Certified Outpatient Documentation Expert (CDEO)

The Certified Documentation Expert Outpatient (CDEO) Certificate of Authorization confirms specialist knowledge in verifying the accuracy of outpatient documentation to support coding, quality measurements, and clinical requirements. CDEO experts provide feedback to providers to improve clinical documentation and enable continuous improvement of documentation to meet all medical record requirements. To become CDEO, documentation professionals must demonstrate knowledge of pathophysiology, coding and billing guidelines, and quality metrics.

The CDEO exam

• 150 multiple choice questions (supervised)
• 5 hours and 40 minutes to complete the exam
• A free rehearsal
• Open codebook (manuals)
• The exam consists of questions to review outpatient medical records to verify the accuracy and correct application of CPT®, ICD-10-CM, HCPCS Level II codes and quality measures. Applicants should also demonstrate knowledge of proper interview procedures and effective communication to improve documentation.

The CDEO exam includes the following:

Objective of the CDI

• 8 questions
• Holistic, integrated and aggregated use of the medical record
• Explain the goal of medical improvement in clinical documentation
• A clear picture of health and condition
• Improved patient outcomes

Communication and compliance with suppliers

• 15 questions
• Explain how the OIG can help identify areas of interest for the DCI
• Identify strategies for communicating important messages
• Demonstrate the ability to write a query for a non-leading supplier
• Demonstrate the ability to provide rationale for queries

Clinical conditions

• 45 questions
• For each of the clinical conditions listed below: understanding of the clinical picture, diagnostic criteria (lab work, radiology, etc.), common medications, common abbreviations, common treatment profiles. Understand the documentation requirements required for code assignment based on ICD-10 guidelines.
• Aortic aneurysm
• amputation
• Artificial openings
• Aortic stenosis / sclerosis
• Adjuvant therapy
• Burns
• GOUJAT
• Congenital or acquired conditions
• Anemia (blood loss) polycythemia
• Crohn’s disease
• Common ear diseases
• Common illnesses during pregnancy
• cirrhosis
• Chronic kidney disease
• Cardiomyopathy
• Cardiac Conduction Conditions – A-Fib, Sick Sinus Syndrome
• Chronic obstructive pulmonary disease – bronchitis, asthma
• CVA vs. TIA
• Drug addiction
• Diabetes
• Deep vein thrombosis
• epilepsy
• Fractures
• Heart failure
• Head injury
• HIV / AIDS
• Hemiplegia
• hypertension
• Active against neoplasia in the anamnesis
• Hypoxia
• Malnutrition
• Major depression
• Metastatic
• Heart attack
• Morbid obesity and BMI
• Neuropathy
• Parkinson’s disease
• Pathologic osteoporotic fractures
• Pulmonary infection
• Common diseases of the perinatal period
• Bedsores
• Peripheral vascular disease
• Rheumatoid arthritis
• sepsis
• Follow-up events (stroke, trauma)
• Registry status
• Congestive venous ulcers

Diagnostic coding

• 22 questions
• Identify clinically active and historical relationships
• Ensure that the support for etiology and manifestation is documented
• Apply Coding Clinic advice to ICD-10 coding problems.
• Remember the ICD-10 CM ambulatory coding guidelines
• Code the selected conditions with the highest specificity supported by the documentation.
• Select the first diagnosis listed for a complaint

Documentation requirements

• 15 questions
• Ability to correctly correct errors and audit requirements of those who have documented
• Identify cloned documents and cut and paste them
• Requirements for a complete medical record
• Understand the requirements for using models correctly
• Identify correctly authenticated notes in situations where multiple authors have documented in a note (employee, writer, vendor).
• Demonstrate an understanding of the responsibilities of medical and clinical staff with respect to documentation
• Electronic signature requirements versus paper signature requirements
• Documentation to support billing and coding of consumables (pharmaceuticals) administered in the office
• Documentation in support of diagnostic tests (laboratories, radiology, medicine)
• Selection of codes from a selection list in the coding software
• Identify clinically valid diagnoses by using the number of conditions treated and treated and identifying “notable bloating”.
• Managing problem lists
• Distinguish between acceptable and unacceptable use of abbreviations in the medical record (readability)
• Timely completion of medical records

Payment models

• 8 questions
• Understand the method of payment of service charges
• Explain how the HCC Risk Adjustment Model can identify areas of DCI interest
• Explain how the documentation affects the HCC risk adjustment and the patient’s RAF values
• Understand new payment models and documentation requirements (e.g. bulk payments, value-based payment modifiers)

Coding method

• 22 questions
• Use the CPT® Assistant guide for coding procedures
• Apply CPT® coding guidelines
• Apply understanding of important and separately identifiable data when coding multiple I / M and E / M services with procedures
• Show how data analysis affects the complexity of medical decision-making (interpreted by a doctor).
• Evaluate medical literature to determine the complexity of medical decision making
• Identify the correct use of time in the E / M documentation.
• Apply the risk table to determine the complexity of medical decision making
• Sick visits have been reported with preventive visits

Quality measures

• 15 questions
• Understand and identify HEDIS measures
• Know the requirements for meaningful use
• Identify the PQRS measurements and the correct documentation for the support
• Demonstrate knowledge of quality metrics and other value-based payment systems
• Understand strategies for capturing quality standards in documentation
• Understand the purpose of star ratings and domains.

Approved Manuals for Use During Examination

• CPT® Books (AMA standard or professional edition ONLY). No other publisher is allowed.
• Your choice of ICD-10-CM.
• Your choice of HCPCS Level II.