CDEO Exam With 100% Correct Answers 2024, Exams of Advanced Education

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CDEO Exam With 100% Correct Answers

Clinical Documentation Improvement (CDI) programs can help: - Correct Answer-- Build effective documentation compliance policies

• Capture clinical data required for continuity of care documentation deficiency that has a negative impact on patient outcomes - Correct Answer-Failure to include the complications of drug for prescriptions taken by a patient. What is best practice to communicate document deficiencies to a provider? - Correct Answer-Provide examples of the provider's documentation errors with suggestions for improvement. A physician who specializes in elder care undergoes a CDI audit. Fifteen charts are found with the diagnosis of marasmus. Your correct response: - Correct Answer-Display in your query the Index entry for marasmus and the codes and descriptions for E41 and R54. Ask for guidance on which to report.

The best approach when querying a physician regarding documentation is to approach the problem as one of: - Correct Answer-- Evidence based medicine

• Financial motive
  • Malpractice liability
• Documentation impact on reimbursement
• Documentation impact on compliance Which EMR feature is non-compliant with CMS? - Correct Answer-Templates that allow the provider to de-select a prepopulated "normal" checkmark when the system is abnormal in the ROS When providing CDI to a provider, does the message change depending on whether you are performing a prospective or retrospective audit? - Correct Answer-Yes, because the auditor cannot ask leading questions regarding documentation before a claim is submitted. What is NOT considered a purpose of documentation improvement programs? - Correct Answer-Increase reimbursements

CDI programs can help with: - Correct Answer-Consistency of documentation & Team building Which is NOT an acceptable cause for query? - Correct Answer-Signs and symptoms without a diagnosis Which is a leading query? - Correct Answer-Your sarcoidosis patient has sarcoid lesions on the cerebral cortex, correct? The surgeon documents liver cancer, but the pathology report states angiosarcoma of liver. You: - Correct Answer-Code the liver cancer as angiosarcoma, a primary liver cancer, based on the pathologist's documentation. In reviewing the provider's assessment the documentation states "lab tests reviewed: +K." You correctly query: - Correct Answer-Can you please address the patient's potassium status in further detail? Documentation states: Patient has a history of a recent myocardial infarct and is admitted today with an ST elevation MI of the anterior wall.

The flaw in this documentation from a coding standpoint: - Correct Answer-The duration between the recent myocardial infarct and the current myocardial infarct will impact coding, so "recent" is insufficient documentation Which term or phrase, when used between a manifestation and etiology, does NOT always show a causal relationship? - Correct Answer-likely Which is an example of poor documentation that is especially problematic as there is no "unspecified" code for the condition in ICD-10-CM? - Correct Answer-Degenerative disc disease (DDD) When reviewing documentation and you notice information is missing, what is the proper procedure? - Correct Answer-The information should be added as a documented late entry/addendum only when necessary. Is it an acceptable practice to use a template that always documents a complete review of systems? - Correct Answer- No. The extent of ROS performed and documented is dependent upon clinical judgment and the nature of the presenting problem(s).

Which type of documentation can be used to report diagnoses under risk adjustment models? - Correct Answer-Inpatient Admission Note What type of payment does an ACO (Accountable Care Organization) receive? - Correct Answer-An ACO receives reimbursements based on quality metrics and reductions in the total cost of care for an assigned population of patients. Which statement is TRUE regarding RAFs? - Correct Answer-A patient with a RAF score of 3.09 will likely consume more health care in the coming year than a patient with a RAF score of 1.89. Documentation for 9/1/20XX OV: CHIEF COMPLAINT: follow-up on Dr. Kundeling's visit. HPI: Tim is here for a follow-up. Overall he has been doing well. His energy level has not changed much from the other time, but overall he is doing well. He does not have any acute complaints. When he saw Dr. Kundeling, he was put on a new medication. Unfortunately, he does not recall the name. He seems to be tolerating it well.

