CDEO Exam Prep QUESTIONS WITH 100%VERIFIED
SOLUTIONS|WITH RATIONALES
What must be included in a business associate agreement? a.
The name of each person who will see the PHI.
b. The permitted and required uses of PHI by the business associate.
c. Each record that is shared with the business associate must be identified individually,
included names and dates of service.
d. There are no requirements for what is included in the business associate agreement.
- ANSWER b. The permitted and required uses of PHI by the business associate.
When documenting physical therapy treatment encounter for Medicare, what should be
documented for the modalities?
a. Each individual modality used with total duration of time in minutes
b. A list of all modalities considered for treatment
c. Additional modalities used outside of the treatment plan and why they were used
d. Modalities expected to be used on the next treatment date - ANSWER a. Each
individual modality used with total duration of time in minutes.
Treatment encounter notes for each treatment day and should include: · Date of
treatment
· Treatment, intervention, or activity
· Total timed treatment by individual modality and total treatment time in minutes
(includes timed codes and untimed codes)
· Signature and professional identity of the qualified professional furnishing the
treatment
· Additional information may include response to treatment or changes.
What is the Health Care Fraud and Abuse Control Program?
a. A program that keeps track of the financial success of each of the Fraud and Abuse
programs run by the US government.
b. A program established by HIPAA to combat fraud and abuse in healthcare.
c. The OIG's Health Care Fraud Prevention and Enforcement Team.
d. A program established by the OIG to create sample compliance plans. - ANSWER b.
A program established by HIPAA to combat fraud and abuse in healthcare.
When a minor procedure is performed in the office, what is the documentation
requirement?
a. A formal operative report must be documented.
b. A reference to the operation without the detail can be included in the documentation
for the office visit.
c. The detail of the procedure can be included in the documentation for the office visit.
,d. The surgery is not required to be documented if it is performed during an evaluation
and management service. - ANSWER c. The detail of the procedure can be included in
the documentation for the office visit.
What is considered protected health information (PHI)? a.
Individually identifiable health information
b. Health information that is randomly gathered for research purposes
c. Statistical information relating to a specific demographic area
d. Provider information submitted on a claim for payment - ANSWER a. Individually
identifiable health information
When is incidental use and disclosure of PHI permitted?
a. When there is authorization from the individual whose information is shared.
b. When there is retribution for the use and disclosure.
c. When the covered entity has reasonable safeguards in place to ensure the
information shared is being limited to the minimum necessary.
d. When the covered entity has policies and procedures in place to identify each person
who has incidentally had access to the record. - ANSWER c. When the covered
entity has reasonable safeguards in place to ensure the information shared is being
limited to the minimum necessary.
What are healthcare institutions to do in the absence of clearly defined laws
and regulations relating to the content of a medical record? a. Establish their
own standards
b. Not put any in place
c. Call HHS and ask for clarification
d. Continue practicing without guidance until an issue arises - ANSWER a. Establish
their own standards
Which section of an operative report would you expect to find the reason or
medical necessity for the procedure? a. Indication for surgery
b. Body of the operative report
c. Findings
d. In the office visit prior to the surgery - ANSWER a. Indication for surgery
According to the Joint Commission (JC) Official "Do Not Use" List, what would be
considered an abbreviation that should not be used in a medical record and why?
a. IU; because it can be mistaken for IV or the number 10.
b. HTN; because there should be more specification on the type of hypertension.
c. PRN; because it may be misunderstood to be a privacy issue.
d. IV; because it can be mistaken for IU. - ANSWER a. IU; because it can be mistaken
for IV or the number 10.
In an operative note, where should information be taken to ensure accurate assignment
,of a CPT® code?
a. From the header, where the title of the planned surgery is listed.
b. From the body of the operative note
c. From the OR schedule, based on how the procedure was scheduled by the
physician.
d. From the findings area of the report - ANSWER b. From the body of the operative
note
What program was established by HIPAA to combat fraud and abuse committed
against all health plans, both public and private?
a. Health and Human Services Fraud Prevention Program
b. Compliance Program
c. OIG HEAT
d. Health Care Fraud and Abuse Control Program - ANSWER d. Health Care Fraud
and Abuse Control Program
How long does HIPAA require medical records to be maintained?
a. Five years from the date of its creation or the date from which it was last in effect
(whichever is later).
b. Six years from the date of its creation or the date from which it was last in effect
(whichever is later).
c. Ten years from the date of its creation or the date from which it was last in effect
(whichever is later).
d. Five years past the date of death of the patient. - ANSWER b. Six years from
the date of its creation or the date from which it was last in effect (whichever is later).
