CDEO EXAM UPDATED ACTUAL Exam
Questions and CORRECT Answers
HIPPA - CORRECT 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 - CORRECT ANSWER - Demographic data,
name, address, birth date, and SS number.
central focus of clinical documentation - CORRECT ANSWER - should be to demonstrate
the quality of care provided to the patient with detail and accuracy to facilitate optimum patient
care.
CDEO Focus - CORRECT 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 - CORRECT 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 - CORRECT 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 - 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:
Medical Record Validates - CORRECT 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 - CORRECT 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 - CORRECT 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 - CORRECT ANSWER - Quality
assurance of patient care is only evident if:
CDI Programs intent - CORRECT 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. - CORRECT 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. -
CORRECT 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. - CORRECT 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. -
CORRECT ANSWER - Which of the following is/are considered a purpose of
documentation improvement programs?
How can an effective CDI program improve patient outcomes? - CORRECT 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? - CORRECT 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 - CORRECT 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? -
CORRECT ANSWER - Documentation deficiencies may not be identified until after the
provider has left.
Documentation Challenges - CORRECT 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.
Questions and CORRECT Answers
HIPPA - CORRECT 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 - CORRECT ANSWER - Demographic data,
name, address, birth date, and SS number.
central focus of clinical documentation - CORRECT ANSWER - should be to demonstrate
the quality of care provided to the patient with detail and accuracy to facilitate optimum patient
care.
CDEO Focus - CORRECT 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 - CORRECT 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 - CORRECT 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 - 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:
Medical Record Validates - CORRECT 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 - CORRECT 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 - CORRECT 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 - CORRECT ANSWER - Quality
assurance of patient care is only evident if:
CDI Programs intent - CORRECT 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. - CORRECT 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. -
CORRECT 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. - CORRECT 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. -
CORRECT ANSWER - Which of the following is/are considered a purpose of
documentation improvement programs?
How can an effective CDI program improve patient outcomes? - CORRECT 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? - CORRECT 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 - CORRECT 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? -
CORRECT ANSWER - Documentation deficiencies may not be identified until after the
provider has left.
Documentation Challenges - CORRECT 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.
