CDEO Exam Prep exam with correct
answers
c. |To |facilitate |optimum |patient |care
The |central |focus |of |all |clinical |documentation |should |be |to |demonstrate |the |quality |of |care |provided
|to |the |patient |with |detail |and |accuracy |to |facilitate |optimum |patient |care. |- |✔✔💯What |is |the
|central |focus |of |clinical |documentation?
a. |Protection |against |mal-practice |claims
b. |Communication |to |office |staff |and |other |departments |about |the |patient's |care
c. |To |facilitate |optimum |patient |care
d. |Communication |to |other |the |providers |and |ancillary |personnel |concerning |the |patient |encounter
d. |No, |CDEOs |review |records |on |a |proactive |basis |to |prevent |documentation |deficiencies
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. |See |Page |1 |- |✔✔💯The |CDEO
|will |focus |his |or |her |attention |on |records |requested |for |post |payment |review.
a. |Yes, |CDEOs |only |review |records |that |might |be |an |audit |concern |and |require |physician |education.
b. |Yes, |CDEOs |only |review |records |for |paid |claims |by |government |payers.
c. |No, |CDEOs |do |not |review |records |unless |it |is |requested |by |the |compliance |officier.
d. |No, |CDEOs |review |records |on |a |proactive |basis |to |prevent |documentation |deficiencies
c. |Prevent |deficient |documentation
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. |-
|✔✔💯The |CDEO |will |review |the |findings |of |the |auditor |in |order |to:
a. |Reprocess |claims
b. |Make |an |addendum |to |the |medical |record
c. |Prevent |deficient |documentation
d. |Know |what |accounts |should |be |adjusted |off
I, |II, |III, |and |IV
,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. |-
|✔✔💯Which |of |the |following |sources |other |than |federal |healthcare |plans |may |request |the |medical
|records?
I. |Patients
II. |Providers |involved |with |the |patient's |care
III. |Employers |for |worker's |compensation |claims
IV. |Private |payers
a. |The |appropriateness |of |the |services |provided
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. |- |✔✔💯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:
a. |The |appropriateness |of |the |services |provided
b. |The |patient's |certificate |of |birth
c. |The |identity |of |the |patient's |extended |family
d. |The |cost |of |healthcare |benefits |used |for |the |year.
c. |Detailed, |well |documented |notes
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. |- |✔✔💯A
|provider's |best |defense |in |any |legal |situation |is:
a. |Patient |records |maintained |for |five |years
b. |An |experienced |healthcare |attorney
c. |Detailed, |well |documented |notes
d. |Updated |computer |storage |systems
c. |During |the |encounter |or |as |soon |as |possible
,The |best |way |to |achieve |the |most |accurate, |detailed |documentation |is |for |the |provider |to |document
|the |encounter/services |as |soon |as |possible |after |(if |not |during) |the |encounter. |- |✔✔💯To |maintain
|an |accurate |medical |record, |what |is |the |recommended |appropriate |time |for |provider
|documentation?
a. |Within |48 |hours |of |patient |visit
b. |A |minimum |of |bi-weekly
c. |During |the |encounter |or |as |soon |as |possible
d. |The |end |of |each |day |for |all |encounters |that |day
d. |If |it |is |documented |in |the |patient's |medical |record
Quality |assurance |in |patient |care |is |only |evident |if |it |is |documented |in |the |medical |record. |Quality
|services |may |have |been |provided; |however, |if |this |is |not |evident |within |the |medical |record, |problems
|may |arise. |- |✔✔💯Quality |assurance |of |patient |care |is |only |evident |if:
a. |The |patient |maintains |a |state |of |optimum |health
b. |Visits |are |only |required |for |well-checks |or |injury
c. |The |patient |survey |and |ROS |does |not |change
d. |If |it |is |documented |in |the |patient's |medical |record
b. |Documentation |reviews |can |be |performed |on |a |prospective |basis.
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. |-
|✔✔💯Which |of |the |following |statements |is |TRUE |regarding |clinical |documentation |improvement
|efforts?
a. |Documentation |reviews |should |be |limited |to |the |costliest |chronic |conditions |to |treat.
b. |Documentation |reviews |can |be |performed |on |a |prospective |basis.
c. |Documentation |reviews |must |be |completed |yearly.
d. |Documentation |reviews |require |access |to |the |denial |data.
a. |It |encourages |physician |participation.
Getting |physicians |involved |in |CDI |helps |to |gain |physician |buy |in |and |encourages |other |physicians |to
|participate |and |is |a |great |way |to |educate |physicians. |- |✔✔💯Why |is |it |important |to |involve
|physicians |in |Clinical |Documentation |Improvement |(CDI) |programs?
a. |It |encourages |physician |participation.
b. |It |helps |justify |the |need |for |CDI |programs.
, c. |It |will |eliminate |the |need |to |query |providers.
d. |It |will |help |providers |time |management.
b. |Failure |to |include |the |instructions |for |post |procedure |care |and |potential |complications.
