Certified Documentation Expert Outpatient (CDEO®) - Certification Exam

The Certified Documentation Expert Outpatient (CDEO®) credential validates expertise in reviewing outpatient documentation for accuracy to support coding, quality measures, and clinical requirements. CDEO professionals provide feedback to providers to improve clinical documentation and facilitate ongoing documentation improvement to meet all requirements of the medical record. To become a CDEO, documentation professionals must demonstrate knowledge of pathophysiology, coding and billing guidelines, and quality measures.

How Much CDEOs Earn May Surprise You

AAPC's 2022 Medical Coding Salary Survey showed that obtaining CDEO certification can help healthcare business professionals exceed the average annual medical coding salary of $54,797. In fact, the CDEO is among the highest paid credential, with an average annual salary of $73,723.

With a CDEO credential, you have:

  • Expertise in reviewing medical documentation for accuracy
  • The ability to identify and communicate documentation deficiencies to providers to improve documentation for accurate risk adjustment coding
  • A sound knowledge of medical coding guidelines and regulations, including compliance and reimbursement. This allows for a clear understanding of the impact of coding on payment models.
  • A thorough understanding of anatomy, pathophysiology, and medical terminology necessary to correctly code using CPT®, ICD-10-CM, and HCPCS Level II coding systems.

The CDEO® Exam

  • 100 multiple choice questions (proctored)
  • 4 hours to finish the exam
  • Open code book (manuals)

The examination consists of questions regarding the review of outpatient medical records for accuracy and correct application of CPT®, ICD-10-CM, HCPCS Level II codes, and quality measures. Examinees must also demonstrate knowledge on proper query procedures and effective communication for documentation improvement.

The CDEO exam thoroughly covers:

  • 5 questions
  • Holistic, integrated, aggregate use of the medical record
  • Explain the goal of physician based clinical documentation improvement
  • Clear picture of health and status
  • Improved patient outcomes
  • 10 questions
  • Explain how the OIG can assist in determining areas of CDI focus
  • Identify strategies for communicating crucial messages
  • Demonstrate ability to write a non-leading provider query
  • Demonstrate ability to provide a rationale for queries
  • 20 questions
  • For each of clinical conditions listed below: understand clinical picture, criteria for diagnosis (lab work, radiology, etc.), common medications, common abbreviations, common treatment profiles. Understand documentation requirements necessary for code assignment based on ICD-10 guidelines.
    • Aortic aneurysm
    • Amputation
    • Artificial openings
    • Aortic stenosis/sclerosis
    • Adjuvant therapy
    • Burns
    • CAD
    • Congenital versus acquired conditions
    • Anemia (blood loss) polycythemia
    • Crohn's disease
    • Common conditions of the ear
    • Common conditions in pregnancy
    • Cirrhosis
    • Chronic Kidney Disease
    • Cardiomyopathy
    • Cardiac conduction conditions – A-fib, sick sinus syndrome
    • Chronic Obstructive Pulmonary Disease– bronchitis, asthma
    • CVA vs. TIA
    • Drug Dependence
    • Diabetes
    • Deep Vein Thrombosis
    • Epilepsy
    • Fractures
    • Heart failure
    • Head injury
    • HIV/AIDS
    • Hemiplegia
    • Hypertension
    • Active versus history of neoplasm
    • Hypoxia
    • Malnutrition
    • Major Depression
    • Metastatic
    • Myocardial infarction
    • Morbid obesity and BMI
    • Neuropathy
    • Parkinson's disease
    • Pathological osteoporosis fractures
    • Pneumonia
    • Common conditions in the perinatal period
    • Pressure ulcers
    • Peripheral vascular disease
    • Rheumatoid arthritis
    • Sepsis
    • Sequelae events (stroke, trauma)
    • Transplant status
    • Venous stasis ulcers
  • 10 questions
  • Identify clinically active vs. historical conditions
  • Ensure support documented for etiology and manifestation
  • Apply Coding Clinic guidance to ICD-10 coding issues.
  • Recall ICD-10-CM Outpatient Coding Guidelines
  • Code selected conditions to the highest level of specificity that documentation supports.
  • Select the first listed diagnosis on a claim
  • 10 questions
  • Ability to properly correct errors and audit requirements of who documented
  • Identify cloned and cut and paste documentation
  • Requirements for a complete medical record
  • Understand requirements for proper use of templates
  • Identify correctly authenticated notes in situations where multiple authors have documented within a note (MA, scribe, provider)
  • Demonstrate an understanding of the responsibilities of medical and clinical staff as it relates to documentation
  • Electronic signature requirements vs paper signature requirements
  • Documentation to support billing and coding for supplies (drugs) administered in office
  • Documentation to support diagnostic tests (labs, radiology, medicine)
  • Selecting the codes from a coding software pick lists
  • Identify clinically valid diagnoses when considering number of conditions managed and treated and identifying "note bloat"
  • Management of problem lists
  • Distinguish between acceptable and unacceptable use of abbreviations within the medical record (Legibility)
  • Timely completion of medical records
  • 5 questions
  • Understand fee-for-service payment methodology
  • Explain how the HCC Risk adjustment model can determine areas of CDI focus
  • Explain how documentation affects HCC risk adjustment and patient RAF scores
  • Understand new payment models and documentation requirements (eg, bundled payments, value based payment modifiers)
  • 10 questions
  • Apply CPT® Assistant guidance related to procedure coding
  • Apply CPT® coding guidelines
  • Apply understanding of significant and separately identifiable when coding multiple E/M services and E/M services with procedures
  • Show how analysis of data applies to complexity of medical decision making (interpreted by a physician)
  • Evaluate physician documentation to determine complexity of medical decision making
  • Identify correct use of time in documentation of E/M
  • Apply the table of risk in determining complexity of medical decision making
  • Sick visits reported with preventive visits
  • 10 questions
  • Understand and identify HEDIS measures
  • Know the requirements for meaningful use
  • Identify PQRS measures and proper documentation for support
  • Demonstrate knowledge of quality measures and other value based payment systems
  • Understand strategies for capturing quality measures within documentation
  • Understand the purpose of the Stars rating and the domains.
  • 10 cases with 20 multiple choice questions
  • Identify documentation to support codes.
  • Identify documentation deficiencies in a medical record.
  • Select a provider query applicable to the medical record.
  • Select supporting regulations to identify why additional documentation is required.
  • Select the correct cods based on documentation.

