CDEO ASSESSMENT GUIDE 2025
|MOST COMMON QUESTIONS WITH CORRECTLY
VERIFIED ANSWERS (the recent quizes)|ALREADY
A+ GRADED|GUARANTEED PASS
Clinical Documentation Improvement (CDI) programs can help: - - Build effective
documentation compliance policies
- Capture clinical data required for continuity of care
documentation deficiency that has a negative impact on patient outcomes - Failure to
include the complications of drug for prescriptions taken by a patient.
What is best practice to communicate document deficiencies to a provider? - Provide
examples of the provider's documentation errors with suggestions for improvement.
A physician who specializes in elder care undergoes a CDI audit. Fifteen charts are found with
the diagnosis of marasmus. Your correct response: - Display in your query the Index entry
for marasmus and the codes and descriptions for E41 and R54. Ask for guidance on which to
report.
The best approach when querying a physician regarding documentation is to approach the
problem as one of: - - Evidence based medicine
- Financial motive
- Malpractice liability
- Documentation impact on reimbursement
- Documentation impact on compliance
Which EMR feature is non-compliant with CMS? - Templates that allow the provider to
de-select a prepopulated "normal" checkmark when the system is abnormal in the ROS
When providing CDI to a provider, does the message change depending on whether you are
performing a prospective or retrospective audit? - Yes, because the auditor cannot ask
leading questions regarding documentation before a claim is submitted.
,What is NOT considered a purpose of documentation improvement programs? - Increase
reimbursements
CDI programs can help with: - Consistency of documentation & Team building
Which is NOT an acceptable cause for query? - Signs and symptoms without a diagnosis
Which is a leading query? - Your sarcoidosis patient has sarcoid lesions on the cerebral
cortex, correct?
The surgeon documents liver cancer, but the pathology report states angiosarcoma of liver. You:
- Code the liver cancer as angiosarcoma, a primary liver cancer, based on the
pathologist's documentation.
In reviewing the provider's assessment the documentation states "lab tests reviewed: +K." You
correctly query: - Can you please address the patient's potassium status in further detail?
Documentation states:
Patient has a history of a recent myocardial infarct and is admitted today with an ST elevation
MI of the anterior wall.
The flaw in this documentation from a coding standpoint: - The duration between the
recent myocardial infarct and the current myocardial infarct will impact coding, so "recent" is
insufficient documentation
Which term or phrase, when used between a manifestation and etiology, does NOT always show
a causal relationship? - likely
Which is an example of poor documentation that is especially problematic as there is no
"unspecified" code for the condition in ICD-10-CM? - Degenerative disc disease (DDD)
When reviewing documentation and you notice information is missing, what is the proper
procedure? - The information should be added as a documented late entry/addendum
only when necessary.
Is it an acceptable practice to use a template that always documents a complete review of
systems? - No. The extent of ROS performed and documented is dependent upon clinical
judgment and the nature of the presenting problem(s).
Which type of documentation can be used to report diagnoses under risk adjustment models? -
Inpatient Admission Note
,What type of payment does an ACO (Accountable Care Organization) receive? - An ACO
receives reimbursements based on quality metrics and reductions in the total cost of care for an
assigned population of patients.
Which statement is TRUE regarding RAFs? - A patient with a RAF score of 3.09 will likely
consume more health care in the coming year than a patient with a RAF score of 1.89.
Documentation for 9/1/20XX OV:
CHIEF COMPLAINT: follow-up on Dr. Kundeling's visit.
HPI: Tim is here for a follow-up. Overall he has been doing well. His energy level has not
changed much from the other time, but overall he is doing well. He does not have any acute
complaints. When he saw Dr. Kundeling, he was put on a new medication. Unfortunately, he
does not recall the name. He seems to be tolerating it well.
ROS: Today is a negative for back pain, energy level unchanged from the last time, no nausea or
vomiting, also lower leg edema is unchanged.
O: Blood pressure is 118/60, respirations are 20, elevated pulse of 128, temperature is 98.0, and
weight is 213 pounds. In general, Tim is a very pleasant male in no acute distress. He is alert. He
responds to questions appropriately.
A/P: At this time, I think any past fatigue could be related to his past history of anemia and
hypothyroidism. However, given the fact tha - - No chief complaint
- No diagnoses in assessment
- Pulse rate is not discussed in assessment
- "Past history" disorders are likely current problems
- Entire note seems very vague
A patient with ESRD on dialysis comes in with an infection at the peritoneal dialysis catheter
site. The provider evaluated the infected skin and determined a staph infection. The provider
prescribed antibiotics and performed a dressing change.
