CDEO EXAM PREP STUDY GUIDE AND PRACTICE

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CDEO EXAM PREP / STUDY GUIDE AND PRACTICE

EXAM NEWEST 2025 TEST BANK| COMPLETE 450

ACTUAL EXAM QUESTIONS AND CORRECT

DETAILED ANSWERS (VERIFIED ANSWERS )

ALREADY GRADED A+| BRAND NEW!!

To maintain an accurate medical record, what is the recommended appropriate time for provider documentation?

• Within 48 hours of patient visit
• A minimum of bi-weekly
• During the encounter or as soon as possible
• The end of each day for all encounters that day - Correct Answer - C.

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:

• The patient maintains a state of optimum health
• Visits are only required for well-checks or injury
• The patient survey and ROS does not change
• If it is documented in the patient's medical record - Correct Answer -

D.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. 1 / 4

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pg. 2 Which of the following statements is TRUE regarding clinical documentation improvement efforts?

• Documentation reviews should be limited to the costliest chronic

conditions to treat.

• Documentation reviews can be performed on a prospective basis.
• Documentation reviews must be completed yearly.
• Documentation reviews require access to the denial data. - Correct

Answer - B.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.

Why is it important to involve physicians in Clinical Documentation Improvement (CDI) programs?

• It encourages physician participation.
• It helps justify the need for CDI programs.
• It will eliminate the need to query providers.
• It will help providers time management. - Correct Answer - A.

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.

Which of the following documentation deficiencies has a negative impact on patient outcomes? 2 / 4

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• Failure to indicate the date of the patient's last blood test.
• Failure to include the instructions for post procedure care and

potential complications.

• Failure to sign the patient's medical records provided by another

physician.

• Failure to report the patient's pharmacy preference for insurance

participation. - Correct Answer -B.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.

What is an effective method for communicating documentation deficiencies to a provider?

• Provide documentation tips for the most common chronic conditions

treated.

• Provide the documentation deficiency report quarterly.
• Provide a report to the medical director that includes the findings for

all the providers in the practice.

• Provide examples of the provider's documentation deficiencies with

suggestions for improvement. - Correct Answer - D.Effective provider education regarding documentation deficiencies is to provide examples of the physician's documentation deficiency and feedback and tips on how to correct the deficiency.

How can an effective CDI program improve patient outcomes?

• Maximize the reimbursement received. 3 / 4

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• Prohibit claim processing errors.
• Provide a detailed record of the care provided to the patient.
• Allow providers to support higher levels of E/M services. - Correct

Answer - C.The main goal for detailed medical records is to promote the continuity of care for the patient. This allows providers to communicate

Which of the following recommendations should be made to providers regarding the patient's problem list?

• Significant changes should be documented at each encounter.
• Problem lists consists of all past medical complications.
• Problem lists should only be used if the patient has at least on chronic

illness.

• Significant changes should be documented once a year. - Correct

Answer - A.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.

Failure to document which of the following statements could lead to a negative patient outcome?

a. Allergies: PCN

• Patient denies loss of appetite or vomiting.
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