CDEO EXAM PREP QUESTIONS WITH
COMPLETE SOLUTIONS 2024
How can an effective CDI program improve patient outcomes?
a. Maximize the reimbursement received.
b. Prohibit claim processing errors.
c. Provide a detailed record of the care provided to the patient.
d. Allow providers to support higher levels of E/M services.
Correct Answer 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
Which of the following recommendations should be made to
providers regarding the patient's problem list?
a. Significant changes should be documented at each encounter.
b. Problem lists consists of all past medical complications.
c. Problem lists should only be used if the patient has at least on
chronic illness.
d. Significant changes should be documented once a year.
Correct Answer a. Significant changes should be documented at
each encounter.
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.
Failure to document which of the following statements could lead
to a negative patient outcome?
a. Allergies: PCN
,b. Patient denies loss of appetite or vomiting.
c. Patient has remained on her diet.
d. Patient indicates her daughter lives with her to assist in her
care. Correct Answer a. Allergies: PCN
Failure to document an allergy could lead to an allergic reaction if
the provider prescribes a medication not realizing the patient is
allergic.
What is a documentation challenge for services provided by
providers in an inpatient facility?
a. Documentation may not include the progress note for a
subsequent inpatient encounter.
b. Documentation deficiencies may not be identified until after the
provider has left.
c. Providers may not have access to the entire record for the
inpatient stay.
d. Providers may not have access to the hospital EHR to
document the inpatient encounters. Correct Answer b.
Documentation deficiencies may not be identified until after the
provider has left.
Maintaining consistent and quality documentation can be difficult
in the inpatient setting because deficiencies may not be identified
until after the provider has left the facility.
Adhering to the CMS Documentation Guidelines for E/M services
will meet the clinical documentation requirements for all
encounters.
a. Yes, E/M documentation guidelines help the provider document
all requirements needed for a detailed record.
b. Yes, CDI is a proactive approach to ensure E/M services are
reimbursed correctly.
c. No, the CMS documentation guidelines provide the least
expected documentation to support a visit.
d. No, CDI programs do not include monitoring of the correct
coding of E/M services. Correct Answer c. No, the CMS
,documentation guidelines provide the least expected
documentation to support a visit.
The basic CMS documentation guidelines for E/M services
include the least expected documentation to support an
encounter. Quality is going above and beyond the basic
information.
What are some common documentation deficiencies? I. Incorrect
dates of service
II. Misspelled words
III. Inconsistencies within the record
IV. Incomplete dictation
V. Missing orders for diagnostic tests Correct Answer I, II, III, IV,
V
When initiating a CDI program, which of the following statements
is TRUE?
a. Focus on services with the highest reimbursement
b. Focus on the highest risk area
c. Focus on chronic illnesses
d. Focus on preventive medicine services Correct Answer b.
Focus on the highest risk area
For a CDI program to be effective, the CDEO should focus on
correction of documentation deficiencies for identified risk areas
specific to the practice.
What type of health plan is exempt from HIPAA?
a. Health maintenance organizations
b. Government insurers
c. Church-sponsored group health plans
d. Employer who solely establishes and maintains the plan with
fewer than 50 participants. Correct Answer d. Employer who
solely establishes and maintains the plan with fewer than 50
participants.
, What standards are set by the Privacy Rule set?
a. Pre-existing standards
b. Group health standards
c. Transaction and code set standards
d. Standards for how protected health information is used Correct
Answer d. Standards for how protected health information is
used.
Which option would be excluded from an individual's right to
access their PHI?
a. Psychotherapy notes
b. Family practice notes
c. Emergency department notes
d. Operative reports Correct Answer a. Psychotherapy notes.
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.
When a correction is made in an electronic health record, what
must exist?
a. Identity of a witness to the correction made in the electronic
health record.
b. The entire medical record duplicated with the corrections only
made to the duplication.
c. Reliable means to clearly identify the original content and the
modified content.
d. There are no requirements for corrections to electronic medical
records. Correct Answer c. Reliable means to clearly identify the
original content and the modified content.
For electronic health records (EHR), the amendment, correction,
or delayed entry must be distinctly identified. There must also be
a way to provide a reliable means to clearly identify the original
content and the modified content. The person altering the record
and the date of the revision, amendment, or addenda must also
be documented.