What are the correct codes and sequence? - T85.71XA, L08.89, B95.8, N18.6, Z99.2
Which of the following information should be documented to properly code hypertension in
ICD-10-CM? - Type (essential, secondary)
The patient is documented as a cigarette smoker. The correct code: - F17.210
, Which statement is TRUE for the use of a sign/symptom code with a definitive diagnosis code? -
Codes that describe symptoms and signs are acceptable for reporting purposes when a
related definitive diagnosis has not been established (confirmed) by the provider.
When would morbid obesity be considered clinically significant: - Morbid obesity is
always clinically significant and reportable if documented by the provider.
Which code systems are included in HEDIS? - CPT®
CDT
HCPCS Level II
Which of the following is a HEDIS measure? - Adult BMI Assessment
Cervical Cancer Screening
Breast Cancer Screening
Which CPT® code submitted on a claim would support the lead screening in children HEDIS
measure? - 83655
A patient is diagnosed with acute on chronic gastrointestinal bleeding due to a small bowel
peripheral arteriovenous malformation (AVM). Documentation does not indicate whether the
AVM is acquired or congenital. What is the correct ICD-10-CM code to report? - K55.21
How is the cost category under MIPS going to be determined? - Adjudicated claims
A 4 year-old is getting over his cold and will be getting three immunizations in the pediatrician's
office by the nurse. The first vaccination administered is the Polio vaccine intramuscularly. The
next vaccination is the live influenza (LAIV3) administered in the nose. The last vaccination is the
Varicella (live) by subcutaneous route. What CPT® codes are reported for the administration and
vaccines? - 90713, 90660, 90716, 90471, 90472, 90474
Patient has a suspicious lesion of the right axilla. The area was infiltrated with local anesthetic
and prepped and draped in a sterile fashion. With the use of a 3 mm punch tool the total lesion
with margins was excised and closed with 5.0 Prolene suture. Pathology report indicated this
was a seborrheic keratosis. What CPT® and ICD-10-CM codes are reported? - 11400,
L82.1
Acute and Chronic Respiratory Failure with Mild Hypoxemia
How many codes would be required to report the respiratory failure? - One: Report acute
and chronic respiratory failure unspecified whether with hypoxia or hypercapnia
|MOST COMMON QUESTIONS WITH CORRECTLY
VERIFIED ANSWERS (the recent quizes)|ALREADY
A+ GRADED|GUARANTEED PASS
Clinical Documentation Improvement (CDI) programs can help: - - Build effective
documentation compliance policies
- Capture clinical data required for continuity of care
documentation deficiency that has a negative impact on patient outcomes - Failure to
include the complications of drug for prescriptions taken by a patient.
What is best practice to communicate document deficiencies to a provider? - Provide
examples of the provider's documentation errors with suggestions for improvement.
A physician who specializes in elder care undergoes a CDI audit. Fifteen charts are found with
the diagnosis of marasmus. Your correct response: - Display in your query the Index entry
for marasmus and the codes and descriptions for E41 and R54. Ask for guidance on which to
report.
The best approach when querying a physician regarding documentation is to approach the
problem as one of: - - Evidence based medicine
- Financial motive
- Malpractice liability
- Documentation impact on reimbursement
- Documentation impact on compliance
Which EMR feature is non-compliant with CMS? - Templates that allow the provider to
de-select a prepopulated "normal" checkmark when the system is abnormal in the ROS
When providing CDI to a provider, does the message change depending on whether you are
performing a prospective or retrospective audit? - Yes, because the auditor cannot ask
leading questions regarding documentation before a claim is submitted.
,What is NOT considered a purpose of documentation improvement programs? - Increase
reimbursements
CDI programs can help with: - Consistency of documentation & Team building
Which is NOT an acceptable cause for query? - Signs and symptoms without a diagnosis
Which is a leading query? - Your sarcoidosis patient has sarcoid lesions on the cerebral
cortex, correct?
The surgeon documents liver cancer, but the pathology report states angiosarcoma of liver. You:
- Code the liver cancer as angiosarcoma, a primary liver cancer, based on the
pathologist's documentation.
In reviewing the provider's assessment the documentation states "lab tests reviewed: +K." You
correctly query: - Can you please address the patient's potassium status in further detail?
Documentation states:
Patient has a history of a recent myocardial infarct and is admitted today with an ST elevation
MI of the anterior wall.