ROS: Today is a negative for back pain, energy level unchanged from the last time, no nausea or vomiting, also lower leg edema is unchanged. O: Blood pressure is 118/60, respirations are 20, elevated pulse of 128, temperature is 98.0, and weight is 213 pounds. In general, Tim is a very pleasant male in no acute distress. He is alert. He responds to questions appropriately. A/P: At this time, I think any past fatigue could be related to his past history of anemia and hypothyroidism. However, given the fact tha - Correct Answer-- No chief complaint

• No diagnoses in assessment
• Pulse rate is not discussed in assessment
• "Past history" disorders are likely current problems
• Entire note seems very vague A patient with ESRD on dialysis comes in with an infection at the peritoneal dialysis catheter site. The provider evaluated the infected skin and determined a staph infection. The provider prescribed antibiotics and performed a dressing change. What are the correct codes and sequence? - Correct Answer- T85.71XA, L08.89, B95.8, N18.6, Z99.

Which of the following information should be documented to properly code hypertension in ICD-10-CM? - Correct Answer- Type (essential, secondary) The patient is documented as a cigarette smoker. The correct code: - Correct Answer-F17. Which statement is TRUE for the use of a sign/symptom code with a definitive diagnosis code? - Correct Answer-Codes that describe symptoms and signs are acceptable for reporting purposes when a related definitive diagnosis has not been established (confirmed) by the provider. When would morbid obesity be considered clinically significant: - Correct Answer-Morbid obesity is always clinically significant and reportable if documented by the provider. Which code systems are included in HEDIS? - Correct Answer- CPT® CDT HCPCS Level II

Which of the following is a HEDIS measure? - Correct Answer- Adult BMI Assessment Cervical Cancer Screening Breast Cancer Screening Which CPT® code submitted on a claim would support the lead screening in children HEDIS measure? - Correct Answer- A patient is diagnosed with acute on chronic gastrointestinal bleeding due to a small bowel peripheral arteriovenous malformation (AVM). Documentation does not indicate whether the AVM is acquired or congenital. What is the correct ICD-10-CM code to report? - Correct Answer-K55. How is the cost category under MIPS going to be determined?

• Correct Answer-Adjudicated claims A 4 year-old is getting over his cold and will be getting three immunizations in the pediatrician's office by the nurse. The first vaccination administered is the Polio vaccine intramuscularly. The next vaccination is the live influenza (LAIV3) administered in the nose. The last vaccination is the Varicella (live) by subcutaneous route. What CPT® codes are

reported for the administration and vaccines? - Correct Answer-90713, 90660, 90716, 90471, 90472, 90474 Patient has a suspicious lesion of the right axilla. The area was infiltrated with local anesthetic and prepped and draped in a sterile fashion. With the use of a 3 mm punch tool the total lesion with margins was excised and closed with 5.0 Prolene suture. Pathology report indicated this was a seborrheic keratosis. What CPT® and ICD-10-CM codes are reported? - Correct Answer-11400, L82. Acute and Chronic Respiratory Failure with Mild Hypoxemia How many codes would be required to report the respiratory failure? - Correct Answer-One: Report acute and chronic respiratory failure unspecified whether with hypoxia or hypercapnia a status code for a BKA is informative because the status... - Correct Answer-may affect the course of treatment and its outcome These would be reported as a history of breast cancer rather than active breast cancer - Correct Answer--Breast cancer, post mastectomy, on tamoxifen prophylaxis

-Breast cancer, post mastectomy, now undergoing prophylactic contralateral mastectomy -Breast cancer, post mastectomy, undergoing chemotherapy for secondary bone cancer Consider the following final diagnostic statement: Acute renal failure in patient with history of renal transplant. What advice would you give to the provider regarding whether this documentation is sufficient to document a kidney transplant complication. - Correct Answer-Conditions that affect the function of a transplanted kidney, other than CKD, can be established as kidney transplant complications. Acute renal failure would affect the function of the kidney transplant and it would be appropriate to assign a kidney transplant complication code. COPD can be exacerbated by - Correct Answer--Viral bronchitis -Pneumonia -Inhalation of irritable substances such as smoke Diabetic ulcers are staged by - Correct Answer--Skin -Subcutaneous tissue

