CDEO ASSESSMENT GUIDE 2025
|MOST COMMON QUESTIONS WITH CORRECTLY
VERIFIED ANSWERS (the recent quizes)|ALREADY
A+ GRADED|GUARANTEED PASS
HIPPA - 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 - Demographic data, name, address, birth date,
and SS number.
central focus of clinical documentation - should be to demonstrate the quality of care
provided to the patient with detail and accuracy to facilitate optimum patient care.
CDEO Focus - 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 - 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 - 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 - 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 - 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 - 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 - 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 - Quality assurance of patient care is
only evident if:
CDI Programs intent - 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. - 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. -
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. - What is an effective method for communicating documentation
deficiencies to a provider?
Improve patient outcomes, Improve patient outcomes, and improve the provider query process.
- Which of the following is/are considered a purpose of documentation improvement
programs?
How can an effective CDI program improve patient outcomes? - 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? - 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 - 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? -
Documentation deficiencies may not be identified until after the provider has left.
Documentation Challenges - 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 - 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 - 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 - 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 - 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 - 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 - 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? - The contract must describe
the permitted and required uses of protected health information by the business associate, limit
the business associate from using or further disclosing the protected health information (except
where permitted by contract or required by law), and require the business associate to follow
appropriate safeguards to prevent use or disclosure of the protected health information, except
as expressly defined in the contract.
What is appropriate to document in a radiology report for contrast material used in a radiologic
study? - The type and amount of contrast used, along with the route of administration is
documented.
Contrast Material for radiology - The amount and type of contrast material should be
documented in the radiology report along with the route of administration
HIPAA established the Health Care Fraud and Abuse Control Program - a far-reaching
program to combat fraud and abuse in health care, including both public and private health
plans.
|MOST COMMON QUESTIONS WITH CORRECTLY
VERIFIED ANSWERS (the recent quizes)|ALREADY
A+ GRADED|GUARANTEED PASS
HIPPA - 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 - Demographic data, name, address, birth date,
and SS number.
central focus of clinical documentation - should be to demonstrate the quality of care
provided to the patient with detail and accuracy to facilitate optimum patient care.
CDEO Focus - 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 - 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 - 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 - 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 - 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 - 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 - 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 - Quality assurance of patient care is
only evident if:
CDI Programs intent - 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. - 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. -
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. - What is an effective method for communicating documentation
deficiencies to a provider?
Improve patient outcomes, Improve patient outcomes, and improve the provider query process.
- Which of the following is/are considered a purpose of documentation improvement
programs?
How can an effective CDI program improve patient outcomes? - 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? - 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 - 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? -
Documentation deficiencies may not be identified until after the provider has left.
Documentation Challenges - 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 - 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 - 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 - 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 - 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 - 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 - 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? - The contract must describe
the permitted and required uses of protected health information by the business associate, limit
the business associate from using or further disclosing the protected health information (except
where permitted by contract or required by law), and require the business associate to follow
appropriate safeguards to prevent use or disclosure of the protected health information, except
as expressly defined in the contract.
What is appropriate to document in a radiology report for contrast material used in a radiologic
study? - The type and amount of contrast used, along with the route of administration is
documented.
Contrast Material for radiology - The amount and type of contrast material should be
documented in the radiology report along with the route of administration
HIPAA established the Health Care Fraud and Abuse Control Program - a far-reaching
program to combat fraud and abuse in health care, including both public and private health
plans.
