CDEO EXAM QUESTIONS AND
ANSWERS
HIPPA - Correct Answers -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 - Correct Answers -Demographic data, name,
address, birth date, and SS number.
central focus of clinical documentation - Correct Answers -should be to demonstrate the
quality of care provided to the patient with detail and accuracy to facilitate optimum
patient care.
CDEO Focus - Correct Answers -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.
CDEO Review - Correct Answers -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 - Correct Answers -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 - Correct Answers -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:
Medical Record Validates - Correct Answers -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 - Correct Answers -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 - Correct Answers -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 - Correct Answers -Quality assurance
of patient care is only evident if:
CDI Programs intent - Correct Answers -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.
It encourages physician participation. - Correct Answers -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. -
Correct Answers -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. - Correct Answers -What is an effective method for communicating
documentation deficiencies to a provider?
Improve patient outcomes, Improve patient outcomes, and improve the provider query
process. - Correct Answers -Which of the following is/are considered a purpose of
documentation improvement programs?
How can an effective CDI program improve patient outcomes? - Correct Answers -The
main goal for detailed medical records is to promote the continuity of care for the
patient. This allows providers to communicate with each other on the care that has been
provided to the patient. Coding higher level services that are not medically necessary is
not a goal to improve patient outcomes.
Which of the following recommendations should be made to providers regarding the
patient's problem list? - Correct Answers -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.
ANSWERS
HIPPA - Correct Answers -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 - Correct Answers -Demographic data, name,
address, birth date, and SS number.
central focus of clinical documentation - Correct Answers -should be to demonstrate the
quality of care provided to the patient with detail and accuracy to facilitate optimum
patient care.
CDEO Focus - Correct Answers -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.
CDEO Review - Correct Answers -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 - Correct Answers -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 - Correct Answers -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:
Medical Record Validates - Correct Answers -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 - Correct Answers -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 - Correct Answers -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 - Correct Answers -Quality assurance
of patient care is only evident if:
CDI Programs intent - Correct Answers -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.
It encourages physician participation. - Correct Answers -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. -
Correct Answers -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. - Correct Answers -What is an effective method for communicating
documentation deficiencies to a provider?
Improve patient outcomes, Improve patient outcomes, and improve the provider query
process. - Correct Answers -Which of the following is/are considered a purpose of
documentation improvement programs?
How can an effective CDI program improve patient outcomes? - Correct Answers -The
main goal for detailed medical records is to promote the continuity of care for the
patient. This allows providers to communicate with each other on the care that has been
provided to the patient. Coding higher level services that are not medically necessary is
not a goal to improve patient outcomes.
Which of the following recommendations should be made to providers regarding the
patient's problem list? - Correct Answers -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.