The flaw in this documentation from a coding standpoint: - The duration between the
recent myocardial infarct and the current myocardial infarct will impact coding, so "recent" is
insufficient documentation
Which term or phrase, when used between a manifestation and etiology, does NOT always show
a causal relationship? - likely
Which is an example of poor documentation that is especially problematic as there is no
"unspecified" code for the condition in ICD-10-CM? - Degenerative disc disease (DDD)
When reviewing documentation and you notice information is missing, what is the proper
procedure? - The information should be added as a documented late entry/addendum
only when necessary.
Is it an acceptable practice to use a template that always documents a complete review of
systems? - No. The extent of ROS performed and documented is dependent upon clinical
judgment and the nature of the presenting problem(s).
Which type of documentation can be used to report diagnoses under risk adjustment models? -
Inpatient Admission Note
,What type of payment does an ACO (Accountable Care Organization) receive? - An ACO
receives reimbursements based on quality metrics and reductions in the total cost of care for an
assigned population of patients.
Which statement is TRUE regarding RAFs? - A patient with a RAF score of 3.09 will likely
consume more health care in the coming year than a patient with a RAF score of 1.89.
Documentation for 9/1/20XX OV:
CHIEF COMPLAINT: follow-up on Dr. Kundeling's visit.
HPI: Tim is here for a follow-up. Overall he has been doing well. His energy level has not
changed much from the other time, but overall he is doing well. He does not have any acute
complaints. When he saw Dr. Kundeling, he was put on a new medication. Unfortunately, he
does not recall the name. He seems to be tolerating it well.
ROS: Today is a negative for back pain, energy level unchanged from the last time, no nausea or
vomiting, also lower leg edema is unchanged.
O: Blood pressure is 118/60, respirations are 20, elevated pulse of 128, temperature is 98.0, and
weight is 213 pounds. In general, Tim is a very pleasant male in no acute distress. He is alert. He
responds to questions appropriately.
A/P: At this time, I think any past fatigue could be related to his past history of anemia and
hypothyroidism. However, given the fact tha - - No chief complaint
- No diagnoses in assessment
- Pulse rate is not discussed in assessment
- "Past history" disorders are likely current problems
- Entire note seems very vague
A patient with ESRD on dialysis comes in with an infection at the peritoneal dialysis catheter
site. The provider evaluated the infected skin and determined a staph infection. The provider
prescribed antibiotics and performed a dressing change.
What are the correct codes and sequence? - T85.71XA, L08.89, B95.8, N18.6, Z99.2
Which of the following information should be documented to properly code hypertension in
ICD-10-CM? - Type (essential, secondary)
The patient is documented as a cigarette smoker. The correct code: - F17.210
, Which statement is TRUE for the use of a sign/symptom code with a definitive diagnosis code? -
Codes that describe symptoms and signs are acceptable for reporting purposes when a
related definitive diagnosis has not been established (confirmed) by the provider.
When would morbid obesity be considered clinically significant: - Morbid obesity is
always clinically significant and reportable if documented by the provider.
Which code systems are included in HEDIS? - CPT®
CDT
HCPCS Level II
Which of the following is a HEDIS measure? - Adult BMI Assessment
Cervical Cancer Screening
Breast Cancer Screening
Which CPT® code submitted on a claim would support the lead screening in children HEDIS
measure? - 83655
A patient is diagnosed with acute on chronic gastrointestinal bleeding due to a small bowel
peripheral arteriovenous malformation (AVM). Documentation does not indicate whether the
AVM is acquired or congenital. What is the correct ICD-10-CM code to report? - K55.21
How is the cost category under MIPS going to be determined? - Adjudicated claims
A 4 year-old is getting over his cold and will be getting three immunizations in the pediatrician's
office by the nurse. The first vaccination administered is the Polio vaccine intramuscularly. The
next vaccination is the live influenza (LAIV3) administered in the nose. The last vaccination is the
Varicella (live) by subcutaneous route. What CPT® codes are reported for the administration and
vaccines? - 90713, 90660, 90716, 90471, 90472, 90474
Patient has a suspicious lesion of the right axilla. The area was infiltrated with local anesthetic
and prepped and draped in a sterile fashion. With the use of a 3 mm punch tool the total lesion
with margins was excised and closed with 5.0 Prolene suture. Pathology report indicated this
was a seborrheic keratosis. What CPT® and ICD-10-CM codes are reported? - 11400,
L82.1
Acute and Chronic Respiratory Failure with Mild Hypoxemia
How many codes would be required to report the respiratory failure? - One: Report acute
and chronic respiratory failure unspecified whether with hypoxia or hypercapnia
