CDEO EXAM questions with correct
answers
HIPPA |- |VERIFIED |ANSWER-Health |Insurance |Portability |and |Accountability |Act |of |1996 |and |the |
Healthcare |Fraud |and |abuse |control |program. |Far-reaching |program |to |combat |fraud |and |abuse |in |
healthcare |including |both |public |and |private |health |plans.
Individuals |protected |health |information |- |VERIFIED |ANSWER-Demographic |data, |name, |address, |birth
|date, |and |SS |number.
central |focus |of |clinical |documentation |- |VERIFIED |ANSWER-should |be |to |demonstrate |the |quality |of |
care |provided |to |the |patient |with |detail |and |accuracy |to |facilitate |optimum |patient |care.
CDEO |Focus |- |VERIFIED |ANSWER-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.
CDEO |Review |- |VERIFIED |ANSWER-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.
Other |request |than |Federal |Healthplans |- |VERIFIED |ANSWER-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.
The |appropriateness |of |the |services |provided |- |VERIFIED |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:
Medical |Record |Validates |- |VERIFIED |ANSWER-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.
Detailed, |well |documented |notes |- |VERIFIED |ANSWER-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.
,During |the |encounter |or |as |soon |as |possible |- |VERIFIED |ANSWER-To |maintain |an |accurate |medical |
record, |what |is |the |recommended |appropriate |time |for |provider |documentation?
If |it |is |documented |in |the |patient's |medical |record |- |VERIFIED |ANSWER-Quality |assurance |of |patient |
care |is |only |evident |if:
CDI |Programs |intent |- |VERIFIED |ANSWER-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.
It |encourages |physician |participation. |- |VERIFIED |ANSWER-Why |is |it |important |to |involve |physicians |in
|Clinical |Documentation |Improvement |(CDI) |programs?
Failure |to |include |the |instructions |for |post |procedure |care |and |potential |complications. |- |VERIFIED |
ANSWER-Which |of |the |following |documentation |deficiencies |has |a |negative |impact |on |patient |
outcomes?
Provide |examples |of |the |provider's |documentation |deficiencies |with |suggestions |for |improvement. |- |
VERIFIED |ANSWER-What |is |an |effective |method |for |communicating |documentation |deficiencies |to |a |
provider?
Improve |patient |outcomes, |Improve |patient |outcomes, |and |improve |the |provider |query |process. |- |
VERIFIED |ANSWER-Which |of |the |following |is/are |considered |a |purpose |of |documentation |
improvement |programs?
How |can |an |effective |CDI |program |improve |patient |outcomes? |- |VERIFIED |ANSWER-The |main |goal |for |
detailed |medical |records |is |to |promote |the |continuity |of |care |for |the |patient. |This |allows |providers |to
|communicate |with |each |other |on |the |care |that |has |been |provided |to |the |patient. |Coding |higher |level
|services |that |are |not |medically |necessary |is |not |a |goal |to |improve |patient |outcomes.
Which |of |the |following |recommendations |should |be |made |to |providers |regarding |the |patient's |
problem |list? |- |VERIFIED |ANSWER-Problem |lists |should |be |updated |when |a |significant |change |takes |
place |to |make |sure |the |information |on |the |problem |list |is |still |current |and |accurate. |A |common |
problem |is |the |list |is |created |but |it |is |not |maintained |so |it |becomes |difficult |to |know |which |conditions
|are |current |and |which |are |resolved. |If |the |problem |list |is |maintained, |it |is |an |effective |tool |for |
managing |the |patient's |conditions.
negative |patient |outcomes |- |VERIFIED |ANSWER-Failure |to |document |an |allergy |could |lead |to |an |
allergic |reaction |if |the |provider |prescribes |a |medication |not |realizing |the |patient |is |allergic.
What |is |a |documentation |challenge |for |services |provided |by |providers |in |an |inpatient |facility? |- |
VERIFIED |ANSWER-Documentation |deficiencies |may |not |be |identified |until |after |the |provider |has |left.
Documentation |Challenges |- |VERIFIED |ANSWER-Maintaining |consistent |and |quality |documentation |can
|be |difficult |in |the |inpatient |setting |because |deficiencies |may |not |be |identified |until |after |the |provider
|has |left |the |facility.
, Quality |Care |standard |- |VERIFIED |ANSWER-The |basic |CMS |documentation |guidelines |for |E/M |services |
include |the |least |expected |documentation |to |support |an |encounter. |Quality |is |going |above |and |
beyond |the |basic |information.
What |are |some |common |documentation |deficiencies |- |VERIFIED |ANSWER-ommon |documentation |
deficiencies |include: |Sloppy |text
Misspelled |words
Phrases |that |do |not |make |sense
Dictation |that |is |not |complete
Skips |in |the |text |that |indicate |the |words |were |not |understoodIncomplete |sentences
Evidence |of |cloning |or |copying |data |from |previous |dates |of |service |that |is |not |relevant |to |the |current
|serviceIncorrect |dates |of |service
Missing |dates |of |service
Missing |dosage |and |strength |of |medication |ordered
Missing |orders |for |diagnostic |tests
Focus |on |the |highest |risk |area |- |VERIFIED |ANSWER-For |a |CDI |program |to |be |effective, |the |CDEO |
should |focus |on |correction |of |documentation |deficiencies |for |identified |risk |areas |specific |to |the |
practice.
