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CDEO Exam Prep Latest /Questions And Answers (A+)
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CDEO Exam Prep Latest 2023 -2024/Questions And Answers (A+)
Answer:c. To facilitate optimum patient care
The central focus of all clinical documentation should be to demonstrate the
quality of care provided to the patient with detail and accuracy to facilitate
optimum patient care. - Quiz :What is the central focus of clinical
documentation?
a. Protection against mal-practice claims
b. Communication to office staff and other departments about the patient's
care
c. To facilitate optimum patient care
d. Communication to other the providers and ancillary personnel concerning
the patient encounter
√Answer :d. No, CDEOs review records on a proactive basis to prevent
documentation deficiencies
Clinical documentation improvement is a proactive measure. The CDS will
develop and monitor policies and procedures that affect the documentation
process. CDI should begin at the front end of all services and care. Prevention
,of documentation issues is the key. See Page 1 - Quiz :The CDEO will focus his
or her attention on records requested for post payment review.
a. Yes, CDEOs only review records that might be an audit concern and require
physician education.
b. Yes, CDEOs only review records for paid claims by government payers.
c. No, CDEOs do not review records unless it is requested by the compliance
officier.
d. No, CDEOs review records on a proactive basis to prevent documentation
deficiencies
√Answer :c. Prevent deficient documentation
The CDEO will review the findings of the auditor to determine what should be
done to resolve documentation the issues on a proactive basis to prevent
documentation and compliance risks. - Quiz :The CDEO will review the findings
of the auditor in order to:
a. Reprocess claims
b. Make an addendum to the medical record
c. Prevent deficient documentation
d. Know what accounts should be adjusted off
√Answer :I, II, III, and IV
For different reasons other than reimbursement, requests for medical records
come from different sources, for a multitude of different reasons. A few of
these, other than Federal Health Care Plans, are patients who are becoming
more active in their care , attorneys seeking information for third party liability
claims or 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. - Quiz :Which of the
following sources other than federal healthcare plans may request the medical
records?
I. Patients
II. Providers involved with the patient's care
III. Employers for worker's compensation claims
IV. Private payers
√Answer :a. The appropriateness of the services provided
In addition to facilitating high quality patient care, a properly documented
medical record verifies and documents precisely what services were actually
provided. The medical record may be used to validate: (a) The site of the
,service; (b) The appropriateness of the services provided; (c) The accuracy of
the billing; and (d) The identity of the caregiver. - Quiz :In addition to
facilitating high quality patient care, a properly documented medical record
verifies and documents precisely what services were actually provided. Other
than the site of service the medical record may be used to validate:
a. The appropriateness of the services provided
b. The patient's certificate of birth
c. The identity of the patient's extended family
d. The cost of healthcare benefits used for the year.
√Answer :c. Detailed, well documented notes
The details in a well-documented note are a provider's best defense in any
legal situation. If the record is deficient in details, there is no "evidence" to
support a provider's testimony. - Quiz :A provider's best defense in any legal
situation is:
a. Patient records maintained for five years
b. An experienced healthcare attorney
c. Detailed, well documented notes
d. Updated computer storage systems
√Answer :c. During the encounter or as soon as possible
The best way to achieve the most accurate, detailed documentation is for the
provider to document the encounter/services as soon as possible after (if not
during) the encounter. - Quiz :To maintain an accurate medical record, what is
the recommended appropriate time for provider documentation?
a. Within 48 hours of patient visit
b. A minimum of bi-weekly
c. During the encounter or as soon as possible
d. The end of each day for all encounters that day
√Answer :d. If it is documented in the patient's medical record
Quality assurance in patient care is only evident if it is documented in the
medical record. Quality services may have been provided; however, if this is
not evident within the medical record, problems may arise. - Quiz :Quality
assurance of patient care is only evident if:
a. The patient maintains a state of optimum health
b. Visits are only required for well-checks or injury
c. The patient survey and ROS does not change
d. If it is documented in the patient's medical record
, √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. -
Quiz :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.
√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. - Quiz :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.
√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. - Quiz :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.
√Answer :d. Provide examples of the provider's documentation deficiencies
with suggestions for improvement.
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