-Muscle -Bone What are common signs and symptoms of a patient presenting with deep vein thrombosis (DVT)? - Correct Answer-Swelling in the leg According to documentation, A 34-week gestation patient with diabetes delivers twins. Fetus A was delivered without complication, with APGARs of 8 and 8. Fetus B's delivery was complicated by a knot in the umbilical cord, and his APGARs were 3 and 5. Which query is appropriate? - Correct Answer- What type of diabetes did the patient have? The provider states that the patient is hypertensive and is interested in beginning a diet. He discusses weight loss strategies, but does not document that the patient is overweight, obese or morbidly obese. BMI documented in the vitals is 42, blood pressure 145/82. The patient receives a prescription for amlodipine. You: - Correct Answer-Query the provider, asking if there is a diagnosis to go with the weight loss strategy counseling that was performed.

As the provider was treating actinic keratoses of the patient's face and neck with cryosurgery, the liquid nitrogen canister misfired, inadvertently burning the patient's cheek. This wound is treated with ELA-Max. The provider documented that there were "no intraoperative complications." You correctly: - Correct Answer-Ask the provider to review the operative note to clarify documentation of the patient's inadvertent cheek burn and the note that there were no intraoperative complications. acceptable signatures according to CMS - Correct Answer- Handwritten Electronic A pathology report might show: - Correct Answer-The histology of a breast biopsy specimen The section in the operative note which provides a detailed description of the patient's history relative to the condition for which surgery is being done? - Correct Answer-Body of the operative report What is required for documentation to be complete? - Correct Answer-Support the treatment and care provided

The EMR system must have the ability to identify the date of service and also identify changes made to the original data entry document with the date and time Deletion of rendered treatment the change occurred. Which of the following is an inappropriate change to the original document? - Correct Answer-Deletion of rendered treatment When ordering an CT of the abdomen, what must be documented in the order? - Correct Answer-Medically necessary indication for the test; With or without contrast; Date the test was ordered When are HCC scores normalized by CMS? - Correct Answer- Yearly What information is considered under a risk adjustment payment methodology to predict the probability of incurring medical costs by a patient? - Correct Answer-Disability status Which of the following conditions, if listed under Past Medical History and documented nowhere else in the 12-month

record, would create a clinical documentation improvement opportunity? - Correct Answer-Down syndrome; Parkinson's disease; Schizophrenia; Sickle cell anemia Chief complaint: T3 prostate carcinoma, Gleason's score 7. Previous treatment: Prostatectomy followed by radiation to 64.8 gray completed 8/10/20X Interval history: Mr. Smith returns for follow-up. He has been doing well in the interim. He is not having any bone pain, abdominal pain or pelvic pain. He has no GI or GU complaints. Physical exam: General: the patient is a well-developed, well- nourished male in no acute distress. Vitals: Weight is 222 pounds. BP is 155/98 Temperature is 98.9 degrees. Pulse rate is 98. Respirations are 20. KPS is 90%. Rectal: Exam with normal anal sphincter tone. No masses palpable in the rectal vault. The prostate bed is flat, smooth. There are no nodules or masses. Extremities: No cyanosis, clubbing, or edema. Labs: PSA is 0.04. This is unchanged from December when it was 0.04. Impression and plan: Prostate carcinoma - clinically and biochemically no evidence of disease (NED) at this t - Correct Answer-The provider should not list a chief complaint of prostate cancer, as there is no evidence of disease (NED) and treatment has been completed. Instead, a history of prostate cancer, post prostatectomy should be documented.

Which of the following is TRUE regarding a final diagnostic statement of alcoholic liver disease: - Correct Answer- Alcoholic liver disease is a nonspecific diagnosis and the provider should be queried for additional detail. the following paired conditions has an assumed causal relationship when coded in ICD-10-CM - Correct Answer-- Heart disease and hypertension

• Hypertension and kidney disease It is appropriate to assign code ____________________________, for a documented healthcare acquired condition. - Correct Answer-Y95, Nosocomial condition Medical record documentation states the patient is a 68-year- old gentleman with hypertension and stage 3 CKD with a creatinine of 1.8. Based on current diagnostic coding guidelines what is the correct coding? - Correct Answer-I12.9, N18.

