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Certified Documentation Expert Outpatient (CDEO®)

The CDEO credential validates a documentation professional’s expertise in reviewing outpatient documentation for accuracy in the support of 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.

The Certified Documentation Expert-Outpatient abilities include:

  • Expertise in reviewing medical documentation for accuracy.
  • 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 – allowing a CDEO to understand the impact of coding on payment models.
  • Knowledge of anatomy, pathophysiology, and medical terminology necessary to correctly code CPT®, ICD-10-CM, and HCPCS Level II.

The CDEO® Exam

  • 150 multiple choice questions (proctored)
  • 5 hours and 40 minutes to finish the exam
  • One free retake
  • $350 ($290 AAPC Students) Limited time Introductory price $175 ($145 AAPC Students)
  • 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:

  • 8 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
  • 15 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
  • 45 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
  • 22 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
  • 15 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
  • 8 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)
  • 22 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
  • 15 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.

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 (Exams will test ICD-10 effective January 1, 2016).
  • Your choice of HCPCS Level II.
  • One reference of your choice

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 these manuals may also be used. No other manuals are allowed. Each code set is updated annually; it is essential that examinees use the current calendar year's coding manuals when taking the certification exam.

Non-Approved Manuals for Use During Examination

Due to the advantages of additional information and/or ease of use, the following books cannot be used during the exam:

  • Current Procedural Coding Expert® - Ingenix
  • Current Procedural Coding Expert® - Ingenix
  • Procedural Coding Professional - Contexo
  • Procedural Coding Professional - AAPC
  • Procedural Coding Expert - Contexo
  • Procedural Coding Expert - AAPC
  • CPT® Insider's View - AMA
  • CPT® Plus! - PMIC
  • Coders' Choice CPT® - PMIC
  • ICD-10-CM Easy Coder

Exam Requirements

While there is no experience requirement, we strongly recommend that the candidate have at least two years of experience in clinical documentation improvement.

Please be aware that this is a difficult, high-level examination which is not meant for individuals with little, limited or no clinical documentation improvement

Other requirements:

  • We recommend having an associate's degree
  • Pay examination fee at the time of application submission
  • Maintain current membership with the AAPC
    • Renewing members must have a current membership at the time of submission and when exam results are released.
    • Renewing members must be current at the time of application submission as well as when results are sent
  • Materials to bring:
    • Current CPT® (AMA Standard or Professional versions only)
    • ICD-10-CM
    • HCPCS Level II
    • One reference book of your choice

Exam Recommendation

The CDEO™ examination is recommended for a certified coder, medical record auditor or clinical documentation improvement professional who has experience reviewing documentation for outpatient services and extensive knowledge of coding and quality measure reporting. Clinical documentation improvement involves compliance to documentation requirements and effective communication with providers to improve documentation.

Maintaining Certification

Membership is required to be renewed annually and 36 Continuing Education Units (CEU's) must be submitted every two years for verification and authentication of expertise. For CEU requirements please see our CEU Information page.

Which certification is right for you?

Call 877-290-0440 or have a career counselor call you.

Questions about what books to order?

Call 877-524-5027 to speak with a specialist.