CDEO EXAM QUESTIONS AND
ANSWERS
Clinical Documentation Improvement (CDI) programs can help: - Correct Answers --
Build effective documentation compliance policies
- Capture clinical data required for continuity of care
documentation deficiency that has a negative impact on patient outcomes - Correct
Answers -Failure to include the complications of drug for prescriptions taken by a
patient.
What is best practice to communicate document deficiencies to a provider? - Correct
Answers -Provide examples of the provider's documentation errors with suggestions for
improvement.
A physician who specializes in elder care undergoes a CDI audit. Fifteen charts are
found with the diagnosis of marasmus. Your correct response: - Correct Answers -
Display in your query the Index entry for marasmus and the codes and descriptions for
E41 and R54. Ask for guidance on which to report.
The best approach when querying a physician regarding documentation is to approach
the problem as one of: - Correct Answers -- Evidence based medicine
- Financial motive
- Malpractice liability
- Documentation impact on reimbursement
- Documentation impact on compliance
Which EMR feature is non-compliant with CMS? - Correct Answers -Templates that
allow the provider to de-select a prepopulated "normal" checkmark when the system is
abnormal in the ROS
When providing CDI to a provider, does the message change depending on whether
you are performing a prospective or retrospective audit? - Correct Answers -Yes,
because the auditor cannot ask leading questions regarding documentation before a
claim is submitted.
What is NOT considered a purpose of documentation improvement programs? - Correct
Answers -Increase reimbursements
, CDI programs can help with: - Correct Answers -Consistency of documentation & Team
building
Which is NOT an acceptable cause for query? - Correct Answers -Signs and symptoms
without a diagnosis
Which is a leading query? - Correct Answers -Your sarcoidosis patient has sarcoid
lesions on the cerebral cortex, correct?
The surgeon documents liver cancer, but the pathology report states angiosarcoma of
liver. You: - Correct Answers -Code the liver cancer as angiosarcoma, a primary liver
cancer, based on the pathologist's documentation.
In reviewing the provider's assessment the documentation states "lab tests reviewed:
+K." You correctly query: - Correct Answers -Can you please address the patient's
potassium status in further detail?
Documentation states:
Patient has a history of a recent myocardial infarct and is admitted today with an ST
elevation MI of the anterior wall.
The flaw in this documentation from a coding standpoint: - Correct Answers -The
duration between the recent myocardial infarct and the current myocardial infarct will
impact coding, so "recent" is insufficient documentation
Which term or phrase, when used between a manifestation and etiology, does NOT
always show a causal relationship? - Correct Answers -likely
Which is an example of poor documentation that is especially problematic as there is no
"unspecified" code for the condition in ICD-10-CM? - Correct Answers -Degenerative
disc disease (DDD)
When reviewing documentation and you notice information is missing, what is the
proper procedure? - Correct Answers -The information should be added as a
documented late entry/addendum only when necessary.
Is it an acceptable practice to use a template that always documents a complete review
of systems? - Correct Answers -No. The extent of ROS performed and documented is
dependent upon clinical judgment and the nature of the presenting problem(s).
Which type of documentation can be used to report diagnoses under risk adjustment
models? - Correct Answers -Inpatient Admission Note
What type of payment does an ACO (Accountable Care Organization) receive? -
Correct Answers -An ACO receives reimbursements based on quality metrics and
reductions in the total cost of care for an assigned population of patients.
ANSWERS
Clinical Documentation Improvement (CDI) programs can help: - Correct Answers --
Build effective documentation compliance policies
- Capture clinical data required for continuity of care
documentation deficiency that has a negative impact on patient outcomes - Correct
Answers -Failure to include the complications of drug for prescriptions taken by a
patient.
What is best practice to communicate document deficiencies to a provider? - Correct
Answers -Provide examples of the provider's documentation errors with suggestions for
improvement.
A physician who specializes in elder care undergoes a CDI audit. Fifteen charts are
found with the diagnosis of marasmus. Your correct response: - Correct Answers -
Display in your query the Index entry for marasmus and the codes and descriptions for
E41 and R54. Ask for guidance on which to report.
The best approach when querying a physician regarding documentation is to approach
the problem as one of: - Correct Answers -- Evidence based medicine
- Financial motive
- Malpractice liability
- Documentation impact on reimbursement
- Documentation impact on compliance
Which EMR feature is non-compliant with CMS? - Correct Answers -Templates that
allow the provider to de-select a prepopulated "normal" checkmark when the system is
abnormal in the ROS
When providing CDI to a provider, does the message change depending on whether
you are performing a prospective or retrospective audit? - Correct Answers -Yes,
because the auditor cannot ask leading questions regarding documentation before a
claim is submitted.
What is NOT considered a purpose of documentation improvement programs? - Correct
Answers -Increase reimbursements
, CDI programs can help with: - Correct Answers -Consistency of documentation & Team
building
Which is NOT an acceptable cause for query? - Correct Answers -Signs and symptoms
without a diagnosis
Which is a leading query? - Correct Answers -Your sarcoidosis patient has sarcoid
lesions on the cerebral cortex, correct?
The surgeon documents liver cancer, but the pathology report states angiosarcoma of
liver. You: - Correct Answers -Code the liver cancer as angiosarcoma, a primary liver
cancer, based on the pathologist's documentation.
In reviewing the provider's assessment the documentation states "lab tests reviewed:
+K." You correctly query: - Correct Answers -Can you please address the patient's
potassium status in further detail?
Documentation states:
Patient has a history of a recent myocardial infarct and is admitted today with an ST
elevation MI of the anterior wall.
The flaw in this documentation from a coding standpoint: - Correct Answers -The
duration between the recent myocardial infarct and the current myocardial infarct will
impact coding, so "recent" is insufficient documentation
Which term or phrase, when used between a manifestation and etiology, does NOT
always show a causal relationship? - Correct Answers -likely
Which is an example of poor documentation that is especially problematic as there is no
"unspecified" code for the condition in ICD-10-CM? - Correct Answers -Degenerative
disc disease (DDD)
When reviewing documentation and you notice information is missing, what is the
proper procedure? - Correct Answers -The information should be added as a
documented late entry/addendum only when necessary.
Is it an acceptable practice to use a template that always documents a complete review
of systems? - Correct Answers -No. The extent of ROS performed and documented is
dependent upon clinical judgment and the nature of the presenting problem(s).
Which type of documentation can be used to report diagnoses under risk adjustment
models? - Correct Answers -Inpatient Admission Note
What type of payment does an ACO (Accountable Care Organization) receive? -
Correct Answers -An ACO receives reimbursements based on quality metrics and
reductions in the total cost of care for an assigned population of patients.
