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