Privacy |Practice |Notice |- |VERIFIED |ANSWER-must |be |provided |by |each |covered |entity, |and |must |
contain |certain |elements |to |notify |individuals |as |to |how |the |covered |entity |will |use |and |disclose |the |
individual's |protected |health |information. |The |notice |must |clearly |explain |the |covered |entity's |
obligation |to |protect |privacy, |provide |a |notice |of |privacy |practices, |and |abide |by |the |terms |of |the |
current |notice. |The |covered |entity |must |also |inform |the |patient |of |his |or |her |individual |rights, |and |
the |steps |to |follow |(including |a |point |of |contact |for |further |information) |if |an |individual |feels |his |or |
her |privacy |rights |have |been |violated.
Health |Plan |covered |entities |- |VERIFIED |ANSWER-are |organizations |that |pay |providers |on |behalf |of |an |
individual |receiving |medical |care. |These |plans |include |health, |dental, |vision, |and |prescription |drug |
insurers. |Some |examples |include |Health |Maintenance |Organizations |(HMOs), |Medicare, |Medicaid, |and
|Medicare |supplement |insurers, |as |well |as |employer, |government, |and |church-sponsored |group |health
|plans. |An |exception |is |an |employer |who |solely |establishes |and |maintains |the |plan |with |fewer |than |50
|participants |and |is |exempt. |Two |types |of |government-funded |programs |are |not |health |plans. |These |
are |food |stamps |and |community |health |centers. |Insurers |providing |only |worker's |compensation, |
automobile |insurance, |and |property |and |casualty |insurance |are |not |considered |to |be |health |plans.
Release |of |Information |- |VERIFIED |ANSWER-Patients |allow |the |release |of |their |medical |records |by |
signing |this |form. |This |often |has |a |place |to |allow |the |patient |to |designate |who |the |medical |
information |can |be |released |to.
What |must |be |included |in |a |business |associate |agreement? |- |VERIFIED |ANSWER-The |contract |must |
describe |the |permitted |and |required |uses |of |protected |health |information |by |the |business |associate, |
answers
HIPPA |- |VERIFIED |ANSWER-Health |Insurance |Portability |and |Accountability |Act |of |1996 |and |the |
Healthcare |Fraud |and |abuse |control |program. |Far-reaching |program |to |combat |fraud |and |abuse |in |
healthcare |including |both |public |and |private |health |plans.
Individuals |protected |health |information |- |VERIFIED |ANSWER-Demographic |data, |name, |address, |birth
|date, |and |SS |number.
central |focus |of |clinical |documentation |- |VERIFIED |ANSWER-should |be |to |demonstrate |the |quality |of |
care |provided |to |the |patient |with |detail |and |accuracy |to |facilitate |optimum |patient |care.
CDEO |Focus |- |VERIFIED |ANSWER-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.
CDEO |Review |- |VERIFIED |ANSWER-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.
Other |request |than |Federal |Healthplans |- |VERIFIED |ANSWER-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.
The |appropriateness |of |the |services |provided |- |VERIFIED |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:
Medical |Record |Validates |- |VERIFIED |ANSWER-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.
Detailed, |well |documented |notes |- |VERIFIED |ANSWER-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.
,During |the |encounter |or |as |soon |as |possible |- |VERIFIED |ANSWER-To |maintain |an |accurate |medical |
record, |what |is |the |recommended |appropriate |time |for |provider |documentation?
If |it |is |documented |in |the |patient's |medical |record |- |VERIFIED |ANSWER-Quality |assurance |of |patient |
care |is |only |evident |if:
CDI |Programs |intent |- |VERIFIED |ANSWER-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.
It |encourages |physician |participation. |- |VERIFIED |ANSWER-Why |is |it |important |to |involve |physicians |in
|Clinical |Documentation |Improvement |(CDI) |programs?
Failure |to |include |the |instructions |for |post |procedure |care |and |potential |complications. |- |VERIFIED |
ANSWER-Which |of |the |following |documentation |deficiencies |has |a |negative |impact |on |patient |
outcomes?
Provide |examples |of |the |provider's |documentation |deficiencies |with |suggestions |for |improvement. |- |
VERIFIED |ANSWER-What |is |an |effective |method |for |communicating |documentation |deficiencies |to |a |
provider?
Improve |patient |outcomes, |Improve |patient |outcomes, |and |improve |the |provider |query |process. |- |
VERIFIED |ANSWER-Which |of |the |following |is/are |considered |a |purpose |of |documentation |
improvement |programs?
