NBCOT Documentation and Service Management 2 — Questions and Answers
Question 1: Which of the following is an example of an occupational therapy short-term goal?
- Client will return to independent community mobility in 6 months
- Client will don a shirt with modified independence using buttonhook in 2 weeks (Correct answer)
- Client will improve overall ADL performance
- Client will understand home exercise program
Correct answer: Client will don a shirt with modified independence using buttonhook in 2 weeks
Short-term goals should be specific, measurable, include a time frame, and address a discrete skill or step toward the long-term goal.
Question 2: Supervision of a COTA by an OTR should be documented to reflect:
- Only the COTA's credentials
- The frequency, type, and content of supervision provided (Correct answer)
- Only the OTR's signature
- The COTA's scheduling preferences
Correct answer: The frequency, type, and content of supervision provided
COTA supervision documentation should reflect the frequency, nature, and content of supervisory interactions to meet state licensure and accreditation requirements.
Question 3: A therapist realizes they made an error in a written progress note. The correct action is to:
- Use correction fluid to cover the error
- Draw a single line through the error, write 'error', date, and initial it (Correct answer)
- Rewrite the entire note
- Delete the note from the electronic record
Correct answer: Draw a single line through the error, write 'error', date, and initial it
The correct method for correcting a written documentation error is to draw a single line through it, note 'error', and add the date and initials to maintain transparency.
Question 4: In value-based care models, OT outcomes are most effectively measured by:
- Number of therapy units billed
- Functional improvement, goal attainment, and return to meaningful occupations (Correct answer)
- Length of stay only
- Physician satisfaction scores
Correct answer: Functional improvement, goal attainment, and return to meaningful occupations
Value-based care rewards measurable functional outcomes, goal achievement, and return to meaningful occupational roles over volume of services provided.
Question 5: Which billing unit in outpatient OT under Medicare represents 15 minutes of skilled service?
- 1 revenue code unit
- 1 therapy unit (timed code) (Correct answer)
- 1 encounter
- 1 visit
Correct answer: 1 therapy unit (timed code)
Medicare outpatient therapy uses time-based billing where most therapeutic procedure codes are billed in 15-minute timed units.
Question 6: An OT determines that a client no longer requires skilled OT services. Discharge criteria include:
- Client has reached maximum therapeutic benefit or goals are achieved (Correct answer)
- Insurance authorization has expired
- The client requests discharge only
- The OT has a full caseload
Correct answer: Client has reached maximum therapeutic benefit or goals are achieved
Discharge is clinically indicated when the client has achieved goals, reached maximum therapeutic benefit, or when continued skilled services are no longer medically necessary.
NBCOT Documentation and Service Management 2
Which of the following is an example of an occupational therapy short-term goal?