CDEO FINAL EXAM STUDY GUIDE 2025/2026 COMPLETE QUESTIONS WITH CORRECT DETAILED ANSWERS || 100% GUARANTEED PASS BRAND NEW VERSION

CDEO FINAL EXAM STUDY GUIDE 2025/2026 COMPLETE QUESTIONS WITH CORRECT DETAILED ANSWERS || 100% GUARANTEED PASS BRAND NEW VERSION 1. Congestive Heart Failure - ANSWER A chronic condition in which the heart doesn't pump blood as well as it should. 2. Hypertension - ANSWER A condition in which the force of the blood against the artery walls is too high. 3. Civil Monetary Penalties Law (CMPL) - ANSWER Social Security Act authorizes the Secretary of HHS to seek civil monetary penalties (CMPs) and assessments for many types of conduct. The Secretary of HHS has delegated many of these CMPs to the OIG. SEE PAGES 6 & 7 OF THE STUDY GUIDE FOR TABLE OF COMPARISON OF ANTI-KICKBACK LAW AND STARK LAW (PHYSICIAN SELF-REFERRAL LAW)--Gives facts and figures 4. Office of Inspector General (OIG) - ANSWER This office is the largest office in the US Department of HHS and its function is to detect and prevent fraud, waste, and abuse AND to improve efficiency of the HHS program. Most of the OIG's resources are directed toward the oversight of Medicare and Medicaid, but also extend to the Centers for Disease Control (CDC), National Institutes of Health (NIH), and the Food and Drug Administration (FDA). Another function is negotiating, developing, and enforcing CIAs. 5. OIG Work Plan - ANSWER This plan lists various projects that will be addressed during the fiscal year. These projects that will be undertaken by: 1. Office of Audit Services, 2. Office of Evaluation and Inspections, 3. Office of Investigations, 4. Office of Counsel to the Inspector General. It summarizes new AND ongoing reviews and activities that OIG plans to pursue during the next fiscal year and beyond. 6. How the OIG chooses topics for the Workplan - ANSWER Addresses the following: 1. Relative risks in the programs it oversees 2. Identifies areas most in need of attention 3. Setting priorities for the sequence and proportion of resources to be allocated 7. **Each project will list the current focus area and state the primary objective of the review. The word "NEW" after a review title indicates that the review was not included in the previous Work Plan. 8. Corporate Integrity Agreements (CIA) - ANSWER The OIG will require this as a condition of NOT seeking exclusion from participation when an individual or entity seeks to settle civil healthcare fraud cases. This will last 5 years, BUT can be longer. Most of these agreements have core requirements (THESE CAN BE FOUND ON PAGE 8 OF STUDY GUIDE). 9. Independent Review Organization (IRO) - ANSWER THIRD PARTY medical review resource that provides objective, unbiased audits and reports when investigating CIAs for the OIG 10. Discovery Sample - ANSWER 50 sampling units randomly selected to review for a CIA claims review. Used to determine the net financial error rate. If error rate exceeds 5%, a Full Sample must be reviewed, along with a Systems Review. 11. Certificate of Compliance Agreement (CCA) - ANSWER A letter certifying that a provider will continue to operate its existing compliance programs and to report to the OIG for a LESSER PERIOD of time, which is usually THREE (3) YEARS. 12. Compliance Plans - ANSWER Represents comprehensive documentation that a provider, practice, facility, or other healthcare entity is taking steps to adhere to the federal and state laws that affect it. ***7 Mandatory Elements located on PAGE 9 of Study Guide) 13. Compliance Plan Guidance (CPG) - ANSWER Developed by the OIG for a variety of healthcare settings, they provide a comprehensive framework, standards, and principles by which an effective internal compliance program may be established and maintained. Issued for individual and small group physician practices in the Federal Register on October 5, 2000 (BENEFITS and RISKS listed on pages 10 and 11 in study guide) 4 Additional risk areas for physicians are listed in the APPENDIX. 14. Affordable Care Act of 2010 - ANSWER Makes compliance programs mandatory for providers and other healthcare providers who offer services and procedures to Medicare and Medicaid patients. 15. Health Care Financing Administration (HCFA) - ANSWER Established in 1977 to administer the Medicare and Medicaid programs. Renamed the Centers for Medicare and Medicaid (CMS) in 2001, it is the largest agency within the Department of Health an Human Services (HHS). 16. Centers for Medicare and Medicaid (CMS) - ANSWER Administers Medicare, Medicaid, and the Children's Health Insurance Program (CHIP) 17. Internet Only Manual (IOM) - ANSWER Originally paper-based, the CMS manual is offered online. 18. Conditions of Participation (CoP)/Conditions for Coverage (CfC) - ANSWER Standards set forth in the Federal Register that must be met in order to participate in Medicare and Medicaid Programs, they include: Ambulatory Surgical Centers (ASCs), Critical Access Hospitals (CAHs), Hospitals, and Medical Records. 19. ASC - ANSWER Ambulatory Surgical Centers 20. CAH - ANSWER Critical Access Hospitals 4. Engagement of New Medicaid Patients and Follow Up- Seeing new and follow-up Medicaid patients in a timely manner, including individuals dually eligible for Medicaid and Medicare. 