CDEO Exam Prep / MOSTLY TESTED QUESTIONS AND CORRECT
DETAILED ANSWERS| 100% CORRECT SOLUTIONS/GRADE A+
Answer Questions
c. To facilitate optimum patient care What is the central focus of clinical
The central focus of all clinical documentation?
documentation should be to demonstrate a. Protection against mal-practice claims
the quality of care provided to the patient b. Communication to office staff and other
with detail and accuracy to facilitate departments about the patient's care
optimum patient 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 The CDEO will focus his or her attention
proactive basis to prevent documentation on records requested for post payment
deficiencies review.
Clinical documentation improvement is a a. Yes, CDEOs only review records that
proactive measure. The CDS will develop might be an audit concern and require
and monitor policies and procedures that physician education.
affect the documentation process. CDI b. Yes, CDEOs only review records for
should begin at the front end of all services paid claims by government payers.
and care. Prevention of documentation c. No, CDEOs do not review records
issues is the key. See Page 1 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
The CDEO will review the findings of the auditor in order to:
auditor to determine what should be done a. Reprocess claims
to resolve documentation the issues on a b. Make an addendum to the medical
proactive basis to prevent documentation record
and compliance risks. c. Prevent deficient documentation
d. Know what accounts should be
adjusted off
I, II, III, and IV Which of the following sources other than
For different reasons other than federal healthcare plans may request the
reimbursement, requests for medical medical records?
records come from different sources, for a I. Patients
multitude of different reasons. A few of II. Providers involved with the patient's
these, other than Federal Health Care care
Plans, are patients who are becoming more III. Employers for worker's compensation
active in their care , attorneys seeking claims
information for third party liability claims or IV. Private payers
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.
a. The appropriateness of the services In addition to facilitating high quality
provided patient care, a properly documented
In addition to facilitating high quality patient medical record verifies and documents
care, a properly documented medical precisely what services were actually
,record verifies and documents precisely provided. Other than the site of service
what services were actually provided. The the medical record may be used to
medical record may be used to validate: (a) validate:
The site of the service; (b) The a. The appropriateness of the services
appropriateness of the services provided; provided
(c) The accuracy of the billing; and (d) The b. The patient's certificate of birth
identity of the caregiver. c. The identity of the patient's extended
family
d. The cost of healthcare benefits used for
the year.
c. Detailed, well documented notes A provider's best defense in any legal
The details in a well-documented note are a situation is:
provider's best defense in any legal a. Patient records maintained for five
situation. If the record is deficient in details, years
there is no "evidence" to support a b. An experienced healthcare attorney
provider's testimony. c. Detailed, well documented notes
d. Updated computer storage systems
c. During the encounter or as soon as To maintain an accurate medical record,
possible what is the recommended appropriate
The best way to achieve the most accurate, time for provider documentation?
detailed documentation is for the provider a. Within 48 hours of patient visit
to document the encounter/services as b. A minimum of bi-weekly
soon as possible after (if not during) the c. During the encounter or as soon as
encounter. possible
d. The end of each day for all encounters
that day
d. If it is documented in the patient's Quality assurance of patient care is only
medical record evident if:
Quality assurance in patient care is only a. The patient maintains a state of
evident if it is documented in the medical optimum health
record. Quality services may have been b. Visits are only required for well-checks
, provided; however, if this is not evident or injury
within the medical record, problems may c. The patient survey and ROS does not
arise. change
d. If it is documented in the patient's
medical record
b. Documentation reviews can be Which of the following statements is
performed on a prospective basis. TRUE regarding clinical documentation
CDI programs are intended to be performed improvement efforts?
on a prospective basis to improve a. Documentation reviews should be
documentation deficiencies prior to claim limited to the costliest chronic conditions
submission. The intent is to identify to treat.
deficiencies and make the appropriate b. Documentation reviews can be
corrections and prevent future deficiencies. performed on a prospective basis.
CDI programs can also include c. Documentation reviews must be
retrospective reviews. completed yearly.
d. Documentation reviews require access
to the denial data.
a. It encourages physician participation. Why is it important to involve physicians
Getting physicians involved in CDI helps to in Clinical Documentation Improvement
gain physician buy in and encourages other (CDI) programs?
physicians to participate and is a great way a. It encourages physician participation.
to educate physicians. 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 Which of the following documentation
procedure care and potential complications. deficiencies has a negative impact on
Although all the choices are deficiencies in patient outcomes?
capturing patient information, failure to a. Failure to indicate the date of the
inform a patient of potential post-operative patient's last blood test.
