1|Page
CDEO EXAM QUESTIONS WITH VERIFIED
SOLUTIONS
informed consent -correct-answer-s signed by the patient to verify that the
patient understands procedures, outcomes, and options. This consent for a
procedure can be withdrawn by the patient at any time. An informed consent
consists of the patient's diagnosis (if known), the nature and purpose of a
proposed treatment/procedure along with the associated risks and benefits,
alternative treatments/procedures along with the associated risks and benefits,
and the risk and benefits of not receiving the treatment/procedure.
Hand Written Records -correct-answer-are often illegible and abbreviated. In
addition, some information may be left off the medical record to reduce the
amount of time it takes to write the note.
excluded from an individual's right to access their PHI? -correct-answer-Areas
excluded from the rights of access are psychotherapy notes, information related
to legal proceedings, and certain lab results or information held by research
laboratories.
How long does HIPAA require medical records to be maintained -correct-answer-
Six years from the date of its creation or the date from which it was last in effect
(whichever is later).
,2|Page
Covered entities -correct-answer-All "covered entities" are required to follow the
Privacy Rule. Covered entities are defined as health plans, healthcare
clearinghouses, and any healthcare provider who transmits health information in
an electronic format.
Establish their own standards -correct-answer-In the absence of specific statute or
regulations, many health care institutions establish their own standards or
requirements in relation to the content of a medical record.
Requirements for Retaining Radiographic images -correct-answer-Not only is it
necessary to retain the actual images of radiologic services, it is also important
that a written report is obtained, to include the indication for the study and to
summarize the findings. An order or request for the study must also be retained.
Incidental use and disclosure is permitted -correct-answer-as long as the covered
entity has reasonable safeguards in place to ensure that the information being
shared is limited to the "minimum necessary," as required by the Privacy Rule.
Assignment of benefits -correct-answer-This is an authorization form signed by
the patient that allows their insurance carrier to pay the provider directly. Without
,3|Page
this, the payment will go to the beneficiary and the provider will be required to
collect payment from the beneficiary.
Documentation requirements for therapy services -correct-answer-include
progress reports which provide justification for the medical necessity of
treatment. Information required in the progress reports should be written by a
clinician.
Reading and analyzing an operative report -correct-answer-requires time and
great attention to detail. Challenges arise when the report indicates a specific
procedure as being performed in the header, but the details in the body of the
note do not support that procedure, or indicate additional procedures not
reported in the title. For this reason, it is very important to read the entire note
slowly and carefully. Attempt to gain an understanding of the entire surgical case
before taking more time to read the report thoroughly to analyze for proper code
assignment.
Anteroposterior, Oblique, and Swimmers -correct-answer-types of radiological
views used in a radiology report. Prone is not a radiological view, but a body
position when the patient is face down.
Treatment encounter notes for each treatment day and should include:· -correct-
answer-Date of treatment· Treatment, intervention, or activity· Total timed
treatment by individual modality and total treatment time in minutes (includes
, 4|Page
timed codes and untimed codes)· Signature and professional identity of the
qualified professional furnishing the treatment· Additional information may
include response to treatment or changes.
Each provider involved in a surgical case -correct-answer-is expected to document
the portion of the surgical procedure they performed with the exception of a
surgical assistant. When a surgery requires the help of a surgical assistant, the
primary surgeon documents the operative report. The primary surgeon should
clearly explain in the indications section of the note why an assistant was
necessary, and what the assistant surgeon performed that required the assistance.
When the lab report reveals an abnormal finding -correct-answer-the physician
should circle and sign the abnormal result to indicate it was seen. The physician
must also make sure to address the abnormality in the diagnosis and treatment
plan.
Identified in the indications portion of an operative note -correct-answer-gives a
brief history outlining the reason for or medical necessity for the procedure.
The Centers for Medicare and Medicaid Services (CMS) -correct-answer-requires
hospitals to retain all patient records for at least five years after the submission of
their closed cost reports.
