical progress notes must be updated whenever a modification is made to address a medical issue such as skin breakdown.
Under HIPAA, a prosthetic technician shares a patient's fitting details with a colleague not involved in the patient's care. This is:
Answer: A violation of the minimum necessary standard
HIPAA's minimum necessary standard prohibits sharing PHI with individuals not involved in the patient's direct care without proper authorization.
Which element is required in a Certificate of Medical Necessity (CMN) for a lower-limb prosthesis?
Answer: Physician's signature and date
A valid CMN requires a licensed physician's signature and date to certify the medical necessity of the prosthetic device.
A patient record shows a K-level of K2 but the prescribed prosthesis is a microprocessor knee. What should the technician do first?
Answer: Flag the discrepancy and notify the prosthetist
The technician should immediately notify the prosthetist of the inconsistency before fabrication to prevent improper device delivery and billing issues.
How long must prosthetic patient records generally be retained under Medicare regulations?
Answer: 7 years from date of service
Medicare requires suppliers to retain patient records for a minimum of 7 years from the date of service.
Which of the following best describes a 'delivery confirmation' document in prosthetics?
Answer: A signed form confirming the patient received the device
A delivery confirmation is a patient-signed document verifying that the prosthetic device was received, which is required for Medicare billing.
When documenting alignment adjustments during a dynamic gait analysis, the technician should record:
Answer: Specific measurements and the rationale for each change
Documentation of alignment adjustments must include specific measurement data and clinical rationale to support the prosthetic intervention.