Which type of provider is not required to dictate his or her own operative report? a.
Primary surgeon
b. Co-surgeon
c. Surgeons in a surgical team
d. Assistant surgeon - ANSWER d. Assistant surgeon
Each provider involved in a surgical case is expected to document the portion of the
surgical procedure they performed with the exception of a surgical assistant. When a
surgery requires the help of a surgical assistant, the primary surgeon documents the
operative report. The primary surgeon should clearly explain in the indications section of
the note why an assistant was necessary, and what the assistant surgeon performed
that required the assistance.
What information does a privacy practice notice contain?
a. Elements to notify individuals as to how the covered entity will use and disclose the
PHI.
b. Notification of each person who has access to their record and what access level
they will have.
c. Notification of when their payments have been received from the insurance carrier.
, d. Elements contained on a claim form sent to the patient's insurance carrier. -
ANSWER a. Elements to notify individuals as to how the covered entity will use and
disclose the PHI.
What form is used to allow the release of their medical records?
a. Assignment of benefits
b. Release of information
c. Informed consent
d. Patient registration form - ANSWER b. Release of information
For therapy services, what is the reason for a progress note? a.
To indicate services were performed
b. To provide justification for the medical necessity of treatment
c. To serve as the plan of care
d. To serve as the re-certification - ANSWER b. To provide justification for the medical
necessity of treatment
What is identified in the indications portion of an operative note? a.
Specific details about the surgery.
b. A brief history outlining the medical necessity for the procedure.
c. The outcome of the surgical procedure.
d. The provider and anesthesiologist performing the surgery. - ANSWER b. A brief
history outlining the medical necessity for the procedure.
What form is required to be obtained from the patient prior to a surgical procedure?
a. Assignment of benefits
b. Advanced beneficiary notice
c. Release of information
d. Informed consent - ANSWER d. Informed consent
Which governing body is responsible for criminal prosecutions relating to the Privacy
Rule?
a. Office of Civil Rights
b. Secretary of State
c. Office of Inspector General
d. Department of Justice - ANSWER d. Department of Justice
Under what circumstance may providers use or disclose protected health information
without patient consent?
a. Advertising of the entity's services
b. Payment, treatment, or operations
c. Request from a spouse or another family member
d. Request from a neighbor or close friend - ANSWER b. Payment, treatment, or
SOLUTIONS|WITH RATIONALES
What must be included in a business associate agreement? a.
The name of each person who will see the PHI.
b. The permitted and required uses of PHI by the business associate.
c. Each record that is shared with the business associate must be identified individually,
included names and dates of service.
d. There are no requirements for what is included in the business associate agreement.
- ANSWER b. The permitted and required uses of PHI by the business associate.
When documenting physical therapy treatment encounter for Medicare, what should be
documented for the modalities?
a. Each individual modality used with total duration of time in minutes
b. A list of all modalities considered for treatment
c. Additional modalities used outside of the treatment plan and why they were used
d. Modalities expected to be used on the next treatment date - ANSWER a. Each
individual modality used with total duration of time in minutes.
Treatment encounter notes for each treatment day and should include: · Date of
treatment
· Treatment, intervention, or activity
· Total timed treatment by individual modality and total treatment time in minutes
(includes timed codes and untimed codes)
· Signature and professional identity of the qualified professional furnishing the
treatment
· Additional information may include response to treatment or changes.
What is the Health Care Fraud and Abuse Control Program?
a. A program that keeps track of the financial success of each of the Fraud and Abuse
programs run by the US government.
b. A program established by HIPAA to combat fraud and abuse in healthcare.
c. The OIG's Health Care Fraud Prevention and Enforcement Team.
d. A program established by the OIG to create sample compliance plans. - ANSWER b.
A program established by HIPAA to combat fraud and abuse in healthcare.
When a minor procedure is performed in the office, what is the documentation
requirement?
a. A formal operative report must be documented.
b. A reference to the operation without the detail can be included in the documentation
for the office visit.
c. The detail of the procedure can be included in the documentation for the office visit.
,d. The surgery is not required to be documented if it is performed during an evaluation
and management service. - ANSWER c. The detail of the procedure can be included in
the documentation for the office visit.
What is considered protected health information (PHI)? a.
Individually identifiable health information
b. Health information that is randomly gathered for research purposes
c. Statistical information relating to a specific demographic area
d. Provider information submitted on a claim for payment - ANSWER a. Individually
identifiable health information
When is incidental use and disclosure of PHI permitted?
a. When there is authorization from the individual whose information is shared.
b. When there is retribution for the use and disclosure.
c. When the covered entity has reasonable safeguards in place to ensure the
information shared is being limited to the minimum necessary.
d. When the covered entity has policies and procedures in place to identify each person
who has incidentally had access to the record. - ANSWER c. When the covered
entity has reasonable safeguards in place to ensure the information shared is being
limited to the minimum necessary.
