LATEST CDEO Exam Prep 2024-2025
QUESTIONS WITH VERIFIED SOLUTIONS
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 - CORRECT 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.
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
- CORRECT 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
The CDEO will review the findings of the auditor in order to:
a. Reprocess claims
,LATEST CDEO Exam Prep 2024-2025
QUESTIONS WITH VERIFIED SOLUTIONS
b. Make an addendum to the medical record
c. Prevent deficient documentation
d. Know what accounts should be adjusted off - CORRECT 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.
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 - CORRECT 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.
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:
,LATEST CDEO Exam Prep 2024-2025
QUESTIONS WITH VERIFIED SOLUTIONS
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. - CORRECT 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.
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 - CORRECT 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.
To maintain an accurate medical record, what is the recommended appropriate time for
provider documentation?
a. Within 48 hours of patient visit
, LATEST CDEO Exam Prep 2024-2025
QUESTIONS WITH VERIFIED SOLUTIONS
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 - CORRECT 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.
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 - CORRECT 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.
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. - CORRECT ANSWER b.
Documentation reviews can be performed on a prospective basis.
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