CDEO EXAM Study Guide.
HIPPA - answerHealth Insurance Portability and Accountability Act of 1996 and the
Healthcare Fraud and abuse control program. Far-reaching program to combat fraud and abuse in
healthcare including both public and private health plans.
Individuals protected health informat...
HIPPA - answer✔✔Health Insurance Portability and Accountability Act of 1996 and the
Healthcare Fraud and abuse control program. Far-reaching program to combat fraud and abuse in
healthcare including both public and private health plans.
Individuals protected health information - answer✔✔Demographic data, name, address, birth
date, and SS number.
central focus of clinical documentation - answer✔✔should be to demonstrate the quality of care
provided to the patient with detail and accuracy to facilitate optimum patient care.
CDEO Focus - answer✔✔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.
CDEO Review - answer✔✔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.
Other request than Federal Healthplans - answer✔✔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.
The appropriateness of the services provided - answer✔✔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:
Medical Record Validates - answer✔✔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.
Detailed, well documented notes - answer✔✔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.
During the encounter or as soon as possible - answer✔✔To maintain an accurate medical record,
what is the recommended appropriate time for provider documentation?
If it is documented in the patient's medical record - answer✔✔Quality assurance of patient care
is only evident if:
CDI Programs intent - answer✔✔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.
It encourages physician participation. - answer✔✔Why is it important to involve physicians in
Clinical Documentation Improvement (CDI) programs?
Failure to include the instructions for post procedure care and potential complications. -
answer✔✔Which of the following documentation deficiencies has a negative impact on patient
outcomes?
Provide examples of the provider's documentation deficiencies with suggestions for
improvement. - answer✔✔What is an effective method for communicating documentation
deficiencies to a provider?
Improve patient outcomes, Improve patient outcomes, and improve the provider query process. -
answer✔✔Which of the following is/are considered a purpose of documentation improvement
programs?
How can an effective CDI program improve patient outcomes? - answer✔✔The main goal for
detailed medical records is to promote the continuity of care for the patient. This allows
providers to communicate with each other on the care that has been provided to the patient.
Coding higher level services that are not medically necessary is not a goal to improve patient
outcomes.
Which of the following recommendations should be made to providers regarding the patient's
problem list? - answer✔✔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.
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