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CDEO LATEST EXAM PREP 2024 WITH 100%
CORRECT SOLUTIONS| BEST GRADES
GURANTEED.
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 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. 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. 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.
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. - -- 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 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 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 The CDEO will review the findings of the auditor to determine what should be done to resolve documentation the issues on a proactive
of the caregiverIn 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. 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. 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 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 encounterTo 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
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. 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 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. 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. 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. What is an
d. Allow providers to support higher levels of E/M services. 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. - -- ANSWERS Which of the following recommendations should be made to providers regarding the patient's problem list? a. Significant changes should be documented at each encounter. b. Problem lists consists of all past medical complications. c. Problem lists should only be used if the patient has at least on chronic illness. d. Significant changes should be documented once a year. a. Allergies: PCN Failure to document an allergy could lead to an allergic reaction if the provider prescribes a medication not realizing the patient is allergic. - --ANSWERS Failure to document which of the following statements could lead to a negative patient outcome? b. Patient denies loss of appetite or vomiting. c. Patient has remained on her diet. d. Patient indicates her daughter lives with her to assist in her care. b. Documentation deficiencies may not be identified until after the provider has left.
Maintaining consistent and quality documentation can be difficult in the inpatient setting because deficiencies may not be identified until after the provider has left the facility. - --ANSWERS What is a documentation challenge for services provided by providers in an inpatient facility? a. Documentation may not include the progress note for a subsequent inpatient encounter. b. Documentation deficiencies may not be identified until after the provider has left. c. Providers may not have access to the entire record for the inpatient stay. d. Providers may not have access to the hospital EHR to document the inpatient encounters. c. No, the CMS documentation guidelines provide the least expected documentation to support a visit. The basic CMS documentation guidelines for E/M services include the least expected documentation to support an encounter. Quality is going above and beyond the basic information. - -- ANSWERS Adhering to the CMS Documentation Guidelines for E/M services will meet the clinical documentation requirements for all encounters. a. Yes, E/M documentation guidelines help the provider document all requirements needed for a detailed record. b. Yes, CDI is a proactive approach to ensure E/M services are reimbursed correctly. c. No, the CMS documentation guidelines provide the least expected documentation to support a visit.
d. Employer who solely establishes and maintains the plan with fewer than 50 participants. d. Standards for how protected health information is used. - -- ANSWERS What standards are set by the Privacy Rule set? a. Pre-existing standards b. Group health standards c. Transaction and code set standards d. Standards for how protected health information is used a. Psychotherapy notes. Areas excluded from the rights of access are psychotherapy notes, information related to legal proceedings, and certain lab results or information held by research laboratories. - --ANSWERS Which option would be excluded from an individual's right to access their PHI? a. Psychotherapy notes b. Family practice notes c. Emergency department notes d. Operative reports c. Reliable means to clearly identify the original content and the modified content. For electronic health records (EHR), the amendment, correction, or delayed entry must be distinctly identified. There must also be a way to provide a reliable means to clearly identify the original content and the modified content. The person altering the record and the
date of the revision, amendment, or addenda must also be documented. - --ANSWERS When a correction is made in an electronic health record, what must exist? a. Identity of a witness to the correction made in the electronic health record. b. The entire medical record duplicated with the corrections only made to the duplication. c. Reliable means to clearly identify the original content and the modified content. d. There are no requirements for corrections to electronic medical records. d. A specific requirement does not exist. There are no specific requirements as to how the medical records must be retained. They may be kept in their original format, or reproduced in a way that is legally acceptable. The most important component of retention is that the record is protected, to ensure the security and integrity of the records. - --ANSWERS How must medical records be retained? a. Electronically b. Paper format c. Microfiche d. A specific requirement does not exist b. The permitted and required uses of PHI by the business associate.
- --ANSWERS What must be included in a business associate agreement?
b. A program established by HIPAA to combat fraud and abuse in healthcare. - --ANSWERS What is the Health Care Fraud and Abuse Control Program? a. A program that keeps track of the financial success of each of the Fraud and Abuse programs run by the US government. b. A program established by HIPAA to combat fraud and abuse in healthcare. c. The OIG's Health Care Fraud Prevention and Enforcement Team. d. A program established by the OIG to create sample compliance plans. c. The detail of the procedure can be included in the documentation for the office visit. - --ANSWERS When a minor procedure is performed in the office, what is the documentation requirement? a. A formal operative report must be documented. b. A reference to the operation without the detail can be included in the documentation for the office visit. c. The detail of the procedure can be included in the documentation for the office visit. d. The surgery is not required to be documented if it is performed during an evaluation and management service. a. Individually identifiable health information - --ANSWERS What is considered protected health information (PHI)? a. Individually identifiable health information b. Health information that is randomly gathered for research purposes
c. Statistical information relating to a specific demographic area d. Provider information submitted on a claim for payment c. When the covered entity has reasonable safeguards in place to ensure the information shared is being limited to the minimum necessary. - --ANSWERS When is incidental use and disclosure of PHI permitted? a. When there is authorization from the individual whose information is shared. b. When there is retribution for the use and disclosure. c. When the covered entity has reasonable safeguards in place to ensure the information shared is being limited to the minimum necessary. d. When the covered entity has policies and procedures in place to identify each person who has incidentally had access to the record. a. Establish their own standards - --ANSWERS What are healthcare institutions to do in the absence of clearly defined laws and regulations relating to the content of a medical record? a. Establish their own standards b. Not put any in place c. Call HHS and ask for clarification d. Continue practicing without guidance until an issue arises a. Indication for surgery - --ANSWERS Which section of an operative report would you expect to find the reason or medical necessity for the procedure?
