CDEO 2026 Exam Prep: Documentation Expert
Outpatient Practice Questions with Answer
Rationales Clinical Documentation | Coding
Guidelines | Medical Necessity | Compliance Audit
Review
1. A patient is seen for an office visit for management of hypertension. The
physician documents "HTN, stable, continue current medications." What ICD-10-
CM code is most appropriate?
A. I10
B. I11.9
C. I12.9
D. I15.0
Correct Answer: A
Rationale: I10 (Essential hypertension) is used when the documentation states
"hypertension" without mention of heart or kidney disease. "Stable" does not
change the code assignment. I11.9 requires heart disease, I12.9 requires CKD, and
I15.0 is renovascular hypertension.
2. Under Medicare's 2021 E/M guidelines, which of the following is NOT a
component for selecting an office visit level?
A. History
B. Exam
C. Medical decision making
D. Time
Correct Answer: A
Rationale: The 2021 AMA/Medicare E/M changes eliminated history and
exam as key components for level selection in office/outpatient settings. Levels
,are now based on either medical decision making (MDM) or total time on the date
of the encounter.
3. A coder reviews a chart where the provider documents "possible
pneumonia." What should the coder do?
A. Code pneumonia as confirmed
B. Query the provider for clarification
C. Code the symptom only
D. Code both pneumonia and the symptom
Correct Answer: B
Rationale: "Possible," "probable," and "rule out" diagnoses are not coded in
outpatient settings. The coder should query the provider for clarification before
assigning a code.
4. Which documentation element is required to support medical necessity for a
diagnostic test?
A. Patient's insurance information
B. Signs, symptoms, or diagnosis related to the test
C. Provider's NPI number
D. Date of the previous visit
Correct Answer: B
Rationale: Medical necessity for diagnostic testing requires documentation of
the signs, symptoms, or confirmed diagnosis that justifies the test. Without this,
the service may be denied.
5. A physician performs a level 4 established patient visit. Which of the following
best supports the level based on MDM?
A. One self-limited problem, minimal data
B. Two or more stable chronic illnesses, moderate data
,C. One acute uncomplicated illness, low data
D. One chronic illness with exacerbation, moderate data
Correct Answer: D
Rationale: A level 4 visit requires moderate MDM. A chronic illness with
exacerbation/progression, plus prescription drug management or moderate data
review, supports moderate MDM.
6. What is the primary purpose of a compliance audit in outpatient coding?
A. To increase revenue
B. To identify and correct coding errors and improve documentation
C. To punish providers
D. To reduce patient volume
Correct Answer: B
Rationale: Compliance audits are designed to identify coding and
documentation errors, educate providers, and ensure regulatory compliance—not
primarily to increase revenue or penalize staff.
7. A patient presents with a cough and fever. The provider documents "acute
bronchitis" and prescribes antibiotics. What is the first-listed diagnosis?
A. Cough
B. Fever
C. Acute bronchitis
D. Antibiotic prescription
Correct Answer: C
Rationale: When a definitive diagnosis is established at the encounter, the
definitive diagnosis (acute bronchitis) is coded and sequenced first, rather than
the symptoms (cough, fever).
, 8. Which of the following is an example of a "contributing factor" in medical
decision making?
A. Number of diagnoses
B. Social determinants of health
C. Amount of data reviewed
D. Risk of complications
Correct Answer: B
Rationale: Social determinants of health (e.g., homelessness, food insecurity)
are considered contributing factors that may increase the complexity of MDM.
The others are elements of MDM levels.
9. A provider documents "status post cholecystectomy." How is this coded?
A. As a current condition
B. As a history code (Z90.49 or similar)
C. As a complication code
D. It is not coded
Correct Answer: B
Rationale: "Status post" indicates a historical condition no longer requiring
treatment. It is coded with a Z code (e.g., Z90.49 for absence of gallbladder) when
relevant to care.