What are healthcare institutions to do in the absence of clearly defined laws
and regulations relating to the content of a medical record? a. Establish their
own standards
b. Not put any in place
c. Call HHS and ask for clarification
d. Continue practicing without guidance until an issue arises - ANSWER a. Establish
their own standards
Which section of an operative report would you expect to find the reason or
medical necessity for the procedure? a. Indication for surgery
b. Body of the operative report
c. Findings
d. In the office visit prior to the surgery - ANSWER a. Indication for surgery
According to the Joint Commission (JC) Official "Do Not Use" List, what would be
considered an abbreviation that should not be used in a medical record and why?
a. IU; because it can be mistaken for IV or the number 10.
b. HTN; because there should be more specification on the type of hypertension.
c. PRN; because it may be misunderstood to be a privacy issue.
d. IV; because it can be mistaken for IU. - ANSWER a. IU; because it can be mistaken
for IV or the number 10.
In an operative note, where should information be taken to ensure accurate assignment
,of a CPT® code?
a. From the header, where the title of the planned surgery is listed.
b. From the body of the operative note
c. From the OR schedule, based on how the procedure was scheduled by the
physician.
d. From the findings area of the report - ANSWER b. From the body of the operative
note
What program was established by HIPAA to combat fraud and abuse committed
against all health plans, both public and private?
a. Health and Human Services Fraud Prevention Program
b. Compliance Program
c. OIG HEAT
d. Health Care Fraud and Abuse Control Program - ANSWER d. Health Care Fraud
and Abuse Control Program
How long does HIPAA require medical records to be maintained?
a. Five years from the date of its creation or the date from which it was last in effect
(whichever is later).
b. Six years from the date of its creation or the date from which it was last in effect
(whichever is later).
c. Ten years from the date of its creation or the date from which it was last in effect
(whichever is later).
d. Five years past the date of death of the patient. - ANSWER b. Six years from
the date of its creation or the date from which it was last in effect (whichever is later).
Which type of provider is not required to dictate his or her own operative report? a.
Primary surgeon
b. Co-surgeon
c. Surgeons in a surgical team
d. Assistant surgeon - ANSWER d. Assistant surgeon
Each provider involved in a surgical case is expected to document the portion of the
surgical procedure they performed with the exception of a surgical assistant. When a
surgery requires the help of a surgical assistant, the primary surgeon documents the
operative report. The primary surgeon should clearly explain in the indications section of
the note why an assistant was necessary, and what the assistant surgeon performed
that required the assistance.
What information does a privacy practice notice contain?
a. Elements to notify individuals as to how the covered entity will use and disclose the
PHI.
b. Notification of each person who has access to their record and what access level
they will have.
c. Notification of when their payments have been received from the insurance carrier.
, d. Elements contained on a claim form sent to the patient's insurance carrier. -
ANSWER a. Elements to notify individuals as to how the covered entity will use and
disclose the PHI.
What form is used to allow the release of their medical records?
a. Assignment of benefits
b. Release of information
c. Informed consent
d. Patient registration form - ANSWER b. Release of information
For therapy services, what is the reason for a progress note? a.
To indicate services were performed
b. To provide justification for the medical necessity of treatment
c. To serve as the plan of care
d. To serve as the re-certification - ANSWER b. To provide justification for the medical
necessity of treatment
What is identified in the indications portion of an operative note? a.
Specific details about the surgery.
b. A brief history outlining the medical necessity for the procedure.
c. The outcome of the surgical procedure.
d. The provider and anesthesiologist performing the surgery. - ANSWER b. A brief
history outlining the medical necessity for the procedure.
What form is required to be obtained from the patient prior to a surgical procedure?
a. Assignment of benefits
b. Advanced beneficiary notice
c. Release of information
d. Informed consent - ANSWER d. Informed consent
Which governing body is responsible for criminal prosecutions relating to the Privacy
Rule?
a. Office of Civil Rights
b. Secretary of State
c. Office of Inspector General
d. Department of Justice - ANSWER d. Department of Justice
Under what circumstance may providers use or disclose protected health information
without patient consent?
a. Advertising of the entity's services
b. Payment, treatment, or operations
c. Request from a spouse or another family member
d. Request from a neighbor or close friend - ANSWER b. Payment, treatment, or
