CDEO EXAM QUESTIONS AND
ANSWERS
The best approach when querying a physician regarding documentation is to approach
the problem as one of:
I. Evidence based medicine
II. Financial motive
III. Malpractice liability
IV. Documentation impact on reimbursement
V. Documentation impact on compliance
A. ll, IV, and V
B. I, II, III, IV, and V
C. I, II, and IV
D. IV and V - Correct Answers -Depending on the documentation issue, any of these
responses might be appropriate. Failing to address flaws in documentation can result in
medical errors, financial losses and diminished patient care.
Clinical Documentation Improvement (CDI) programs can help:
I. Build effective documentation compliance policies
II. Capture clinical data required for continuity of care
III. Promote failures identified in documentation review
A. I and III
B. I, II and III
C. II and III
D. I and II - Correct Answers -I and II
I. Build effective documentation compliance policies
II. Capture clinical data required for continuity of care
An effective CDI program never emphasizes failures; it promotes continuity of care and
development of effective CDI policies.
Question 2
Which of the following documentation deficiencies have a negative impact on patient
outcomes?
A. Failure to indicate the patient's insurance information.
B. Failure to include the complications of drug for prescriptions taken by a patient.
C. Failure to sign the patient's documented review of systems when obtaining a history.
,D. Failure to report the patient's employment in the social history. - Correct Answers -B.
Failure to include the complications of drug for prescriptions taken by a patient.
All answer options are documentation deficiencies. The only deficiency that would affect
the care of the patient is failure to communicate drug interactions that could harm a
patient caused by prescription drugs they are given.
Question 4
A physician who specializes in elder care undergoes a CDI audit. Fifteen charts are
found with the diagnosis of marasmus. Your correct response:
A. Congratulate the physician for correctly capturing an often-overlooked malnutrition
diagnosis.
B. 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.
C. Report code E41
D. Report code R54 - Correct Answers -B. 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 provider did not link the age of the patient to the marasmus, so we cannot report
R54. E41 describes a form of marasmus usually associated with children who are
protein deficient. Because of the ambiguity of the diagnosis, you would not select A. The
correct answer is B, to provide the Index entries for the provider to view, so that he
might choose the code he intended.
Question 5
The best approach when querying a physician regarding documentation is to approach
the problem as one of:
I. Evidence based medicine
II. Financial motive
III. Malpractice liability
IV. Documentation impact on reimbursement
V. Documentation impact on compliance
A. ll, IV, and V
B. I, II, III, IV, and V
C. I, II, and IV
D. IV and V - Correct Answers -B. I, II, III, IV, and V
Depending on the documentation issue, any of these responses might be appropriate.
Failing to address flaws in documentation can result in medical errors, financial losses
and diminished patient care.
Question 6
According to documentation, A 34-week gestation patient with diabetes delivers twins.
Fetus A was delivered without complication, with APGARs of 8 and 8. Fetus B's delivery
, was complicated by a knot in the umbilical cord, and his APGARs were 3 and 5. Which
query is appropriate?
A. For ICD-10 coding purposes, is Fetus A the same as Fetus 1, and Fetus B the same
as Fetus 2?
B. What type of diabetes did the patient have?
C. Was the knotted cord in Fetus B compressed?
D. Does a delivery at 34 weeks indicate prematurity in fetus A and B? - Correct Answers
-B. What type of diabetes did the patient have?
The correct answer is B, "What type of diabetes did the patient have?" This is pertinent
because gestational, type 1 and type 2 diabetes are mutually exclusive. There is a
default for unspecified diabetes in pregnancy, but of the four answers, this is the only
question worthy of asking. Answer A is incorrect because the identification of each fetus
in a multiple birth may be documented in many ways, but in ICD-10 we apply
corresponding numbers to each fetus. This is clear in the notes with the code. C is
incorrect because a knot in the umbilical cord indicates a compression. This is clear in
the inclusion notes under O69.2 Labor and delivery complicated by other cord
entanglement, with compression. The inclusion term reads, "Labor and delivery
complicated by knot in cord." D is incorrect because the Includes note under O60
defines preterm labor as onset (spontaneous) of labor before 37 completed weeks of
gestation." No query is necessary.
Question 7
The provider states that the patient is hypertensive and is interested in beginning a diet.
He discusses weight loss strategies, but does not document that the patient is
overweight, obese or morbidly obese. BMI documented in the vitals is 42, blood
pressure 145/82. The patient receives a prescription for amlodipine. You:
A. Report the BMI, obesity and the hypertension codes because the provider did not
document morbid obesity but did discuss weight loss.
B. Report BMI, hypertension and morbid obesity because a 42 BMI translates to morbid
obesity.
C. Code only the hypertension code.
D. Query the provider, asking if there is a diagnosis to go with the weight loss strategy
counseling that was performed. - Correct Answers -D. Query the provider, asking if
there is a diagnosis to go with the weight loss strategy counseling that was performed..
We cannot extrapolate from the BMI a code related to weight. The weight disorder must
be documented. While C would be the correct selection in a scenario without the ability
to query, we will seek information when possible if it helps complete the clinical picture.
