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Documentation Review- Final
Documentation Review- Final
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PTA 107 Review- Final Exam
Flashcards
100 cards
F
Practice quiz
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Host live
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Questions
100
Answers
1
Name for alpha-numeric codes used for billing, such as L codes for orthotic/prosthetic devices.
HCPCS
Modifiers
CPT codes
ICD-10 codes
2
Which of the following statements is considered non-skilled and should be avoided in documentation?
Caregiver training provided...
...In order to promote recovery
Patient did...
Pt ambulated...
3
Medicare Part A covers 100% for the first _____ days of treatment, then _____% afterwards
80; 20
100; 50
20; 80
50; 25
4
Which of the following is a standardized form used in pediatric therapy documentation?
IEP
CMS-700
CMS-701
Functional outcome reporting
5
A disease or medical diagnosis is also known as a patient's ________.
Functional limitation
Pathology
Participation restriction
Impairment
6
"L ankle DF AROM 0-15* (0-10* on initial eval)" should be documented as what type of data?
Subjective
Objective
Assessment
Plan
7
Pain profile used to rate pain by
marking
along a continuous line, from 1-10.
VAS
Wong-Baker
NRS
McGill Pain Questionnaire
8
Students do NOT need to refrain from discussing pt information in hallways/elevators
True
False
9
This is the new modifier code, implemented Jan 2020, identifying that services (in part/whole) were performed by a PTA
CO
GP
CQ
59
10
Service-based/untimed codes are billed __ unit/s, regardless of how many min of tx are provided
0
2
3
1
11
PHI stands for __________
Personal history information
Personal health identification
Protected health information
Protected health insurance
12
How should hand-written notes be documented?
During or right after tx
In blue or black ink
Legibly
All of the above
13
Which of the following statements is TRUE regarding documenting vital signs?
BP should be documented as diastolic over systolic
HR is documented as mm Hg
Document before, during, and after activity
The unit documented for RR is "bpm"
14
Which of the following PPS reimbursement models is in effect for SNFs?
PDPM
PDGM
IPPS
MPFS
15
HIPAA stands for ________
Human Identification Protection Accountability Act
Health Identification Protection Accountability Act
Health Insurance Privacy Accountability Act
Health Insurance Portability and Accountability Act
16
Which of the following is NOT a component of "examination" in the pt/client management model?
Pt education
Systems review
Tests/measures
Pt history
17
This is the year the PTA profession was
created
.
1921
1969
1977
1967
18
This is a Federal government agency who establishes documentation guidelines
FSBPT
Medicare
Hospital
APTA
19
"Pt completed static standing at FWW, CGA to decrease fall risk" is missing what A-F component?
D
C
B
F
20
Which of the following payment models uses relative value units (RVUs) to calculate fees?
Fee-for-service (FFS)
Medicare Physician Fee Schedule (MPFS)
Prospective Payment System (PPS)
Alternative payment models (APMs)
21
"When a procedure/modality is not paid as distinct and separate" (e.g., Medicare and hot/cold packs)
Reimbursement
Bundling
Group therapy
Billable
22
Intentionally billing for services not provided/has higher reimbursement than what was provided...
Abuse
Fraud
23
"Pt B LE has improved from 3/5 to 4+/5 and has progressed to now requiring min A for xfers"
Objective data
Plan data
Assessment data
Subjective data
24
What is the patient assessment tool used in SNF settings?
MIPS
IPPS
MDS 3.0
DRG
25
How is this billed? "Pt completed static sitting on EOM x5' w/ min A and tactile cues to improve postural control"
97116
97150
97112
97110
26
Limited ROM is an example of THIS.
Impairment
Pathology
Activity limitation
Participation restriction
27
When pt performs less than 25% of a task (therapist provides >75% assist)
Dependent
Min assist
Mod assist
Max assist
28
"Productivity" is calculated by dividing the total # of billable tx minutes by the total time worked in a facility.
True
False
29
Using the 8-minute rule, how many units should be billed for a treatment session of 41 minutes?
3
2
4
1
30
Patients have the right to refuse therapy
False
True
31
Which of the following items is included in a PT prognosis/POC?
Patient education
Pain level/location
Rehab potential
Chart review/pt history
32
Which of the following is an example of an IADL?
Ambulating up/down stairs
Taking a shower
Brushing teeth
Driving to/from work
33
Which of the following codes is NOT used for initial PT evaluations?
97163
97164
97162
97161
34
Which of the following components is NOT within a PTA's scope of practice?
Pt/client education
Evaluation
Communication and documentation
Procedural interventions
35
Muscle weakness is an example of _________.
Functional limitation
Impairment
Disability
Pathology
36
PTAs are responsible for discharging pt from PT because they're typically the primary therapist
False
True
37
Which of the following is LEAST appropriate to document as assessment data?
