CDEO 2025 Exam Questions | Multiple-
Choice Practice with Verified Answers
and Detailed Rationales
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 - ✓✓-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.
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.
d. No, CDEOs review records on a proactive basis to prevent documentation
deficiencies - ✓✓-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
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 - ✓✓-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.
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
IV. Private payers - ✓✓-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.
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. - ✓✓-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.
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 - ✓✓-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.
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 - ✓✓-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.
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 - ✓✓-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.
Which of the following statements is TRUE regarding clinical documentation
improvement efforts?
a. Documentation reviews should be limited to the costliest chronic conditions to treat.
b. Documentation reviews can be performed on a prospective basis.
c. Documentation reviews must be completed yearly.
d. Documentation reviews require access to the denial data. - ✓✓-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.
Why is it important to involve physicians in Clinical Documentation Improvement (CDI)
programs?
a. It encourages physician participation.
b. It helps justify the need for CDI programs.
c. It will eliminate the need to query providers.
d. It will help providers time management. - ✓✓-a. It encourages physician participation.
Getting physicians involved in CDI helps to gain physician buy in and encourages other
physicians to participate and is a great way to educate physicians.
Which of the following documentation deficiencies has a negative impact on patient
outcomes?
a. Failure to indicate the date of the patient's last blood test.
b. Failure to include the instructions for post procedure care and potential complications.
c. Failure to sign the patient's medical records provided by another physician.
d. Failure to report the patient's pharmacy preference for insurance participation. - ✓✓-
b. Failure to include the instructions for post procedure care and potential complications.
Although all the choices are deficiencies in capturing patient information, failure to
inform a patient of potential post-operative complications could impact the patient's
recovery. In this question, you are determining the option that affects clinical care of the
patient.
What is an effective method for communicating documentation deficiencies to a
provider?
a. Provide documentation tips for the most common chronic conditions treated.
b. Provide the documentation deficiency report quarterly.
c. Provide a report to the medical director that includes the findings for all the providers
in the practice.
d. Provide examples of the provider's documentation deficiencies with suggestions for
improvement. - ✓✓-d. Provide examples of the provider's documentation deficiencies
with suggestions for improvement.
, Effective provider education regarding documentation deficiencies is to provide
examples of the physician's documentation deficiency and feedback and tips on how to
correct the deficiency.
Which of the following is/are considered a purpose of documentation improvement
programs?
I. Improve patient outcomes.
II. Prepare physicians to provide documentation that supports quality measures.
III. Promote coding lower level services.
IV. Improve the provider query process. - ✓✓-I, II, and IV
It is appropriate to work towards proper reimbursement but the goal of CDI should never
be increasing or lowering revenue.
How can an effective CDI program improve patient outcomes?
a. Maximize the reimbursement received.
b. Prohibit claim processing errors.
c. Provide a detailed record of the care provided to the patient.
d. Allow providers to support higher levels of E/M services. - ✓✓-c. Provide a detailed
record of the care provided to the patient.
The main goal for detailed medical records is to promote the continuity of care for the
patient. This allows providers to communicate
Which of the following recommendations should be made to providers regarding the
patient's problem list?
a. Significant changes should be documented at each encounter.
b. Problem lists consists of all past medical complications.
c. Problem lists should only be used if the patient has at least on chronic illness.
d. Significant changes should be documented once a year. - ✓✓-a. Significant changes
should be documented at each encounter.
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.
Failure to document which of the following statements could lead to a negative patient
outcome?
a. Allergies: PCN
b. Patient denies loss of appetite or vomiting.
c. Patient has remained on her diet.
d. Patient indicates her daughter lives with her to assist in her care. - ✓✓-a. Allergies:
PCN
Failure to document an allergy could lead to an allergic reaction if the provider
prescribes a medication not realizing the patient is allergic.
Choice Practice with Verified Answers
and Detailed Rationales
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 - ✓✓-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.
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.
d. No, CDEOs review records on a proactive basis to prevent documentation
deficiencies - ✓✓-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
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 - ✓✓-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.
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
IV. Private payers - ✓✓-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.
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. - ✓✓-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.
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 - ✓✓-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.
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 - ✓✓-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.
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 - ✓✓-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.
Which of the following statements is TRUE regarding clinical documentation
improvement efforts?
a. Documentation reviews should be limited to the costliest chronic conditions to treat.
b. Documentation reviews can be performed on a prospective basis.
c. Documentation reviews must be completed yearly.
d. Documentation reviews require access to the denial data. - ✓✓-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.
Why is it important to involve physicians in Clinical Documentation Improvement (CDI)
programs?
a. It encourages physician participation.
b. It helps justify the need for CDI programs.
c. It will eliminate the need to query providers.
d. It will help providers time management. - ✓✓-a. It encourages physician participation.
Getting physicians involved in CDI helps to gain physician buy in and encourages other
physicians to participate and is a great way to educate physicians.
Which of the following documentation deficiencies has a negative impact on patient
outcomes?
a. Failure to indicate the date of the patient's last blood test.
b. Failure to include the instructions for post procedure care and potential complications.
c. Failure to sign the patient's medical records provided by another physician.
d. Failure to report the patient's pharmacy preference for insurance participation. - ✓✓-
b. Failure to include the instructions for post procedure care and potential complications.
Although all the choices are deficiencies in capturing patient information, failure to
inform a patient of potential post-operative complications could impact the patient's
recovery. In this question, you are determining the option that affects clinical care of the
patient.
What is an effective method for communicating documentation deficiencies to a
provider?
a. Provide documentation tips for the most common chronic conditions treated.
b. Provide the documentation deficiency report quarterly.
c. Provide a report to the medical director that includes the findings for all the providers
in the practice.
d. Provide examples of the provider's documentation deficiencies with suggestions for
improvement. - ✓✓-d. Provide examples of the provider's documentation deficiencies
with suggestions for improvement.
, Effective provider education regarding documentation deficiencies is to provide
examples of the physician's documentation deficiency and feedback and tips on how to
correct the deficiency.
Which of the following is/are considered a purpose of documentation improvement
programs?
I. Improve patient outcomes.
II. Prepare physicians to provide documentation that supports quality measures.
III. Promote coding lower level services.
IV. Improve the provider query process. - ✓✓-I, II, and IV
It is appropriate to work towards proper reimbursement but the goal of CDI should never
be increasing or lowering revenue.
How can an effective CDI program improve patient outcomes?
a. Maximize the reimbursement received.
b. Prohibit claim processing errors.
c. Provide a detailed record of the care provided to the patient.
d. Allow providers to support higher levels of E/M services. - ✓✓-c. Provide a detailed
record of the care provided to the patient.
The main goal for detailed medical records is to promote the continuity of care for the
patient. This allows providers to communicate
Which of the following recommendations should be made to providers regarding the
patient's problem list?
a. Significant changes should be documented at each encounter.
b. Problem lists consists of all past medical complications.
c. Problem lists should only be used if the patient has at least on chronic illness.
d. Significant changes should be documented once a year. - ✓✓-a. Significant changes
should be documented at each encounter.
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.
Failure to document which of the following statements could lead to a negative patient
outcome?
a. Allergies: PCN
b. Patient denies loss of appetite or vomiting.
c. Patient has remained on her diet.
d. Patient indicates her daughter lives with her to assist in her care. - ✓✓-a. Allergies:
PCN
Failure to document an allergy could lead to an allergic reaction if the provider
prescribes a medication not realizing the patient is allergic.
