CDEO flashcards

32 cards. Read the term and the definition here. The deck at the top of this page is optional.

Total time threshold

For 2021 office and outpatient E/M, 99214 requires 30 to 39 minutes of total time on the encounter date, including both face-to-face and non-face-to-face activities by the billing provider.

MDM two-of-three rule

A level of medical decision making is supported when at least two of three elements are met: number and complexity of problems addressed, amount and complexity of data, and risk of morbidity or mortality.

Extended HPI

Four or more documented HPI elements such as location, quality, severity, duration, timing, context, modifying factors, and associated signs or symptoms constitute an extended history of present illness.

Complete review of systems

A review of systems is complete when 10 or more of the 14 organ systems are reviewed, or when a statement of all other systems negative follows documentation of at least two systems.

Prescription drug management

Under the 2021 MDM risk tables, prescription drug management is a moderate-risk element, while over-the-counter medication use counts as low risk.

Documentation amendment rules

Corrections must be dated, timed, and signed by the author with the original content retained; entries may never be backdated, deleted, or overwritten in the medical record.

Cloned documentation

Identical or copy-pasted note content across different encounters indicates cloning, which may be treated as unsupported or fraudulent and is routinely flagged during compliance audits.

Medical necessity standard

Services must be reasonable and necessary for diagnosing or treating illness or injury, and the record must show the clinical rationale rather than only listing diagnoses or tests.

Modifier 25

Reports a significant, separately identifiable evaluation and management service by the same provider on the day of a procedure; the E/M must have its own documented indication and findings.

NCCI indicator zero

A procedure-to-procedure edit with modifier indicator 0 cannot be bypassed by any modifier; both codes cannot be reported for the same patient encounter.

Incident-to requirements

Medicare incident-to billing requires an established patient, a service that is part of a physician-established plan of care, and direct supervision by the billing physician.

Global surgical package

Postoperative care included in the surgical code: 000 days for minor procedures without follow-up, 010 days for minor with follow-up, and 090 days for major procedures.

Teaching physician documentation

Resident or student notes may support history, exam, and review of systems when the teaching physician verifies them; medical decision making must be personally documented by the teaching physician.

Place of service 11

Place of service code 11 designates services furnished in a physician office, which generally pays at a different rate than the same service in an outpatient hospital setting.

Compliance program elements

The seven elements are written policies, a designated compliance officer, effective training, open communication, internal monitoring and auditing, enforcement of standards, and corrective action.

Undercoding exposure

Reporting a service lower than what documentation supports loses legitimate revenue and can be viewed as misrepresentation of services, making it a reviewable compliance risk.

HCC hierarchy

When multiple conditions map to related hierarchical condition categories, only the most specific and highest-ranked condition in the hierarchy is counted toward the risk score.

MEAT criteria

Chronic conditions are supported for risk adjustment when documentation shows monitoring, evaluation, assessment, or treatment, and each condition's status should be addressed at least annually.

Risk score of 1.0

A risk score of 1.0 represents average expected cost for the population; scores above 1.0 predict higher-than-average future healthcare expenditure for that member.

RADV audit

Risk Adjustment Data Validation audits confirm that diagnoses submitted for Medicare Advantage payment are supported by the medical record; unsupported diagnoses must be repaid.

HEDIS

The Healthcare Effectiveness Data and Information Set is a standardized set of quality performance measures used by health plans, calculated largely from claims and encounter data.

MIPS Quality category

The Merit-based Incentive Payment System Quality category is weighted 30 percent and scores clinicians on measures such as diabetes control and cancer screening.

Unsupported suspect diagnosis

A condition that is only suspected, implied, or listed without provider confirmation cannot be reported as confirmed; outpatient records require provider documentation of the condition as present.

Controlling high blood pressure

A HEDIS measure assessing the percentage of adults aged 18 to 85 with hypertension whose most recent blood pressure reading was adequately controlled.

Effective provider feedback

Feedback is most effective when timely, behavior-specific, tied to documented evidence and published guidelines, delivered privately, and framed around patient care rather than punishment.

Non-leading query

A compliant query presents the clinical facts and asks the provider for clarification without suggesting a specific diagnosis or code the provider has not already documented.

Provider education documentation

Record the date, audience, topics covered, materials used, and any acknowledgement; retained education records evidence an ongoing and effective compliance program.

Error rate trending

Tracking documentation and coding error rates by provider, specialty, and code family over time targets education and demonstrates improvement after an intervention.

Adult learning principles

Provider education is more effective when problem-centered, immediately relevant to the clinician's practice, and built from their own de-identified audited cases.

Query is part of record

Clarifying queries and the provider's responses become part of the medical record and must be retained; diagnoses cannot be added retrospectively solely for coding purposes.

Denial trend review

Analyze denial reason codes and remittance advice data to identify recurring documentation gaps, then route those findings into targeted provider education sessions.

Provider champion

A respected peer clinician who models documentation standards and delivers education within the specialty, improving engagement compared with coder-only outreach.