CDEO Exam Prep UPDATED ACTUAL
Exam Questions and CORRECT Answers
c. To facilitate optimum patient care
The central focus of all clinical documentation should be to demonstrate the quality of care
provided to the patient with detail and accuracy to facilitate optimum patient care. - CORRECT
ANSWER - What is the central focus of clinical documentation?
a. Protection against mal-practice claims
b. Communication to office staff and other departments about the patient's care
c. To facilitate optimum patient care
d. Communication to other the providers and ancillary personnel concerning the patient
encounter
d. No, CDEOs review records on a proactive basis to prevent documentation deficiencies
Clinical documentation improvement is a proactive measure. The CDS will develop and monitor
policies and procedures that affect the documentation process. CDI should begin at the front end
of all services and care. Prevention of documentation issues is the key. See Page 1 - CORRECT
ANSWER - The CDEO will focus his or her attention on records requested for post payment
review.
a. Yes, CDEOs only review records that might be an audit concern and require physician
education.
b. Yes, CDEOs only review records for paid claims by government payers.
c. No, CDEOs do not review records unless it is requested by the compliance officier.
d. No, CDEOs review records on a proactive basis to prevent documentation deficiencies
c. Prevent deficient documentation
The CDEO will review the findings of the auditor to determine what should be done to resolve
documentation the issues on a proactive basis to prevent documentation and compliance risks. -
CORRECT ANSWER - The CDEO will review the findings of the auditor in order to:
a. Reprocess claims
b. Make an addendum to the medical record
,c. Prevent deficient documentation
d. Know what accounts should be adjusted off
I, II, III, and IV
For different reasons other than reimbursement, requests for medical records come from different
sources, for a multitude of different reasons. A few of these, other than Federal Health Care
Plans, are patients who are becoming more active in their care , attorneys seeking information for
third party liability claims or mal-practice claims, other providers involved in the patients' care,
employers for pre-employment applications and worker's compensation cases, private payers,
recruiting offices for military applications, and the social security administration for the patients'
SSI applications. - CORRECT ANSWER - Which of the following sources other than federal
healthcare plans may request the medical records?
I. Patients
II. Providers involved with the patient's care
III. Employers for worker's compensation claims
IV. Private payers
a. The appropriateness of the services provided
In addition to facilitating high quality patient care, a properly documented medical record
verifies and documents precisely what services were actually provided. The medical record may
be used to validate: (a) The site of the service; (b) The appropriateness of the services provided;
(c) The accuracy of the billing; and (d) The identity of the caregiver. - CORRECT ANSWER -
In addition to facilitating high quality patient care, a properly documented medical record
verifies and documents precisely what services were actually provided. Other than the site of
service the medical record may be used to validate:
a. The appropriateness of the services provided
b. The patient's certificate of birth
c. The identity of the patient's extended family
d. The cost of healthcare benefits used for the year.
c. Detailed, well documented notes
,The details in a well-documented note are a provider's best defense in any legal situation. If the
record is deficient in details, there is no "evidence" to support a provider's testimony. -
CORRECT ANSWER - A provider's best defense in any legal situation is:
a. Patient records maintained for five years
b. An experienced healthcare attorney
c. Detailed, well documented notes
d. Updated computer storage systems
c. During the encounter or as soon as possible
The best way to achieve the most accurate, detailed documentation is for the provider to
document the encounter/services as soon as possible after (if not during) the encounter. -
CORRECT ANSWER - To maintain an accurate medical record, what is the recommended
appropriate time for provider documentation?
a. Within 48 hours of patient visit
b. A minimum of bi-weekly
c. During the encounter or as soon as possible
d. The end of each day for all encounters that day
d. If it is documented in the patient's medical record
Quality assurance in patient care is only evident if it is documented in the medical record.
Quality services may have been provided; however, if this is not evident within the medical
record, problems may arise. - CORRECT ANSWER - Quality assurance of patient care is only
evident if:
a. The patient maintains a state of optimum health
b. Visits are only required for well-checks or injury
c. The patient survey and ROS does not change
d. If it is documented in the patient's medical record
b. Documentation reviews can be performed on a prospective basis.
CDI programs are intended to be performed on a prospective basis to improve documentation
deficiencies prior to claim submission. The intent is to identify deficiencies and make the
, appropriate corrections and prevent future deficiencies. CDI programs can also include
retrospective reviews. - CORRECT ANSWER - Which of the following statements is TRUE
regarding clinical documentation improvement efforts?
a. Documentation reviews should be limited to the costliest chronic conditions to treat.
b. Documentation reviews can be performed on a prospective basis.
c. Documentation reviews must be completed yearly.
d. Documentation reviews require access to the denial data.
a. It encourages physician participation.
Getting physicians involved in CDI helps to gain physician buy in and encourages other
physicians to participate and is a great way to educate physicians. - CORRECT ANSWER -
Why is it important to involve physicians in Clinical Documentation Improvement (CDI)
programs?
a. It encourages physician participation.
b. It helps justify the need for CDI programs.
c. It will eliminate the need to query providers.
d. It will help providers time management.
b. Failure to include the instructions for post procedure care and potential complications.
Although all the choices are deficiencies in capturing patient information, failure to inform a
patient of potential post-operative complications could impact the patient's recovery. In this
question, you are determining the option that affects clinical care of the patient. - CORRECT
ANSWER - Which of the following documentation deficiencies has a negative impact on
patient outcomes?
a. Failure to indicate the date of the patient's last blood test.
b. Failure to include the instructions for post procedure care and potential complications.
c. Failure to sign the patient's medical records provided by another physician.
d. Failure to report the patient's pharmacy preference for insurance participation.
d. Provide examples of the provider's documentation deficiencies with suggestions for
improvement.