Approved References for Use During the CDEO Exam

Because code sets are updated annually, it’s essential that you use the current calendar year's code books when taking the certification exam.

Confirm what reference materials are allowed during the CDEO certification exam.

Exam Book Bundle 2022 (CPT®, HCPCS, ICD-10-CM)

AMA CPT® Professional 2022 - Now Shipping
HCPCS Level II Expert 2022 - Now Shipping
ICD-10-CM Complete Code Set 2022 - Now Shipping
Retail: $359.99   Save: $130.00 (36%)
Non-Member: $259.99
Member: $229.99

Exam Bundle includes the AMA CPT® Professional, ICD-10-CM Expert, and HCPCS Level II Expert — the three code books students need for nearly every AAPC exam, including AAPC’s Certified Documentation Expert - Outpatient (CDEO) exam.

Note:

Electronic devices with an on/off switch (cell phones, smart phones, tablets, etc.) are not allowed into the examination room. Failure to comply with this policy may result in disqualification of your exam.

Any officially published errata for the above code books may also be used.

CDEO Certification Exam Requirements

Clinical documentation improvement involves compliance to documentation requirements and effective communication with providers to improve documentation. CDEO candidates should undergo certification training and/or have experience in clinical documentation improvement.

Please be aware that this is a difficult, high-level examination and not intended for individuals with limited clinical documentation improvement background.

Additional Requirements

  • Maintain annual AAPC membership
    • If you haven’t become an AAPC member, you must do so prior to scheduling your CDEO exam
    • Renewing members must have a current membership at the time of exam application and/or when exam results are released.
  • Certified documentation specialists are required to complete 36 Continuing Education Units (CEU's) every two years. For CEU requirements please see ourCEU Information page.

Note:

An overall score of 70% or higher is required to pass the certification exam. If you don’t pass, the areas of study/categories with a score of 65% or less will be provided for your preparation to retest. The areas of study reported reflect scores based on the number of questions in each category/section of the exam.

The CDEO certification exams exclusively measure proficiencies relating to performing the duties of a CDEO. To earn additional credentials requires you to pass additional certification exams.

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