DETAILED ANSWERS| 100% CORRECT SOLUTIONS/GRADE A+
Answer Questions
c. To facilitate optimum patient care What is the central focus of clinical
The central focus of all clinical documentation?
documentation should be to demonstrate a. Protection against mal-practice claims
the quality of care provided to the patient b. Communication to office staff and other
with detail and accuracy to facilitate departments about the patient's care
optimum patient 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 The CDEO will focus his or her attention
proactive basis to prevent documentation on records requested for post payment
deficiencies review.
Clinical documentation improvement is a a. Yes, CDEOs only review records that
proactive measure. The CDS will develop might be an audit concern and require
and monitor policies and procedures that physician education.
affect the documentation process. CDI b. Yes, CDEOs only review records for
should begin at the front end of all services paid claims by government payers.
and care. Prevention of documentation c. No, CDEOs do not review records
issues is the key. See Page 1 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
The CDEO will review the findings of the auditor in order to:
auditor to determine what should be done a. Reprocess claims
to resolve documentation the issues on a b. Make an addendum to the medical
proactive basis to prevent documentation record
and compliance risks. c. Prevent deficient documentation
d. Know what accounts should be
adjusted off
I, II, III, and IV Which of the following sources other than
For different reasons other than federal healthcare plans may request the
reimbursement, requests for medical medical records?
records come from different sources, for a I. Patients
multitude of different reasons. A few of II. Providers involved with the patient's
these, other than Federal Health Care care
Plans, are patients who are becoming more III. Employers for worker's compensation
active in their care , attorneys seeking claims
information for third party liability claims or IV. Private payers
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.
a. The appropriateness of the services In addition to facilitating high quality
provided patient care, a properly documented
In addition to facilitating high quality patient medical record verifies and documents
care, a properly documented medical precisely what services were actually
,record verifies and documents precisely provided. Other than the site of service
what services were actually provided. The the medical record may be used to
medical record may be used to validate: (a) validate:
The site of the service; (b) The a. The appropriateness of the services
appropriateness of the services provided; provided
(c) The accuracy of the billing; and (d) The b. The patient's certificate of birth
identity of the caregiver. c. The identity of the patient's extended
family
d. The cost of healthcare benefits used for
the year.
c. Detailed, well documented notes A provider's best defense in any legal
The details in a well-documented note are a situation is:
provider's best defense in any legal a. Patient records maintained for five
situation. If the record is deficient in details, years
there is no "evidence" to support a b. An experienced healthcare attorney
provider's testimony. c. Detailed, well documented notes
d. Updated computer storage systems
c. During the encounter or as soon as To maintain an accurate medical record,
possible what is the recommended appropriate
The best way to achieve the most accurate, time for provider documentation?
detailed documentation is for the provider a. Within 48 hours of patient visit
to document the encounter/services as b. A minimum of bi-weekly
soon as possible after (if not during) the c. During the encounter or as soon as
encounter. possible
d. The end of each day for all encounters
that day
d. If it is documented in the patient's Quality assurance of patient care is only
medical record evident if:
Quality assurance in patient care is only a. The patient maintains a state of
evident if it is documented in the medical optimum health
record. Quality services may have been b. Visits are only required for well-checks
, provided; however, if this is not evident or injury
within the medical record, problems may c. The patient survey and ROS does not
arise. change
d. If it is documented in the patient's
medical record
b. Documentation reviews can be Which of the following statements is
performed on a prospective basis. TRUE regarding clinical documentation
CDI programs are intended to be performed improvement efforts?
on a prospective basis to improve a. Documentation reviews should be
documentation deficiencies prior to claim limited to the costliest chronic conditions
submission. The intent is to identify to treat.
deficiencies and make the appropriate b. Documentation reviews can be
corrections and prevent future deficiencies. performed on a prospective basis.
CDI programs can also include c. Documentation reviews must be
retrospective reviews. completed yearly.
d. Documentation reviews require access
to the denial data.
a. It encourages physician participation. Why is it important to involve physicians
Getting physicians involved in CDI helps to in Clinical Documentation Improvement
gain physician buy in and encourages other (CDI) programs?
physicians to participate and is a great way a. It encourages physician participation.
to educate physicians. 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 Which of the following documentation
procedure care and potential complications. deficiencies has a negative impact on
Although all the choices are deficiencies in patient outcomes?
capturing patient information, failure to a. Failure to indicate the date of the
inform a patient of potential post-operative patient's last blood test.