Exam Questions and CORRECT Answers
c. To facilitate optimum patient care
The central focus of all clinical documentation should be to demonstrate the quality of care
provided to the patient with detail and accuracy to facilitate optimum patient care. - CORRECT
ANSWER - What is the central focus of clinical documentation?
a. Protection against mal-practice claims
b. Communication to office staff and other departments about the patient's care
c. To facilitate optimum patient care
d. Communication to other the providers and ancillary personnel concerning the patient
encounter
d. No, CDEOs review records on a proactive basis to prevent documentation deficiencies
Clinical documentation improvement is a proactive measure. The CDS will develop and monitor
policies and procedures that affect the documentation process. CDI should begin at the front end
of all services and care. Prevention of documentation issues is the key. See Page 1 - CORRECT
ANSWER - The CDEO will focus his or her attention on records requested for post payment
review.
a. Yes, CDEOs only review records that might be an audit concern and require physician
education.
b. Yes, CDEOs only review records for paid claims by government payers.
c. No, CDEOs do not review records unless it is requested by the compliance officier.
d. No, CDEOs review records on a proactive basis to prevent documentation deficiencies
c. Prevent deficient documentation
The CDEO will review the findings of the auditor to determine what should be done to resolve
documentation the issues on a proactive basis to prevent documentation and compliance risks. -
CORRECT ANSWER - The CDEO will review the findings of the auditor in order to:
a. Reprocess claims
b. Make an addendum to the medical record
,c. Prevent deficient documentation
d. Know what accounts should be adjusted off
I, II, III, and IV
For different reasons other than reimbursement, requests for medical records come from different
sources, for a multitude of different reasons. A few of these, other than Federal Health Care
Plans, are patients who are becoming more active in their care , attorneys seeking information for
third party liability claims or mal-practice claims, other providers involved in the patients' care,
employers for pre-employment applications and worker's compensation cases, private payers,
recruiting offices for military applications, and the social security administration for the patients'
SSI applications. - CORRECT ANSWER - Which of the following sources other than federal
healthcare plans may request the medical records?
I. Patients
II. Providers involved with the patient's care
III. Employers for worker's compensation claims
IV. Private payers
a. The appropriateness of the services provided
In addition to facilitating high quality patient care, a properly documented medical record
verifies and documents precisely what services were actually provided. The medical record may
be used to validate: (a) The site of the service; (b) The appropriateness of the services provided;
(c) The accuracy of the billing; and (d) The identity of the caregiver. - CORRECT ANSWER -
In addition to facilitating high quality patient care, a properly documented medical record
verifies and documents precisely what services were actually provided. Other than the site of
service the medical record may be used to validate:
a. The appropriateness of the services provided
b. The patient's certificate of birth
c. The identity of the patient's extended family
d. The cost of healthcare benefits used for the year.
c. Detailed, well documented notes
,The details in a well-documented note are a provider's best defense in any legal situation. If the
record is deficient in details, there is no "evidence" to support a provider's testimony. -
CORRECT ANSWER - A provider's best defense in any legal situation is:
a. Patient records maintained for five years
b. An experienced healthcare attorney
c. Detailed, well documented notes
d. Updated computer storage systems
c. During the encounter or as soon as possible
The best way to achieve the most accurate, detailed documentation is for the provider to
document the encounter/services as soon as possible after (if not during) the encounter. -
CORRECT ANSWER - To maintain an accurate medical record, what is the recommended
appropriate time for provider documentation?
a. Within 48 hours of patient visit
b. A minimum of bi-weekly
c. During the encounter or as soon as possible
d. The end of each day for all encounters that day
d. If it is documented in the patient's medical record
Quality assurance in patient care is only evident if it is documented in the medical record.
Quality services may have been provided; however, if this is not evident within the medical
record, problems may arise. - CORRECT ANSWER - Quality assurance of patient care is only
evident if:
a. The patient maintains a state of optimum health
b. Visits are only required for well-checks or injury
c. The patient survey and ROS does not change
d. If it is documented in the patient's medical record
b. Documentation reviews can be performed on a prospective basis.
CDI programs are intended to be performed on a prospective basis to improve documentation
deficiencies prior to claim submission. The intent is to identify deficiencies and make the
, appropriate corrections and prevent future deficiencies. CDI programs can also include
retrospective reviews. - CORRECT ANSWER - Which of the following statements is TRUE
regarding clinical documentation improvement efforts?
a. Documentation reviews should be limited to the costliest chronic conditions to treat.
b. Documentation reviews can be performed on a prospective basis.
c. Documentation reviews must be completed yearly.
d. Documentation reviews require access to the denial data.
a. It encourages physician participation.
Getting physicians involved in CDI helps to gain physician buy in and encourages other
physicians to participate and is a great way to educate physicians. - CORRECT ANSWER -
Why is it important to involve physicians in Clinical Documentation Improvement (CDI)
programs?
a. It encourages physician participation.
b. It helps justify the need for CDI programs.
c. It will eliminate the need to query providers.
d. It will help providers time management.
b. Failure to include the instructions for post procedure care and potential complications.
Although all the choices are deficiencies in capturing patient information, failure to inform a
patient of potential post-operative complications could impact the patient's recovery. In this
question, you are determining the option that affects clinical care of the patient. - CORRECT
ANSWER - Which of the following documentation deficiencies has a negative impact on
patient outcomes?
a. Failure to indicate the date of the patient's last blood test.
b. Failure to include the instructions for post procedure care and potential complications.
c. Failure to sign the patient's medical records provided by another physician.
d. Failure to report the patient's pharmacy preference for insurance participation.
d. Provide examples of the provider's documentation deficiencies with suggestions for
improvement.