PT Goals
Recommendations for next session
Pt's response to POC
Pt progress/lack of progress towards goals
38
Which of the following is not billable for therapeutic procedures?
Therapeutic intervention
Transporting patient to rehab gym for therapy
Assessment of intervention
Skilled preparation of intervention
39
Pt education is a __________ service and should be documented as _________ data.
Billable; assessment
Non-billable; assessment
Billable; objective
Non-billable; objective
40
Objective data should be documented from the perspective of what the PTA did, not the patient
True
False
41
This is considered a "Golden Rule" of documentation.
If it isn't written, it didn't happen
Documentation is only needed for changes in pt status
Students are not allowed to document in pt's medical records
Only follow documentation guidelines set by the APTA
42
Cluster of codes to describe diseases/conditions of a pt
G-codes
ICD-10
CPT
HCPCS
43
Which of the following statements indicate hypomobility?
"R shoulder flex/ext AROM 0-5-180 degrees"
"R shoulder flex/ext PROM 5-0-180 degrees"
"R shoulder flex/ext AROM +5-180 degrees"
"R shoulder ext PROM +5 degrees"
44
Which of the following settings utilizes the OASIS as a patient assessment tool?
Outpatient
Inpatient acute care hospitals
Home health
SNF
45
PTA stands for ________
Physical therapist administrator
Physical therapy aide
Physical therapy assistant
Physical therapist assistant
46
Pt complaints of pain during an exercise would be documented as which type of data?
Plan
Objective
Assessment
Subjective
47
Which of the following events would LEAST likely require a PTA to communicate with a supervising PT?
Pt has met LTG
Pt fell during tx session
Pt has progressed from using a walker to a cane
Add an intervention to POC
48
Which of the following is NOT a reason for denials in reimbursement?
Too many abbreviations
Does not demonstrate skilled care
Legibility
Repetitious daily notes showing no change in pt status
49
Which of the following is NOT included when correcting errors in handwritten documentation?
Erase or cover with White-Out
Initials
Date
Single line through mistake
50
"V80.730A" is an example of which type of code?
CPT
Modifier
ICD-10
HCPCS
51
This is an appropriate use of person-first language
The pt with a femur fx
The stroke pt
COVID-19 patients
The amputee in room 412
52
"Will attempt gt training w/ SPC next tx to progress pt toward indep amb" is what type of data?
Objective
Plan
Assessment
Subjective
53
Which of the following statements is FALSE regarding use of the A-F formula?
Can be used to document rehab or personal goals
'Thought map' to create skilled documentation statements
It is used to calculate how many tx minutes a pt needs
Can be modified to document treatment interventions
54
97110 is the code for _________
Neuromuscular re-education
Manual therapy
Therapeutic activities
Therapeutic exercise
55
Requires constant attendance by therapist and typically billed in 15-min increments?
Service-based codes
Time-based codes
56
Which of the following "items" is NOT an example of PHI?
Patient ID bracelet
THA post-surgical instructions
Appointment schedules and patient logs
Medical record number
57
Pt can complete a task, but requires assistive device, cues, or extra time
Independent
Supervision
Modified independent
Stand-by assist
58
Which of the following statements should be avoided for assessment data?
"Pt is progressing toward goals"
"Pt's ROM has improved"
"Pt tolerated tx well"
All of the above are too vague and should be avoided
59
This is the number of pts Medicare defines as 'group therapy'.
6+
2-3
2-6
3-5
60
Which of the following is TRUE regarding contemporary model definitions of health?
Emphasis is treating/curing disease
Defined as free/absent from disease
Does not consider how disease affects a person's daily life
Addresses societal, psychological, and physical functioning
61
This is an example of an
accreditation
agency that provides documentation standards and criteria.
Medicare
Joint Commission
Medicaid
APTA
62
Which of the following is NOT a qualifying criteria for Medicare A coverage?
Admitted to SNF w/in 30 days after qualifying hospital stay
Physician certifies skilled rehab service
Pt is unsafe for outpatient services
Consecutive 2 day hospital stay past midnight
63
Which of the following is NOT necessary/true to obtain informed consent?
Patient must be competent
Consent must be voluntary
Can only be obtained in writing
Provide appropriate information
64
8 Min Rule- 60 min of group tx and 24 min of gt training- how many min/units should be billed?
36 min, 2 units
24 min, 2 units
84 min, 3 units
84 min, 6 units
65
No weight is allowed on involved limb; foot/toes make no contact with floor/ground surface
NWB
PWB
FWB
WBAT
66
How should this be billed?: Pt receives 21 min of gt training and 19 min of ther act
2 units total; 1 unit 97112 and 1 unit 97530
3 units total; 2 units 97116 and 1 unit 97530
2 units total; 1 unit 97116 and 1 unit 97530
3 units total; 2 units 97110 and 1 unit 97530
67
General information reported by the pt/family is documented as which type of data?