Although |all |the |choices |are |deficiencies |in |capturing |patient |information, |failure |to |inform |a |patient
|of |potential |post-operative |complications |could |impact |the |patient's |recovery. |In |this |question, |you
|are |determining |the |option |that |affects |clinical |care |of |the |patient. |- |✔✔💯Which |of |the |following
|documentation |deficiencies |has |a |negative |impact |on |patient |outcomes?
a. |Failure |to |indicate |the |date |of |the |patient's |last |blood |test.
b. |Failure |to |include |the |instructions |for |post |procedure |care |and |potential |complications.
c. |Failure |to |sign |the |patient's |medical |records |provided |by |another |physician.
d. |Failure |to |report |the |patient's |pharmacy |preference |for |insurance |participation.
d. |Provide |examples |of |the |provider's |documentation |deficiencies |with |suggestions |for |improvement.
Effective |provider |education |regarding |documentation |deficiencies |is |to |provide |examples |of |the
|physician's |documentation |deficiency |and |feedback |and |tips |on |how |to |correct |the |deficiency. |-
|✔✔💯What |is |an |effective |method |for |communicating |documentation |deficiencies |to |a |provider?
a. |Provide |documentation |tips |for |the |most |common |chronic |conditions |treated.
b. |Provide |the |documentation |deficiency |report |quarterly.
c. |Provide |a |report |to |the |medical |director |that |includes |the |findings |for |all |the |providers |in |the
|practice.
d. |Provide |examples |of |the |provider's |documentation |deficiencies |with |suggestions |for |improvement.
I, |II, |and |IV
It |is |appropriate |to |work |towards |proper |reimbursement |but |the |goal |of |CDI |should |never |be
|increasing |or |lowering |revenue. |- |✔✔💯Which |of |the |following |is/are |considered |a |purpose |of
|documentation |improvement |programs?
I. |Improve |patient |outcomes.
II. |Prepare |physicians |to |provide |documentation |that |supports |quality |measures.
III. |Promote |coding |lower |level |services.
IV. |Improve |the |provider |query |process.
c. |Provide |a |detailed |record |of |the |care |provided |to |the |patient.
The |main |goal |for |detailed |medical |records |is |to |promote |the |continuity |of |care |for |the |patient. |This
|allows |providers |to |communicate |- |✔✔💯How |can |an |effective |CDI |program |improve |patient
|outcomes?
answers
c. |To |facilitate |optimum |patient |care
The |central |focus |of |all |clinical |documentation |should |be |to |demonstrate |the |quality |of |care |provided
|to |the |patient |with |detail |and |accuracy |to |facilitate |optimum |patient |care. |- |✔✔💯What |is |the
|central |focus |of |clinical |documentation?
a. |Protection |against |mal-practice |claims
b. |Communication |to |office |staff |and |other |departments |about |the |patient's |care
c. |To |facilitate |optimum |patient |care
d. |Communication |to |other |the |providers |and |ancillary |personnel |concerning |the |patient |encounter
d. |No, |CDEOs |review |records |on |a |proactive |basis |to |prevent |documentation |deficiencies
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. |See |Page |1 |- |✔✔💯The |CDEO
|will |focus |his |or |her |attention |on |records |requested |for |post |payment |review.
a. |Yes, |CDEOs |only |review |records |that |might |be |an |audit |concern |and |require |physician |education.
b. |Yes, |CDEOs |only |review |records |for |paid |claims |by |government |payers.
c. |No, |CDEOs |do |not |review |records |unless |it |is |requested |by |the |compliance |officier.
d. |No, |CDEOs |review |records |on |a |proactive |basis |to |prevent |documentation |deficiencies
c. |Prevent |deficient |documentation
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. |-
|✔✔💯The |CDEO |will |review |the |findings |of |the |auditor |in |order |to:
a. |Reprocess |claims
b. |Make |an |addendum |to |the |medical |record
c. |Prevent |deficient |documentation
d. |Know |what |accounts |should |be |adjusted |off
I, |II, |III, |and |IV
,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. |-
|✔✔💯Which |of |the |following |sources |other |than |federal |healthcare |plans |may |request |the |medical
|records?
