CDEO EXAM QUESTIONS AND ANSWERS
100% PASS
HIPPA - ANSWER✔✔-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 - ANSWER✔✔-Demographic
| | | | |
| data, name, address, birth date, and SS number.
| | | | | | |
central focus of clinical documentation - ANSWER✔✔-should be to
| | | | | | | |
demonstrate the quality of care provided to the patient with detail and
| | | | | | | | | | |
| accuracy to facilitate optimum patient care.
| | | | |
CDEO Focus - ANSWER✔✔-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.
| | | | | | | | | | | | |
Page |1/42
,CDEO Review - ANSWER✔✔-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 - ANSWER✔✔-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 - 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:
|
Page |2/42
,Medical Record Validates - ANSWER✔✔-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 - ANSWER✔✔-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 - ANSWER✔✔-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 - ANSWER✔✔-Quality
| | | | | | | | | |
| assurance of patient care is only evident if:| | | | | | |
CDI Programs intent - ANSWER✔✔-CDI programs are intended to be
| | | | | | | | |
| performed on a prospective basis to improve documentation deficiencies
| | | | | | | |
Page |3/42
, 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. - ANSWER✔✔-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. - ANSWER✔✔-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. - ANSWER✔✔-What is an effective method
| | | | | | | |
| for communicating documentation deficiencies to a provider?
| | | | | |
Improve patient outcomes, Improve patient outcomes, and improve the
| | | | | | | |
| provider query process. - ANSWER✔✔-Which of the following is/are
| | | | | | | |
considered a purpose of documentation improvement programs?
| | | | | |
How can an effective CDI program improve patient outcomes? -
| | | | | | | | |
ANSWER✔✔-The main goal for detailed medical records is to promote the | | | | | | | | | |
Page |4/42
100% PASS
HIPPA - ANSWER✔✔-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 - ANSWER✔✔-Demographic
| | | | |
| data, name, address, birth date, and SS number.
| | | | | | |
central focus of clinical documentation - ANSWER✔✔-should be to
| | | | | | | |
demonstrate the quality of care provided to the patient with detail and
| | | | | | | | | | |
| accuracy to facilitate optimum patient care.
| | | | |
CDEO Focus - ANSWER✔✔-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.
| | | | | | | | | | | | |
Page |1/42
,CDEO Review - ANSWER✔✔-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 - ANSWER✔✔-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 - 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:
|
Page |2/42
,Medical Record Validates - ANSWER✔✔-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 - ANSWER✔✔-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 - ANSWER✔✔-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 - ANSWER✔✔-Quality
| | | | | | | | | |
| assurance of patient care is only evident if:| | | | | | |
CDI Programs intent - ANSWER✔✔-CDI programs are intended to be
| | | | | | | | |
| performed on a prospective basis to improve documentation deficiencies
| | | | | | | |
Page |3/42
, 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. - ANSWER✔✔-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. - ANSWER✔✔-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. - ANSWER✔✔-What is an effective method
| | | | | | | |
| for communicating documentation deficiencies to a provider?
| | | | | |
Improve patient outcomes, Improve patient outcomes, and improve the
| | | | | | | |
| provider query process. - ANSWER✔✔-Which of the following is/are
| | | | | | | |
considered a purpose of documentation improvement programs?
| | | | | |
How can an effective CDI program improve patient outcomes? -
| | | | | | | | |
ANSWER✔✔-The main goal for detailed medical records is to promote the | | | | | | | | | |
Page |4/42