COMPLETE SOLUTIONS 2024
How can an effective CDI program improve patient outcomes?
a. Maximize the reimbursement received.
b. Prohibit claim processing errors.
c. Provide a detailed record of the care provided to the patient.
d. Allow providers to support higher levels of E/M services.
Correct Answer 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
Which of the following recommendations should be made to
providers regarding the patient's problem list?
a. Significant changes should be documented at each encounter.
b. Problem lists consists of all past medical complications.
c. Problem lists should only be used if the patient has at least on
chronic illness.
d. Significant changes should be documented once a year.
Correct Answer a. Significant changes should be documented at
each encounter.
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.
Failure to document which of the following statements could lead
to a negative patient outcome?
a. Allergies: PCN
,b. Patient denies loss of appetite or vomiting.
c. Patient has remained on her diet.
d. Patient indicates her daughter lives with her to assist in her
care. Correct Answer a. Allergies: PCN
Failure to document an allergy could lead to an allergic reaction if
the provider prescribes a medication not realizing the patient is
allergic.
What is a documentation challenge for services provided by
providers in an inpatient facility?
a. Documentation may not include the progress note for a
subsequent inpatient encounter.
b. Documentation deficiencies may not be identified until after the
provider has left.
c. Providers may not have access to the entire record for the
inpatient stay.
d. Providers may not have access to the hospital EHR to
document the inpatient encounters. Correct Answer b.
Documentation deficiencies may not be identified until after the
provider has left.
Maintaining consistent and quality documentation can be difficult
in the inpatient setting because deficiencies may not be identified
until after the provider has left the facility.
Adhering to the CMS Documentation Guidelines for E/M services
will meet the clinical documentation requirements for all
encounters.
a. Yes, E/M documentation guidelines help the provider document
all requirements needed for a detailed record.
b. Yes, CDI is a proactive approach to ensure E/M services are
reimbursed correctly.
c. No, the CMS documentation guidelines provide the least
expected documentation to support a visit.
d. No, CDI programs do not include monitoring of the correct
coding of E/M services. Correct Answer c. No, the CMS
,documentation guidelines provide the least expected
documentation to support a visit.
The basic CMS documentation guidelines for E/M services
include the least expected documentation to support an
encounter. Quality is going above and beyond the basic
information.
What are some common documentation deficiencies? I. Incorrect
dates of service
II. Misspelled words
III. Inconsistencies within the record
IV. Incomplete dictation
V. Missing orders for diagnostic tests Correct Answer I, II, III, IV,
V
When initiating a CDI program, which of the following statements
is TRUE?
a. Focus on services with the highest reimbursement
b. Focus on the highest risk area
c. Focus on chronic illnesses
d. Focus on preventive medicine services Correct Answer b.
Focus on the highest risk area
For a CDI program to be effective, the CDEO should focus on
correction of documentation deficiencies for identified risk areas
specific to the practice.
What type of health plan is exempt from HIPAA?
a. Health maintenance organizations
b. Government insurers
c. Church-sponsored group health plans
d. Employer who solely establishes and maintains the plan with
fewer than 50 participants. Correct Answer d. Employer who
solely establishes and maintains the plan with fewer than 50
participants.
, What standards are set by the Privacy Rule set?
a. Pre-existing standards
b. Group health standards
c. Transaction and code set standards
d. Standards for how protected health information is used Correct
Answer d. Standards for how protected health information is
used.
Which option would be excluded from an individual's right to
access their PHI?
a. Psychotherapy notes
b. Family practice notes
c. Emergency department notes
d. Operative reports Correct Answer a. Psychotherapy notes.
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.
When a correction is made in an electronic health record, what
must exist?
a. Identity of a witness to the correction made in the electronic
health record.
b. The entire medical record duplicated with the corrections only
made to the duplication.
c. Reliable means to clearly identify the original content and the
modified content.
d. There are no requirements for corrections to electronic medical
records. Correct Answer c. Reliable means to clearly identify the
original content and the modified content.
For electronic health records (EHR), the amendment, correction,
or delayed entry must be distinctly identified. There must also be
a way to provide a reliable means to clearly identify the original
content and the modified content. The person altering the record
and the date of the revision, amendment, or addenda must also
be documented.