10. What does the acronym "CDEO" stand for in the context of this exam?
A. Clinical Documentation Evaluation Officer
B. Certified Documentation Expert Outpatient
C. Clinical Data Entry Operator
D. Certified Diagnostic Evaluation Officer
Correct Answer: B
Rationale: CDEO stands for Certified Documentation Expert Outpatient, a
Outpatient Practice Questions with Answer
Rationales Clinical Documentation | Coding
Guidelines | Medical Necessity | Compliance Audit
Review
1. A patient is seen for an office visit for management of hypertension. The
physician documents "HTN, stable, continue current medications." What ICD-10-
CM code is most appropriate?
A. I10
B. I11.9
C. I12.9
D. I15.0
Correct Answer: A
Rationale: I10 (Essential hypertension) is used when the documentation states
"hypertension" without mention of heart or kidney disease. "Stable" does not
change the code assignment. I11.9 requires heart disease, I12.9 requires CKD, and
I15.0 is renovascular hypertension.
2. Under Medicare's 2021 E/M guidelines, which of the following is NOT a
component for selecting an office visit level?
A. History
B. Exam
C. Medical decision making
D. Time
Correct Answer: A
Rationale: The 2021 AMA/Medicare E/M changes eliminated history and
exam as key components for level selection in office/outpatient settings. Levels
,are now based on either medical decision making (MDM) or total time on the date
of the encounter.
3. A coder reviews a chart where the provider documents "possible
pneumonia." What should the coder do?
A. Code pneumonia as confirmed
B. Query the provider for clarification
C. Code the symptom only
D. Code both pneumonia and the symptom
Correct Answer: B
Rationale: "Possible," "probable," and "rule out" diagnoses are not coded in
outpatient settings. The coder should query the provider for clarification before
assigning a code.
4. Which documentation element is required to support medical necessity for a
diagnostic test?
A. Patient's insurance information
B. Signs, symptoms, or diagnosis related to the test
C. Provider's NPI number
D. Date of the previous visit
Correct Answer: B
Rationale: Medical necessity for diagnostic testing requires documentation of
the signs, symptoms, or confirmed diagnosis that justifies the test. Without this,
the service may be denied.
5. A physician performs a level 4 established patient visit. Which of the following
best supports the level based on MDM?
A. One self-limited problem, minimal data
B. Two or more stable chronic illnesses, moderate data
,C. One acute uncomplicated illness, low data
D. One chronic illness with exacerbation, moderate data
Correct Answer: D
Rationale: A level 4 visit requires moderate MDM. A chronic illness with
exacerbation/progression, plus prescription drug management or moderate data
review, supports moderate MDM.
6. What is the primary purpose of a compliance audit in outpatient coding?
A. To increase revenue
B. To identify and correct coding errors and improve documentation
C. To punish providers
D. To reduce patient volume
Correct Answer: B
Rationale: Compliance audits are designed to identify coding and
documentation errors, educate providers, and ensure regulatory compliance—not
primarily to increase revenue or penalize staff.
7. A patient presents with a cough and fever. The provider documents "acute
bronchitis" and prescribes antibiotics. What is the first-listed diagnosis?
A. Cough
B. Fever
C. Acute bronchitis
D. Antibiotic prescription
Correct Answer: C
Rationale: When a definitive diagnosis is established at the encounter, the
definitive diagnosis (acute bronchitis) is coded and sequenced first, rather than
the symptoms (cough, fever).
, 8. Which of the following is an example of a "contributing factor" in medical
decision making?
A. Number of diagnoses
B. Social determinants of health
C. Amount of data reviewed
D. Risk of complications
Correct Answer: B
Rationale: Social determinants of health (e.g., homelessness, food insecurity)
are considered contributing factors that may increase the complexity of MDM.
The others are elements of MDM levels.
9. A provider documents "status post cholecystectomy." How is this coded?
A. As a current condition
B. As a history code (Z90.49 or similar)
C. As a complication code
D. It is not coded
Correct Answer: B
Rationale: "Status post" indicates a historical condition no longer requiring
treatment. It is coded with a Z code (e.g., Z90.49 for absence of gallbladder) when
relevant to care.
10. What does the acronym "CDEO" stand for in the context of this exam?
A. Clinical Documentation Evaluation Officer
B. Certified Documentation Expert Outpatient
C. Clinical Data Entry Operator
D. Certified Diagnostic Evaluation Officer
Correct Answer: B
Rationale: CDEO stands for Certified Documentation Expert Outpatient, a