Which term or phrase, when used between a manifestation and etiology, does NOT show a strong causal relationship? - Correct Answer-Likely caused by STARS Ratings are important because they: - Correct Answer- Identify top performing health plans Which of the following MIPS measures replaces PQRS? - Correct Answer-Quality Which of the following is a benefit for providers to utilize electronic health records? - Correct Answer-Improve quality, safety, and efficiency ___________________________ are NOT an eligible providers (EPs) for Medicare under the MIPS Quality Payment Program - Correct Answer-Certified social workers When does the performance year begin for the Medicare Quality Payment Program? - Correct Answer-Jan 1

Which system is given credit for the exam component when a provider documents "no appreciable edema in the ankles?" - Correct Answer-Cardiovascular A/P: Diabetic neuropathy, improved. Started having insomnia. Lyrica should help her with the sleeping; we will monitor how her BS responds to this new medicine. Return to office in 4-5 weeks. For the documentation provided, what is the overall level of MDM using the 2021 Evaluation and Management (E/M) Service Guidelines for selecting a level of office or other outpatient E/M services? - Correct Answer-Low A patient presents to the physician for evaluation of a suspicious skin lesion on the right arm. The patient and physician discuss treatment and agree to excise the lesion of the arm. The size of the lesion is 3.0 cm. and is removed with a scalpel. Simple suture repair is performed to close the wound which measured 3.5 cm. What are the CPT® and diagnosis codes? - Correct Answer-11403, D49. The provider performs three trigger point injections into the vastus lateralis muscle. Select the correct coding. - Correct Answer-

When a significant and separately identifiable E/M is performed on the same date as a minor surgery, _______________________ can be appended to the E/M code. - Correct Answer-Modifier 25 What documentation is required to support transitional care codes? - Correct Answer--Communication with the patient within two business days of discharge

• Medical decision making of moderate to high complexity A 75-year-old patient with a long history of age-related osteoporosis trips on a rug at home and falls breaking her hip. How is the diagnosis code reported? - Correct Answer- Pathologic fracture due to age related osteoporosis What is adjuvant therapy for cancer? - Correct Answer- Treatment given after primary treatment. When a patient is diagnosed with multiple pressure ulcers on the same limb that are of different stages, how should this be reported? - Correct Answer-Report a combination code indicating the site and stage of each ulcer.

What is MPV (mean platelet volume) on a complete blood count measuring? - Correct Answer-Size of platelets These are AIDS related conditions - Correct Answer- tuberculosis (TB), Cytomegalovirus, Candidiasis, Cryptococcal meningitis, Toxoplasmosis, Cryptosporidiosis, Kaposi's sarcoma, Lymphomas, Wasting syndrome, AIDS dementia complex, HIV-associated nephropathy (HIVAN). Which of the indicators below are considered part of the Quick Sepsis-related Organ Failure Assessment (qSOFA) Score:

• Correct Answer-- Respiratory rate ≥22/min
• Systolic blood pressure ≤100 mm Hg
• Altered mentation this documentation deficiencies has a negative impact on patient outcomes - Correct Answer-Failure to advise the patient instructions for colonoscopy preparation. To protect your organization, when you query the provider you should: - Correct Answer-Use your organization's standardized form to ensure consistency.

Documentation excerpt: A: 1. Sleep apnea syndrome. Patient will be scheduled for sleep study.

