Copyright © KAYLIN 2024/2025 ACADEMIC YEAR. ALL RIGHTS RESERVED FIRST PUBLISH NOVEMBER, 2024
CDEO Exam Prep Practice Questions and
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. - 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 - 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.
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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. -
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. - 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
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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. - 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. - 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
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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. - 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. - 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. -
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CDEO Exam Prep Practice Questions and
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. - 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 - 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.
Copyright ©Stuvia International BV 2010-2024 Page 1/117
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,Copyright © KAYLIN 2024/2025 ACADEMIC YEAR. ALL RIGHTS RESERVED FIRST PUBLISH NOVEMBER, 2024
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. -
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. - 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
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,Copyright © KAYLIN 2024/2025 ACADEMIC YEAR. ALL RIGHTS RESERVED FIRST PUBLISH NOVEMBER, 2024
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. - 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. - 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
Copyright ©Stuvia International BV 2010-2024 Page 3/117
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, Copyright © KAYLIN 2024/2025 ACADEMIC YEAR. ALL RIGHTS RESERVED FIRST PUBLISH NOVEMBER, 2024
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. - 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. - 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. -
Copyright ©Stuvia International BV 2010-2024 Page 4/117
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