Plan
Assessment
Objective
Subjective
68
Most PT services are located in which series of coding?
79000
97000
10000
55000
69
Which of the following is FALSE regarding basic documentation guidelines?
Should be written in 1st person
Use abbreviations sparingly
Authenticate documentation with date, signature, designation
Should be written in 3rd person
70
The pt's response to an intervention should be documented as what type of data?
Assessment
Subjective
Objective
Plan
71
"A&O x2" is documented to refer to a patient's _________
Muscle performance
Joint integrity/mobility
Mental function
Postural alignment
72
Refers to unattended e-stim and is NOT recognized by Medicare?
97014
G0283
97032
73
Which of the following BEST describes the purpose of an ABN?
Form used to document an incident report
Form used to notify a Medicare beneficiary that services may not be covered
Form used for providers to submit claims for reimbursement
Form used in school-based rehab settings
74
Which of the following levels of supervision is BEST defined by the PT being onsite and immediately available?
Telecommunication
Direct personal
Direct
General
75
Definition of 2 therapists treating the same pt at the same time.
Individual therapy
Co-treatment
Concurrent therapy
Group therapy
76
Which of the following is NOT true regarding skilled care?
Requires unique judgement for safety/effectiveness
Services can be carried out by HEP or untrained personnel
Requires skills of therapist
Pathology/injury results in documented limitation
77
A
general
rule/principle of CPT codes is one (1) unit of billable service equals ______ minute increments.
15
30
60
8
78
Which of the following statements identifies long-term goals (LTGs)?
Written at impairment level
Functional outcome
Created by PTA during tx session
Anticipated goal
79
2-Digit codes that provide additional information about a billed procedure
Modifier
HCPCS
CPT
G-codes
80
Which of the following is an example of a participation restriction?
SOB/dyspnea/DOE
Pt has COPD
Pt requires assistance at home for ADLs
Gait distance limited to 15'
81
PTA student and sup PT are tx different pts in gym (Med A)... What type of service delivery is being performed?
Concurrent
Individual tx for both student and sup PT
Group therapy
Co-treat
82
Services provided by a PTA student, to a patient with Medicare B, is reimbursable
False
True
83
"Pt amb 75' using FWW w/ mod I to return home. Pt demo safe technique" would BEST be documented as __________
Neuromuscular re-education
Therapeutic activity
Gait training
Therapeutic exercise
84
Which of the following statements is NOT true regarding documentation?
Allows for reproducible interventions
Provides a legal report of pt care
Provides basis for reimbursement
Documentation is not required for each visit
85
When utilizing the 8-Minute Rule, what is the
FIRST
step to determine the max # units that can be billed?
Ask the supervising PT
Apply 8-Minute Rule individually for all services billed, then add together
Total time of time-based codes/services
Total time of service-based codes/services
86
Documentation format organized around each dicipline/service involved in pt's episode of care...
SOAP
FOR
Narrative
SOMR
87
Which of the following is a component of the A-F Formula and describes how a pt completed an activity?
Behavior
Condition
Diagnosis
Function/purpose
88
Students are allowed to complete patient documentation (Medicare Part A and most private insurance co).
True
False
89
Which of the following documentation responsibilities can only be performed by a PT?
Re-evaluation
Discharge summary w/o interpretation
Daily note
Progress note
90
Incident reports are completed for instances that are unexpected and could result in a lawsuit
True
False
91
The PTA is responsible for obtaining a patient's informed consent for the POC.
True
False
92
A standard rule to follow regarding sharing pt info is "minimum amount necessary" on a need-to-know basis
False
True
93
It is acceptable for you to look up a friend/family member's lab results if you have verbal permission
True
False
94
Hip pain and limited ROM are BEST identified as a ________ diagnosis
Medical
Physical therapy
95
Stair training should be documented as ______
97112
97530
97110
97116
96
What is the name for an individual who "purchases a health insurance policy"?
Insurer
Subscriber
Bob
Provider
97
Using the "
Rule of 8s
", how many units should be billed for: 18' of ther ex, 12' of neuro re-ed, and 22' of gt training?
3 units
5 units
4 units
2 units
98
Palpation and therapist observations are documented as which type of data?
Objective
Plan
Assessment
Subjective
99
5-digit numeric codes that describe procedures/treatments provided
CPT
ICD
HCPCS
G-codes
100
A patient is seeking coverage/reimbursement for a bedside commode to use at home after d/c; who should cover this cost?
Medicare Part A
Medicare Part D
Medicare Part B
The patient
