CDEO EXAM PREP QUESTIONS WITH CORRECT
ANSWERS NEW MODIFIED TESTED AND
APPROVED 2026 LATEST UPGRADE
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. --CORRECT ANSWER--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.
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. --CORRECT ANSWER--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.
Page 1 of 98
,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. --
CORRECT ANSWER--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.
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. --CORRECT ANSWER--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.
Which of the following is/are considered a purpose of documentation improvement
programs?
I. Improve patient outcomes.
Page 2 of 98
,II. Prepare physicians to provide documentation that supports quality measures.
III. Promote coding lower level services.
IV. Improve the provider query process. --CORRECT ANSWER--I, II, and IV
It is appropriate to work towards proper reimbursement but the goal of CDI should never be
increasing or lowering revenue.
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.
Page 3 of 98
, 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.
Page 4 of 98
ANSWERS NEW MODIFIED TESTED AND
APPROVED 2026 LATEST UPGRADE
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. --CORRECT ANSWER--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.
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. --CORRECT ANSWER--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.
Page 1 of 98
,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. --
CORRECT ANSWER--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.
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. --CORRECT ANSWER--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.
Which of the following is/are considered a purpose of documentation improvement
programs?
I. Improve patient outcomes.
Page 2 of 98
,II. Prepare physicians to provide documentation that supports quality measures.
III. Promote coding lower level services.
IV. Improve the provider query process. --CORRECT ANSWER--I, II, and IV
It is appropriate to work towards proper reimbursement but the goal of CDI should never be
increasing or lowering revenue.
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.
Page 3 of 98
, 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.
Page 4 of 98