2. Premenopausal bleeding. Patient does have a referral to a gynecologist.
3. Ptosis of bilateral eyelids. Surgical correction performed 2/14/15.
4. Rheumatoid arthritis/osteoarthritis, erosive, involving bilateral hands and back, doing OK. Which of the following is an appropriate query for this note? - Correct Answer-Can you please provide further clinical information regarding "rheumatoid arthritis/osteoarthritis" in this note? Is this a differential or definitive diagnosis? The patient is documented in Past Medical History as having had prostate cancer, with a TURP performed three years ago. NED. The patient is also currently on low dose aspirin and vitamin E therapy. Is a query needed? - Correct Answer-No The patient is seen for her Medicare annual well visit. The prescriptions written during the encounter are for lisinopril, Namenda, Fosamax, and Zetia.

The final assessment includes all conditions documented in the record, and reads:

1. E78.5 Hyperlipidemia
2. I10 Hypertension
3. M81.0 Osteoporosis
4. R60.9 LE edema Which prescription is NOT supported by the diagnoses, and would prompt a query? - Correct Answer-Namenda A CDI professional can determine services that should be reviewed that are performed by the practice based on services identified for audit in the - Correct Answer-OIG Workplan Excerpt from a medical record: Subjective—Patient is a 54-year-old male who complains of an ulcer underneath his L big toe x 3 years. States that he is a truck driver. States that he had 2 previous surgeries from another physician. Patient has a history of gout, chronic ulcers, HTN, and low back pain. Medications—Zestril, Allopurinol. Allergies—NKDA

Which of the following describes an appropriate query approach for the above documentation if the goal is to ensure the chart is coded appropriately? - Correct Answer-Please review the use of the word "history" in this record and specify whether each disorder is a resolved condition or a current condition with ongoing treatment. Does the use of an EHR template with macros with multiple choice options for signs and symptoms lead to cloning of the medical record? - Correct Answer-No, the use of a template with macro options is permitted as long as the information entered is specific to the patient. A patient presented to the office with a foreign body that required removal from his ear. The provider performs the removal and documents the encounter. The next day you review the medical record and identify the provider did not document which ear the foreign body was removed from. What should be done to correct the record? - Correct Answer- Have the provider add an addendum with the current date and reference the date of service and add the laterality. What must be documented when ordering a CBC? - Correct Answer-Reason for the test

A code from subcategory R65.2 Severe sepsis is NOT assigned unless the documentation specifies either severe sepsis or what other condition? - Correct Answer-Associated acute organ dysfunction What is missing from this electronic signature provided below? Electronically signed by: Joseph M. Doe, MD at 11:03:29 - Correct Answer-Date Given the following definitions, which of the following is TRUE related to accurate diagnosis coding in risk adjusted payment models: Definitions: PMPM = per member per month MLR = medical loss ratio; the proportion of premium revenues spent on clinical services and quality improvement. MLR = total claims expense (healthcare costs) divided by premiums received (per member per month payments) - Correct Answer- Providers treating patients with higher medical costs will receive higher PMPM (per member per month) premium payments if they are accurately coding medical conditions supported in the medical record that account for higher expected medical costs.

In June, a Medicare Advantage Organization (MAO) audit of a provider's submitted diagnoses determines conflicting diagnoses submitted from two consecutive years. The following diagnoses were reported for the patient. FY 20X5 Diagnoses: HTN CHF DM DVT Diagnoses through June, 20X6: Diabetic retinopathy HTN Which of the following statements is TRUE? - Correct Answer- The provider likely overlooked documenting CHF in 20X6. Which components are used to determine RVUs? - Correct Answer--Physician work -Practice expense -Malpractice insurance

Which of the following conditions, if listed under Past Medical History and documented nowhere else in the record, would create a clinical documentation improvement opportunity? I. ALS II Hodgkin lymphoma III Acute bronchitis IV Chronic bronchitis V Autism VI Hypothyroidism - Correct Answer--ALS -Chronic bronchitis

• Autism
• Hypothyroidism __________ should not be used for aftercare involving injuries or poisonings. - Correct Answer-Z codes For many etiology and manifestation pairings, use... - Correct Answer-one code that reports both diagnoses The patient was being seen for anemia due to a malignancy of the frontal lobe. What is the first listed diagnosis code? - Correct Answer-C71.1 - Malignant neoplasm of frontal lobe