CDEO EXAM QUESTIONS WITH VERIFIED
SOLUTIONS
informed consent -correct-answer-s signed by the patient to verify that the
patient understands procedures, outcomes, and options. This consent for a
procedure can be withdrawn by the patient at any time. An informed consent
consists of the patient's diagnosis (if known), the nature and purpose of a
proposed treatment/procedure along with the associated risks and benefits,
alternative treatments/procedures along with the associated risks and benefits,
and the risk and benefits of not receiving the treatment/procedure.
Hand Written Records -correct-answer-are often illegible and abbreviated. In
addition, some information may be left off the medical record to reduce the
amount of time it takes to write the note.
excluded from an individual's right to access their PHI? -correct-answer-Areas
excluded from the rights of access are psychotherapy notes, information related
to legal proceedings, and certain lab results or information held by research
laboratories.
How long does HIPAA require medical records to be maintained -correct-answer-
Six years from the date of its creation or the date from which it was last in effect
(whichever is later).
,2|Page
Covered entities -correct-answer-All "covered entities" are required to follow the
Privacy Rule. Covered entities are defined as health plans, healthcare
clearinghouses, and any healthcare provider who transmits health information in
an electronic format.
Establish their own standards -correct-answer-In the absence of specific statute or
regulations, many health care institutions establish their own standards or
requirements in relation to the content of a medical record.
Requirements for Retaining Radiographic images -correct-answer-Not only is it
necessary to retain the actual images of radiologic services, it is also important
that a written report is obtained, to include the indication for the study and to
summarize the findings. An order or request for the study must also be retained.
Incidental use and disclosure is permitted -correct-answer-as long as the covered
entity has reasonable safeguards in place to ensure that the information being
shared is limited to the "minimum necessary," as required by the Privacy Rule.
Assignment of benefits -correct-answer-This is an authorization form signed by
the patient that allows their insurance carrier to pay the provider directly. Without
,3|Page
this, the payment will go to the beneficiary and the provider will be required to
collect payment from the beneficiary.
Documentation requirements for therapy services -correct-answer-include
progress reports which provide justification for the medical necessity of
treatment. Information required in the progress reports should be written by a
clinician.
Reading and analyzing an operative report -correct-answer-requires time and
great attention to detail. Challenges arise when the report indicates a specific
procedure as being performed in the header, but the details in the body of the
note do not support that procedure, or indicate additional procedures not
reported in the title. For this reason, it is very important to read the entire note
slowly and carefully. Attempt to gain an understanding of the entire surgical case
before taking more time to read the report thoroughly to analyze for proper code
assignment.
Anteroposterior, Oblique, and Swimmers -correct-answer-types of radiological
views used in a radiology report. Prone is not a radiological view, but a body
position when the patient is face down.
Treatment encounter notes for each treatment day and should include:· -correct-
answer-Date of treatment· Treatment, intervention, or activity· Total timed
treatment by individual modality and total treatment time in minutes (includes
, 4|Page
timed codes and untimed codes)· Signature and professional identity of the
qualified professional furnishing the treatment· Additional information may
include response to treatment or changes.
Each provider involved in a surgical case -correct-answer-is expected to document
the portion of the surgical procedure they performed with the exception of a
surgical assistant. When a surgery requires the help of a surgical assistant, the
primary surgeon documents the operative report. The primary surgeon should
clearly explain in the indications section of the note why an assistant was
necessary, and what the assistant surgeon performed that required the assistance.
When the lab report reveals an abnormal finding -correct-answer-the physician
should circle and sign the abnormal result to indicate it was seen. The physician
must also make sure to address the abnormality in the diagnosis and treatment
plan.
Identified in the indications portion of an operative note -correct-answer-gives a
brief history outlining the reason for or medical necessity for the procedure.
The Centers for Medicare and Medicaid Services (CMS) -correct-answer-requires
hospitals to retain all patient records for at least five years after the submission of
their closed cost reports.