I. |Patients
II. |Providers |involved |with |the |patient's |care
III. |Employers |for |worker's |compensation |claims
IV. |Private |payers
a. |The |appropriateness |of |the |services |provided
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. |- |✔✔💯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:
a. |The |appropriateness |of |the |services |provided
b. |The |patient's |certificate |of |birth
c. |The |identity |of |the |patient's |extended |family
d. |The |cost |of |healthcare |benefits |used |for |the |year.
c. |Detailed, |well |documented |notes
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. |- |✔✔💯A
|provider's |best |defense |in |any |legal |situation |is:
a. |Patient |records |maintained |for |five |years
b. |An |experienced |healthcare |attorney
c. |Detailed, |well |documented |notes
d. |Updated |computer |storage |systems
c. |During |the |encounter |or |as |soon |as |possible
,The |best |way |to |achieve |the |most |accurate, |detailed |documentation |is |for |the |provider |to |document
|the |encounter/services |as |soon |as |possible |after |(if |not |during) |the |encounter. |- |✔✔💯To |maintain
|an |accurate |medical |record, |what |is |the |recommended |appropriate |time |for |provider
|documentation?
a. |Within |48 |hours |of |patient |visit
b. |A |minimum |of |bi-weekly
c. |During |the |encounter |or |as |soon |as |possible
d. |The |end |of |each |day |for |all |encounters |that |day
d. |If |it |is |documented |in |the |patient's |medical |record
Quality |assurance |in |patient |care |is |only |evident |if |it |is |documented |in |the |medical |record. |Quality
|services |may |have |been |provided; |however, |if |this |is |not |evident |within |the |medical |record, |problems
|may |arise. |- |✔✔💯Quality |assurance |of |patient |care |is |only |evident |if:
a. |The |patient |maintains |a |state |of |optimum |health
b. |Visits |are |only |required |for |well-checks |or |injury
c. |The |patient |survey |and |ROS |does |not |change
d. |If |it |is |documented |in |the |patient's |medical |record
b. |Documentation |reviews |can |be |performed |on |a |prospective |basis.
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. |-
|✔✔💯Which |of |the |following |statements |is |TRUE |regarding |clinical |documentation |improvement
|efforts?
a. |Documentation |reviews |should |be |limited |to |the |costliest |chronic |conditions |to |treat.
b. |Documentation |reviews |can |be |performed |on |a |prospective |basis.
c. |Documentation |reviews |must |be |completed |yearly.
d. |Documentation |reviews |require |access |to |the |denial |data.
a. |It |encourages |physician |participation.
Getting |physicians |involved |in |CDI |helps |to |gain |physician |buy |in |and |encourages |other |physicians |to
|participate |and |is |a |great |way |to |educate |physicians. |- |✔✔💯Why |is |it |important |to |involve
|physicians |in |Clinical |Documentation |Improvement |(CDI) |programs?
a. |It |encourages |physician |participation.
b. |It |helps |justify |the |need |for |CDI |programs.
, c. |It |will |eliminate |the |need |to |query |providers.
d. |It |will |help |providers |time |management.
b. |Failure |to |include |the |instructions |for |post |procedure |care |and |potential |complications.
Although |all |the |choices |are |deficiencies |in |capturing |patient |information, |failure |to |inform |a |patient
|of |potential |post-operative |complications |could |impact |the |patient's |recovery. |In |this |question, |you
|are |determining |the |option |that |affects |clinical |care |of |the |patient. |- |✔✔💯Which |of |the |following
|documentation |deficiencies |has |a |negative |impact |on |patient |outcomes?
a. |Failure |to |indicate |the |date |of |the |patient's |last |blood |test.
b. |Failure |to |include |the |instructions |for |post |procedure |care |and |potential |complications.
c. |Failure |to |sign |the |patient's |medical |records |provided |by |another |physician.
d. |Failure |to |report |the |patient's |pharmacy |preference |for |insurance |participation.
d. |Provide |examples |of |the |provider's |documentation |deficiencies |with |suggestions |for |improvement.
Effective |provider |education |regarding |documentation |deficiencies |is |to |provide |examples |of |the
|physician's |documentation |deficiency |and |feedback |and |tips |on |how |to |correct |the |deficiency. |-
|✔✔💯What |is |an |effective |method |for |communicating |documentation |deficiencies |to |a |provider?
a. |Provide |documentation |tips |for |the |most |common |chronic |conditions |treated.
b. |Provide |the |documentation |deficiency |report |quarterly.
c. |Provide |a |report |to |the |medical |director |that |includes |the |findings |for |all |the |providers |in |the
|practice.
d. |Provide |examples |of |the |provider's |documentation |deficiencies |with |suggestions |for |improvement.
I, |II, |and |IV
It |is |appropriate |to |work |towards |proper |reimbursement |but |the |goal |of |CDI |should |never |be
|increasing |or |lowering |revenue. |- |✔✔💯Which |of |the |following |is/are |considered |a |purpose |of
|documentation |improvement |programs?
I. |Improve |patient |outcomes.
II. |Prepare |physicians |to |provide |documentation |that |supports |quality |measures.
III. |Promote |coding |lower |level |services.
IV. |Improve |the |provider |query |process.
c. |Provide |a |detailed |record |of |the |care |provided |to |the |patient.
The |main |goal |for |detailed |medical |records |is |to |promote |the |continuity |of |care |for |the |patient. |This
|allows |providers |to |communicate |- |✔✔💯How |can |an |effective |CDI |program |improve |patient
|outcomes?
