Certified Documentation Expert–
Outpatient (CDEO) Questions And Correct
Answers (Verified Answers) Plus
Rationales 2026 Q&A
1. Which of the following best reflects the role of a CDEO?
A. Ensures correct coding only
B. Manages billing staff
C. Provides documentation improvement guidance to support
accurate coding
D. Works only with inpatient records
Answer: C
The CDEO focuses on documentation quality to ensure accurate code
assignment and compliance.
2. Which documentation element is required for all E/M visits?
A. Patient's employment
B. Chief complaint
C. Family history
D. Treatment plan
Answer: B
The chief complaint is mandatory for establishing the reason for the
encounter.
3. A provider documents “probable pneumonia” in an outpatient
record. How should this be coded?
,A. Pneumonia
B. Signs/symptoms
C. Ignore the documentation
D. Query the provider
Answer: B
Outpatient coding does not code unconfirmed diagnoses; code
symptoms instead.
4. Which provider type can document a chief complaint?
A. Clinical staff only
B. Providers and ancillary staff
C. Only the rendering provider
D. Coders
Answer: B
Support staff may document the CC, though the provider must
validate the history.
5. A late entry should include:
A. New date only
B. Original date only
C. Both original event date and date of entry
D. No dates
Answer: C
Late entries require clear audit trails with both dates.
6. Which is a required component of medical necessity?
A. Highest-paying code
B. Reasonable and necessary care
C. All tests requested by patient
, D. Billing new patient codes
Answer: B
Medical necessity requires services be reasonable and necessary.
7. A coder notices conflicting documentation between assessments.
What is the correct action?
A. Choose the highest-level diagnosis
B. Ignore conflict
C. Submit a provider query
D. Delete the conflict
Answer: C
Querying supports accuracy and compliance.
8. What is acceptable documentation for a minor procedure?
A. Consent only
B. Chief complaint and past history
C. Indication, the procedure, and outcome
D. No documentation needed
Answer: C
The provider must document the indication, procedure performed,
and findings/results.
9. Which statement about a physician query is correct?
A. Queries must lead the provider
B. Queries may be suggestive
C. Queries must be non-leading
D. Queries can be signed by clinical staff
Answer: C
Queries must be neutral and non-leading.
Outpatient (CDEO) Questions And Correct
Answers (Verified Answers) Plus
Rationales 2026 Q&A
1. Which of the following best reflects the role of a CDEO?
A. Ensures correct coding only
B. Manages billing staff
C. Provides documentation improvement guidance to support
accurate coding
D. Works only with inpatient records
Answer: C
The CDEO focuses on documentation quality to ensure accurate code
assignment and compliance.
2. Which documentation element is required for all E/M visits?
A. Patient's employment
B. Chief complaint
C. Family history
D. Treatment plan
Answer: B
The chief complaint is mandatory for establishing the reason for the
encounter.
3. A provider documents “probable pneumonia” in an outpatient
record. How should this be coded?
,A. Pneumonia
B. Signs/symptoms
C. Ignore the documentation
D. Query the provider
Answer: B
Outpatient coding does not code unconfirmed diagnoses; code
symptoms instead.
4. Which provider type can document a chief complaint?
A. Clinical staff only
B. Providers and ancillary staff
C. Only the rendering provider
D. Coders
Answer: B
Support staff may document the CC, though the provider must
validate the history.
5. A late entry should include:
A. New date only
B. Original date only
C. Both original event date and date of entry
D. No dates
Answer: C
Late entries require clear audit trails with both dates.
6. Which is a required component of medical necessity?
A. Highest-paying code
B. Reasonable and necessary care
C. All tests requested by patient
, D. Billing new patient codes
Answer: B
Medical necessity requires services be reasonable and necessary.
7. A coder notices conflicting documentation between assessments.
What is the correct action?
A. Choose the highest-level diagnosis
B. Ignore conflict
C. Submit a provider query
D. Delete the conflict
Answer: C
Querying supports accuracy and compliance.
8. What is acceptable documentation for a minor procedure?
A. Consent only
B. Chief complaint and past history
C. Indication, the procedure, and outcome
D. No documentation needed
Answer: C
The provider must document the indication, procedure performed,
and findings/results.
9. Which statement about a physician query is correct?
A. Queries must lead the provider
B. Queries may be suggestive
C. Queries must be non-leading
D. Queries can be signed by clinical staff
Answer: C
Queries must be neutral and non-leading.