How |can |an |effective |CDI |program |improve |patient |outcomes? |- |VERIFIED |ANSWER-The |main |goal |for |
detailed |medical |records |is |to |promote |the |continuity |of |care |for |the |patient. |This |allows |providers |to
|communicate |with |each |other |on |the |care |that |has |been |provided |to |the |patient. |Coding |higher |level
|services |that |are |not |medically |necessary |is |not |a |goal |to |improve |patient |outcomes.
Which |of |the |following |recommendations |should |be |made |to |providers |regarding |the |patient's |
problem |list? |- |VERIFIED |ANSWER-Problem |lists |should |be |updated |when |a |significant |change |takes |
place |to |make |sure |the |information |on |the |problem |list |is |still |current |and |accurate. |A |common |
problem |is |the |list |is |created |but |it |is |not |maintained |so |it |becomes |difficult |to |know |which |conditions
|are |current |and |which |are |resolved. |If |the |problem |list |is |maintained, |it |is |an |effective |tool |for |
managing |the |patient's |conditions.
negative |patient |outcomes |- |VERIFIED |ANSWER-Failure |to |document |an |allergy |could |lead |to |an |
allergic |reaction |if |the |provider |prescribes |a |medication |not |realizing |the |patient |is |allergic.
What |is |a |documentation |challenge |for |services |provided |by |providers |in |an |inpatient |facility? |- |
VERIFIED |ANSWER-Documentation |deficiencies |may |not |be |identified |until |after |the |provider |has |left.
Documentation |Challenges |- |VERIFIED |ANSWER-Maintaining |consistent |and |quality |documentation |can
|be |difficult |in |the |inpatient |setting |because |deficiencies |may |not |be |identified |until |after |the |provider
|has |left |the |facility.
, Quality |Care |standard |- |VERIFIED |ANSWER-The |basic |CMS |documentation |guidelines |for |E/M |services |
include |the |least |expected |documentation |to |support |an |encounter. |Quality |is |going |above |and |
beyond |the |basic |information.
What |are |some |common |documentation |deficiencies |- |VERIFIED |ANSWER-ommon |documentation |
deficiencies |include: |Sloppy |text
Misspelled |words
Phrases |that |do |not |make |sense
Dictation |that |is |not |complete
Skips |in |the |text |that |indicate |the |words |were |not |understoodIncomplete |sentences
Evidence |of |cloning |or |copying |data |from |previous |dates |of |service |that |is |not |relevant |to |the |current
|serviceIncorrect |dates |of |service
Missing |dates |of |service
Missing |dosage |and |strength |of |medication |ordered
Missing |orders |for |diagnostic |tests
Focus |on |the |highest |risk |area |- |VERIFIED |ANSWER-For |a |CDI |program |to |be |effective, |the |CDEO |
should |focus |on |correction |of |documentation |deficiencies |for |identified |risk |areas |specific |to |the |
practice.
Privacy |Practice |Notice |- |VERIFIED |ANSWER-must |be |provided |by |each |covered |entity, |and |must |
contain |certain |elements |to |notify |individuals |as |to |how |the |covered |entity |will |use |and |disclose |the |
individual's |protected |health |information. |The |notice |must |clearly |explain |the |covered |entity's |
obligation |to |protect |privacy, |provide |a |notice |of |privacy |practices, |and |abide |by |the |terms |of |the |
current |notice. |The |covered |entity |must |also |inform |the |patient |of |his |or |her |individual |rights, |and |
the |steps |to |follow |(including |a |point |of |contact |for |further |information) |if |an |individual |feels |his |or |
her |privacy |rights |have |been |violated.
Health |Plan |covered |entities |- |VERIFIED |ANSWER-are |organizations |that |pay |providers |on |behalf |of |an |
individual |receiving |medical |care. |These |plans |include |health, |dental, |vision, |and |prescription |drug |
insurers. |Some |examples |include |Health |Maintenance |Organizations |(HMOs), |Medicare, |Medicaid, |and
|Medicare |supplement |insurers, |as |well |as |employer, |government, |and |church-sponsored |group |health
|plans. |An |exception |is |an |employer |who |solely |establishes |and |maintains |the |plan |with |fewer |than |50
|participants |and |is |exempt. |Two |types |of |government-funded |programs |are |not |health |plans. |These |
are |food |stamps |and |community |health |centers. |Insurers |providing |only |worker's |compensation, |
automobile |insurance, |and |property |and |casualty |insurance |are |not |considered |to |be |health |plans.
Release |of |Information |- |VERIFIED |ANSWER-Patients |allow |the |release |of |their |medical |records |by |
signing |this |form. |This |often |has |a |place |to |allow |the |patient |to |designate |who |the |medical |
information |can |be |released |to.
What |must |be |included |in |a |business |associate |agreement? |- |VERIFIED |ANSWER-The |contract |must |
describe |the |permitted |and |required |uses |of |protected |health |information |by |the |business |associate, |