fraud and abuse committed against all health plans, both public and private? a. Health and Human Services Fraud Prevention Program b. Compliance Program c. OIG HEAT d. Health Care Fraud and Abuse Control Program b. Six years from the date of its creation or the date from which it was last in effect (whichever is later). - --ANSWERS How long does HIPAA require medical records to be maintained? a. Five years from the date of its creation or the date from which it was last in effect (whichever is later). b. Six years from the date of its creation or the date from which it was last in effect (whichever is later). c. Ten years from the date of its creation or the date from which it was last in effect (whichever is later). d. Five years past the date of death of the patient. d. Assistant surgeon Each provider involved in a surgical case is expected to document the portion of the surgical procedure they performed with the exception of a surgical assistant. When a surgery requires the help of a surgical assistant, the primary surgeon documents the operative report. The primary surgeon should clearly explain in the indications section of the note why an assistant was necessary, and what the assistant surgeon performed that required the assistance. - -- ANSWERS Which type of provider is not required to dictate his or her own operative report?
a. Primary surgeon b. Co-surgeon c. Surgeons in a surgical team d. Assistant surgeon a. Elements to notify individuals as to how the covered entity will use and disclose the PHI. - --ANSWERS What information does a privacy practice notice contain? a. Elements to notify individuals as to how the covered entity will use and disclose the PHI. b. Notification of each person who has access to their record and what access level they will have. c. Notification of when their payments have been received from the insurance carrier. d. Elements contained on a claim form sent to the patient's insurance carrier. b. Release of information - --ANSWERS What form is used to allow the release of their medical records? a. Assignment of benefits b. Release of information c. Informed consent d. Patient registration form
a. Office of Civil Rights b. Secretary of State c. Office of Inspector General d. Department of Justice b. Payment, treatment, or operations - --ANSWERS Under what circumstance may providers use or disclose protected health information without patient consent? a. Advertising of the entity's services b. Payment, treatment, or operations c. Request from a spouse or another family member d. Request from a neighbor or close friend d. No intent must be proven for the Stark law; the Anti-Kickback law requires proof of intention. The Stark law has strict liability regarding overpayments, meaning no intent must be proven. For civil monetary penalties for the Stark law, though, intent is required for knowing violations. The Anti-Kickback law requires proof of intention. The law state the person must "knowingly and willfully" violate the law. The "willful" verbiage is not founding the Stark law. - --ANSWERS What is on of the differences between the Stark law and the Anti-Kickback law? a. The Start law refers to fraudulent billing; the Anti-Kickback law refers to remuneration for self referrals. b. No intent must be proven for the Anti-Kickback law; the Stark law requires proof of intention.
c. The Anti-kickback law refers to fraudulent billing; the Stark law refers to remuneration for self referrals. d. No intent must be proven for the Stark law; the Anti-Kickback law requires proof of intention. a. No, the OIG does not specify the IRO to be used, but does retain the right to notify the provider i they must select a new IRO. - -- ANSWERS In a Corporate Integrity Agreement (CIA), does the OID specify the Independent Review Organization to be used? a. No, the OIG does not specify the IRO to be used, but does retain the right to notify the provider i they must select a new IRO. b. No, the OIG does not have nay input on the IRO used under any circumstance. c. Yes, the CIA will identify five IROs that can be used for the CIA Review. d. Yes, the specific IRO will be named in the CIA. c. Identifying employees on the exclusions list. The OIG has identified seven elements that should be present in every compliance plan based on criteria adopted by the federal government in the federal sentencing guidelines. The OIG lists seven fundamental elements for an effective compliance program, which are: 1-Implementing written policies, procedures and standards of conduct; 2-Designating a compliance officer and/or compliance committee; 3-Conducting effective training and education; 4- Developing effective lines of communication; 5-Enforcing standards through well-publicized disciplinary guidelines; 6-Conducting internal monitoring and auditing; and 7-Responding promptly to detected offenses and developing corrective action - --ANSWERS Which