Question 8
As the provider was treating actinic keratoses of the patient's face and neck with
cryosurgery, the liquid nitrogen canister misfired, inadvertently burning the patient's
ANSWERS
The best approach when querying a physician regarding documentation is to approach
the problem as one of:
I. Evidence based medicine
II. Financial motive
III. Malpractice liability
IV. Documentation impact on reimbursement
V. Documentation impact on compliance
A. ll, IV, and V
B. I, II, III, IV, and V
C. I, II, and IV
D. IV and V - Correct Answers -Depending on the documentation issue, any of these
responses might be appropriate. Failing to address flaws in documentation can result in
medical errors, financial losses and diminished patient care.
Clinical Documentation Improvement (CDI) programs can help:
I. Build effective documentation compliance policies
II. Capture clinical data required for continuity of care
III. Promote failures identified in documentation review
A. I and III
B. I, II and III
C. II and III
D. I and II - Correct Answers -I and II
I. Build effective documentation compliance policies
II. Capture clinical data required for continuity of care
An effective CDI program never emphasizes failures; it promotes continuity of care and
development of effective CDI policies.
Question 2
Which of the following documentation deficiencies have a negative impact on patient
outcomes?
A. Failure to indicate the patient's insurance information.
B. Failure to include the complications of drug for prescriptions taken by a patient.
C. Failure to sign the patient's documented review of systems when obtaining a history.
,D. Failure to report the patient's employment in the social history. - Correct Answers -B.
Failure to include the complications of drug for prescriptions taken by a patient.
All answer options are documentation deficiencies. The only deficiency that would affect
the care of the patient is failure to communicate drug interactions that could harm a
patient caused by prescription drugs they are given.
Question 4
A physician who specializes in elder care undergoes a CDI audit. Fifteen charts are
found with the diagnosis of marasmus. Your correct response:
A. Congratulate the physician for correctly capturing an often-overlooked malnutrition
diagnosis.
B. 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.
C. Report code E41
D. Report code R54 - Correct Answers -B. 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 provider did not link the age of the patient to the marasmus, so we cannot report
R54. E41 describes a form of marasmus usually associated with children who are
protein deficient. Because of the ambiguity of the diagnosis, you would not select A. The
correct answer is B, to provide the Index entries for the provider to view, so that he
might choose the code he intended.
Question 5
The best approach when querying a physician regarding documentation is to approach
the problem as one of:
I. Evidence based medicine
II. Financial motive
III. Malpractice liability
IV. Documentation impact on reimbursement
V. Documentation impact on compliance
A. ll, IV, and V
B. I, II, III, IV, and V
C. I, II, and IV
D. IV and V - Correct Answers -B. I, II, III, IV, and V
Depending on the documentation issue, any of these responses might be appropriate.
Failing to address flaws in documentation can result in medical errors, financial losses
and diminished patient care.
Question 6
According to documentation, A 34-week gestation patient with diabetes delivers twins.
Fetus A was delivered without complication, with APGARs of 8 and 8. Fetus B's delivery
, was complicated by a knot in the umbilical cord, and his APGARs were 3 and 5. Which
query is appropriate?
A. For ICD-10 coding purposes, is Fetus A the same as Fetus 1, and Fetus B the same
as Fetus 2?
B. What type of diabetes did the patient have?
C. Was the knotted cord in Fetus B compressed?
D. Does a delivery at 34 weeks indicate prematurity in fetus A and B? - Correct Answers
-B. What type of diabetes did the patient have?
The correct answer is B, "What type of diabetes did the patient have?" This is pertinent
because gestational, type 1 and type 2 diabetes are mutually exclusive. There is a
default for unspecified diabetes in pregnancy, but of the four answers, this is the only
question worthy of asking. Answer A is incorrect because the identification of each fetus
in a multiple birth may be documented in many ways, but in ICD-10 we apply
corresponding numbers to each fetus. This is clear in the notes with the code. C is
incorrect because a knot in the umbilical cord indicates a compression. This is clear in
the inclusion notes under O69.2 Labor and delivery complicated by other cord
entanglement, with compression. The inclusion term reads, "Labor and delivery
complicated by knot in cord." D is incorrect because the Includes note under O60
defines preterm labor as onset (spontaneous) of labor before 37 completed weeks of
gestation." No query is necessary.
Question 7
The provider states that the patient is hypertensive and is interested in beginning a diet.
He discusses weight loss strategies, but does not document that the patient is
overweight, obese or morbidly obese. BMI documented in the vitals is 42, blood
pressure 145/82. The patient receives a prescription for amlodipine. You:
A. Report the BMI, obesity and the hypertension codes because the provider did not
document morbid obesity but did discuss weight loss.
B. Report BMI, hypertension and morbid obesity because a 42 BMI translates to morbid
obesity.
C. Code only the hypertension code.
D. Query the provider, asking if there is a diagnosis to go with the weight loss strategy
counseling that was performed. - Correct Answers -D. Query the provider, asking if
there is a diagnosis to go with the weight loss strategy counseling that was performed..
We cannot extrapolate from the BMI a code related to weight. The weight disorder must
be documented. While C would be the correct selection in a scenario without the ability
to query, we will seek information when possible if it helps complete the clinical picture.
Question 8
As the provider was treating actinic keratoses of the patient's face and neck with
cryosurgery, the liquid nitrogen canister misfired, inadvertently burning the patient's