21. Medicare Advantage HMO Plan Part C: Domain 5 - ANSWER Domain 5: Health Plan Customer Service -Plan Makes Timely Decisions About Appeals -Reviewing Appeals Decisions -Call Center- Foreign Language Interpreter and TTY Availability 22. Providers are eligible under MIPS include: - ANSWER • Certified Registered Nurse Anesthetists (CRNA) • Clinical Nurse Specialists (CNS)• Doctors of Chiropractic (DC)• Doctors of Dental Medicine (DMD) • Doctors of Dental Surgery (DDS)• Doctors of Medicine (MD) • Doctors of Optometry (OD)• Doctors of Osteopathy (DO) • Doctors of Podiatric Medicine (DPM)• Nurse Practitioners (NP) • Physician Assistants (PA) 23. What size practice is considered a group practice for reporting MIPS? - ANSWER A provider group is two or more physicians. 24. The Medicare Quality Payment Program data for 2017 must be submitted by ______. - ANSWER March 31, 2018 25. What are examples of Advancing Care Information (ACI): - ANSWER Providers have two options based on the provider's electronic health record edition. Option 1: Advancing Care Information Objectives and Measures Option 2: 2017 Advancing Care Information Transition Objectives and Measures Examples of Advancing Care Information Objective and Measures are: e-prescribing Provide Patient Access Patient-Specific Education 26. Which of the following scenarios supports reporting 4064F-1P? - ANSWER A patient diagnosed with MDD who has a poor medication interaction with his medication for HTN and antidepressants. 27. 1P is appended when the performance measure is not met due to medical reasons. Code 4064F is a Category II CPT® code that identifies a patient with MMD, MDD, ADOL who is prescribed an anti-depressant. 28. How can an independent provider report quality measures? - ANSWER Individual EPs may choose to report quality information through one of the following methods: 1. Medicare Part B claims 2. Qualified PQRS registry 3. Direct Electronic Health Record (EHR) using Certified EHR Technology (CEHRT) 4. CEHRT via Data Submission Vendor 5. Qualified clinical data registry (QCDR) ***CMS web Interface is only available to groups of 25 or more. *** 29. What is missing from this electronic signature provided below? Electronically signed by: Joseph M. Doe, MD at 11:03:29 - ANSWER Date 30. Given the following definitions, which of the following is TRUE related to accurate diagnosis coding in risk adjusted payment models: Definitions: PMPM = per member per month MLR = medical loss ratio; the proportion of premium revenues spent on clinical services and quality improvement. MLR = total claims expense (healthcare costs) divided by premiums received (per member per month payments) - ANSWER Providers treating patients with higher medical costs will receive higher PMPM (per member per month) premium payments if they are accurately coding medical conditions supported in the medical record that account for higher expected medical costs. 31. In June, a Medicare Advantage Organization (MAO) audit of a provider's submitted diagnoses determines conflicting diagnoses submitted from two consecutive years. The following diagnoses were reported for the patient. FY 20X5 Diagnoses: HTN CHF DM DVT Diagnoses through June, 20X6: Diabetic retinopathy HTN Which of the following statements is TRUE? - ANSWER The provider likely overlooked documenting CHF in 20X6. 32. Which components are used to determine RVUs? - ANSWER -Physician work -Practice expense -Malpractice insurance 33. Which of the following conditions, if listed under Past Medical History and documented nowhere else in the record, would create a clinical documentation improvement opportunity? I. ALS II Hodgkin lymphoma III Acute bronchitis IV Chronic bronchitis V Autism VI Hypothyroidism - ANSWER -ALS -Chronic bronchitis - Autism - Hypothyroidism 34. __________ should not be used for aftercare involving injuries or poisonings. - ANSWER Z codes 35. For many etiology and manifestation pairings, use... - ANSWER one code that reports both diagnoses 36. The patient was being seen for anemia due to a malignancy of the frontal lobe. What is the first listed diagnosis code? - ANSWER C71.1 - Malignant neoplasm of frontal lobe 37. A consultation is requested for a patient with third degree burns to his entire back that has developed sepsis after admission. How are the ICD-10-CM codes reported? - ANSWER T21.33XA, T21.34XA, T31.11, A41.9 38. patients who have undergone kidney transplant may still have some form of CKD because the kidney transplant may not fully restore kidney function. Therefore, - ANSWER the presence of CKD alone does not constitute a transplant complication 39. A provider must document the causal link between cigarette dependence and a ______________ to report F17.218. - ANSWER respiratory condition 40. Which diagnosis is exempt from reporting Z3A as an additional diagnosis? - ANSWER Ectopic pregnancy 41. Codes in category Z3A, Weeks of gestation are not applicable, and should not be assigned if the pregnancy is - ANSWER outside the uterus, otherwise nonviable, or with abortive outcomes 42. Which is a benefit for using EHRs? - ANSWER Greater coordination of care. 43. Which MIPS measure replaces meaningful use? - ANSWER promoting interoperability 44. What age range does the HEDIS Breast Cancer Screening measure pertain to? - ANSWER 50-74 45. Documentation in the medical record must support the __________________ reported. - ANSWER quality measure 46. Quality measure for a biopsy follow up requires: - ANSWER Biopsy results for new patients to be communicated to the patient and the referring provider 47. patient is diagnosed with actinic keratosis of the chest and arms. She presents to her physician's office for destruction of these lesions. Using cryosurgery the physician destroys 4 lesions on the right arm, 4 lesions on the left forearm and 4 lesions on the chest. What CPT® and ICD-10-CM codes are reported? - ANSWER 17000, 17003 x 11, L57.0 48. Which organ system is given credit for the exam component in a consultation visit when the provider documents "no appreciable edema in the feet?" - ANSWER Cardio 49. A three-year-old presents to the office with his mother for an MMR vaccine. The nurse confirms the order and physician counseling is given before the vaccine is administered. The vaccine is given subcutaneously. The site, vaccine, lot number, dosage, and date and time are documented in the medical record. What CPT® codes are reported? - ANSWER 90460, 90461 x 2, 90707 50. The presence of ____________ in a Medicare patient would not classify a patient as high-risk for developing colon cancer. - ANSWER diverticulitis 51. sign(s) or symptom(s) for the diagnosis of pulmonary hypertension - ANSWER - Bluish tint to lips - Enlarged jugular veins - Shortness of breath 52. Coding RSV pneumonia (J12.1) when the provider documents only "pneumonia" but a pathologist's report identifies the agent as RSV pneumonia is ok to do. - ANSWER True 53. Chronic diseases treated on an ongoing basis may be coded and reported as many times as the patient receives treatment and care for the condition(s) - ANSWER True 54. Zika is caused by a _________ - ANSWER virus 55. Which statement is TRUE regarding the use of clinician documentation and reporting ICD-10-CM codes? - ANSWER A clinician can document the NIH stroke scale. 56. What is the lowest star rating a plan must achieve to avoid penalties? - ANSWER Plans not obtaining 4 Stars or better may be penalized. 57. How often are HEDIS measures revised? - ANSWER Measures are added, deleted, and revised annually. 58. What is the goal of HEDIS? - ANSWER HEDIS was designed to allow consumers to compare health plan performance to other plans and to regional or national benchmarks. 59. Which of the following are domains in CMS Part C Stars Rating? - ANSWER The CMS Stars Ratings Part C Domains include: • Staying Healthy • Managing Chronic Conditions • Member Experience with Health Plan • Member Complaints, Problems Getting Services, and Improvement in the Health Plan's Performance • Health Plan Customer Service 60. Which statement is TRUE regarding the CMS Stars quality rating system? - ANSWER In an effort to make quality of care a priority, the Affordable Care Act set a requirement that CMS make quality bonus payments (QBPs) to Medicare Advantage health plans based on the plan's quality rating, where Medicare Advantage plans that earn four or more stars in a 5-star quality rating system would receive a bonus payment and those earning fewer than four stars would receive no bonus. 61. Quality bonus payments are made to Medicare Advantage plans who score at least four stars. 62. In review of Dr. N's paper based medical record system, you note that the doctor has documentation in a single encounter of HbA1c Testing and FOBT. Which two areas of HEDIS measures are most likely satisfied in this encounter and should prompt further review to confirm? - ANSWER The HBA1c test is to monitor diabetes. The FOBT is a screening test that qualifies for the colorectal cancer screening HEDIS measure. 63. In a medical record review, which of the following ICD-10-CM codes would prompt satisfaction of the HEDIS measure of Pharmacotherapy Management of COPD Exacerbation and search for potential risk adjustment support. - ANSWER For this measure, COPD, emphysema and chronic bronchitis diagnoses support the measure. 64. STARS Ratings are important because they: - ANSWER STAR ratings is a measuring system for health plans. Identify top performing health plans. 65. What are the four measures and activities that will be used to measure MIPS performance in 2018? - ANSWER Effective for the 2018 performance year, the provider score will be determined based on Quality, Improvement Activities, Advancing Care Information and Cost. 66. Which of the following is NOT a benefit for providers to utilize electronic health records? - ANSWER Electronic health records provide a lot of efficiencies for providers and help improve the continuity of care for the patient. Avoiding fraud and abuse should be a goal but regardless of the tool used for documentation, it will not prevent fraud and abuse if used inappropriately to alter documentation. 67. E-prescribing electronically transmits new and refill prescriptions to a community or mail order pharmacy. What is an advantage to E-Prescribing (eRx)? - ANSWER The provider can determine if a medication they want to prescribe is covered under the patient's insurance prior to sending an e prescription. Point of care provider access to the patient's payer formulary benefits. 68. Which of the following is a HEDIS measure for 2017? - ANSWER I. Controlling high blood pressure II. Medication reconciliation post-discharge