CDEO Exam Prep
A young female, was brought to the clinic by her sister. She has had periods of severe depression for
many years and is on Lithium. Her provider also manages her manic-depressive psychosis,
hypothyroidism, and migraine headaches. Additional medications are Synthroid and Midrin. During the
past week, she became manic, running all her credit cards to the limit, getting inappropriately involved in
a friend's suicide attempt, quitting her job, and trying to take over the pulpit at church. On the day of the
clinic visit, she threatened to strike the telephone repairman with a lead pipe. She was admitted for
Lithium adjustment. Diagnoses are: moderate manic-depressive bipolar with circular current manic state,
hypothyroidism, and migraine. What ICD-10-CM codes are reported?
a. F31.12, E03.9, G43.909
b. F31.62, E03.9, G43.911
c. F31.32, E03.9, G43.909
d. F31.89, G43.911, E03.8
F31.12 - Bipolar disorder, current episode man - a. F31.12, E03.9, G43.909
In the ICD-10-CM Alphabetic Index look for Disorder/bipolar/current (or most recent)
episode/manic/without psychotic features/moderate guiding you to code F31.12. No code assignment is
necessary for depression because depression is a component of bipolar disorder. Although not
psychiatric conditions, both hypothyroidism and migraine headaches are coexisting conditions under
treatment and are coded. In the Alphabetic Index, look for Hypothyroidism which directs you to E03.9
and look for Migraine directing you to code G43.90-. Verify the codes in the Tabular List. When reviewing
code G43.90 in the Tabular List, a 6 th character of 9 is selected because there is no mention of an
intractable migraine or status migrainosus.
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. - 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.
,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 - 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
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 - 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.
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 - 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.
,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. - 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.
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 - 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.
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 - 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.
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 - 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.
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. - 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.
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 -
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.
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.
