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It covers the purpose and requirements of compliant medical records, including HIPAA and record components, and explains provider communication, federal regulations, OIG, and physician queries. The guide also details quality measures such as CMS Star Ratings, HEDIS, and bundled payments, then connects coding and reimbursement topics including CPT®, RBRVS, modifiers, medical necessity, advance beneficiary notice, and risk adjustment, followed by diagnosis coding chapter coverage.",{"@graph":69,"@context":122},[70,84,105],{"@type":71,"itemListElement":72},"BreadcrumbList",[73,77,79,82],{"item":74,"name":75,"@type":76,"position":8},"https://docshare.wps.com","Home","ListItem",{"item":78,"name":9,"@type":76,"position":14},"https://docshare.wps.com/document/",{"item":80,"name":35,"@type":76,"position":81},"https://docshare.wps.com/document/healthcare/",3,{"item":83,"name":65,"@type":76,"position":19},"https://docshare.wps.com/document/cdeo-documentation-expert-outpatient-study-guide-chapter-1-purpose-of-clinical-documentation-improvement/388200/",{"url":83,"name":65,"@type":85,"image":86,"author":91,"headline":65,"publisher":94,"fileFormat":97,"inLanguage":63,"description":67,"dateModified":98,"datePublished":99,"encodingFormat":97,"isAccessibleForFree":100,"interactionStatistic":101},"DigitalDocument",{"url":87,"@type":88,"width":89,"height":90},"https://docshare.wps.com/thumbnails/cdeo-documentation-expert-outpatient-study-guide-chapter-1-purpose-of-clinical-documentation-improvement/388200.png","ImageObject",300,407,{"name":92,"@type":93},"Elsa","Person",{"url":74,"name":95,"@type":96},"DocShare","Organization","application/pdf","2026-09-28","2026-09-25",true,{"@type":102,"interactionType":103,"userInteractionCount":81},"InteractionCounter",{"@type":104},"ViewAction",{"@type":106,"mainEntity":107},"FAQPage",[108,114,118],{"name":109,"@type":110,"acceptedAnswer":111},"What is the main focus of the 2019 CDEO Documentation Expert Outpatient Study Guide?","Question",{"text":112,"@type":113},"It focuses on clinical documentation improvement and compliant documentation practices, then links those concepts to coding and reimbursement for outpatient settings.","Answer",{"name":115,"@type":110,"acceptedAnswer":116},"Which documentation requirements and privacy topic are covered in the guide?",{"text":117,"@type":113},"The guide includes an overview of documentation requirements and specifically covers HIPAA and medical record components and sources.",{"name":119,"@type":110,"acceptedAnswer":120},"What coding and reimbursement areas are addressed in Chapter 5?",{"text":121,"@type":113},"Chapter 5 covers RBRVS, modifier usage (including with NCCI), medical necessity, advance beneficiary notice, risk adjustment, Medicare HCC, and HHS hierarchical condition category modeling.","https://schema.org",{"og:url":83,"og:type":124,"og:title":65,"og:site_name":95,"og:description":67},"article",{"robots":126,"canonical":83},"index,follow",{"doc_id":128,"site_id":62},388200,1790413215,{"code":4,"msg":5,"data":131},{"doc_id":128,"user_id":132,"nickname":92,"user_avatar":133,"doc_module":4,"category_id":34,"category_name":35,"doc_title":65,"doc_description":67,"doc_content":134,"file_id":135,"file_url":136,"file_type":137,"file_size":138,"view_count":81,"is_deleted":4,"is_public":8,"is_downloadable":8,"audit_status":8,"page_count":139,"language":140,"language_code":63,"site_id":62,"html_lang":63,"table_of_contents":141,"faqs":142,"seo_title":143,"seo_description":67,"update_tm":144,"read_time":41},137455077381,"https://ap-avatar.wpscdn.com/davatar_994ba38a5ba835b3df7d355c54d3ed8d","MEDICAL CODING TRAINING  \nCDEO®  \nDOCUMENTATION EXPERT OUTPATIENT  \nSTUDY GUIDE  \n2019  \nCDEO™ Study Guide  \nDisclaimer  \nAAPC does not accept responsibility or liability for any adverse outcome from using this study program for any reason including undetected inaccuracy, opinion, or analysis that might prove erroneous or amended, or the coder’s misunderstanding or misapplication of topics.  \nAAPC has obtained permission from various individuals and companies to include their material in this manual. These agreements do not extend beyond this program. It may not be copied, reproduced, dismantled, quoted, or presented without the expressed written approval of AAPC and the sources contained within.  \nNo part of this publication covered by the copyright herein may be reproduced, stored in a retrieval system, or transmitted in any form or by any means (graphically, electronically, or mechanically, including photocopying, recording or taping) without the expressed written permission from AAPC and the sources contained within.  \nAMA Disclaimer  \nCPT® copyright 2018 American Medical Association (AMA). All rights reserved.  \nFee schedules, relative value units, conversion factors and/or related components are not assigned by the AMA and are not part of CPT®. The AMA is not recommending their use. The AMA does not directly or indirectly practice medicine or dispense medical services. The AMA assumes no liability for data contained or not contained herein.  \nCPT® is a registered trademark of the AMA.  \n© 2018 AAPC  \n2233 South Presidents Dr. Suites F-C, Salt Lake City, UT 84120  \n800-626-2633, Fax 801-236-2258, [www.aapc.com](www.aapc.com)  \nUpdated 01292019. All rights reserved.  \nISBN 978-1-626888-890  \nCPC®, CIC™, COC™, CPC-P®, CPMA®, CPCO™, and CPPM® are trademarks ofAAPC.  \nContents  \nChapter 1  \nPurpose of Clinical Documentation Improvement  ....................................................... 1  \nThe Professional Side of Clinical Documentation .............................................................. 1  \nChapter 2  \nDocumentation Requirements  ....................................................................... 7  \nIntroduction .............................................................................................. 7  \nHealth Insurance Portability and Accountability Act (HIPAA) .................................................. 7  \nThe Medical Record....................................................................................... 14  \nMedical Record Components .............................................................................. 19  \nSources ................................................................................................. 22  \nChapter 3  \nProvider Communication and Compliance  ............................................................ 25  \nFederal Regulations ....................................................................................... 25  \nOffice of Inspector General (OIG) .......................................................................... 28  \nPhysician Queries ........................................................................................ 37  \nChapter 4  \nQuality Measures  ................................................................................. 41  \nCMS Star Ratings......................................................................................... 41  \nThe Healthcare Effectiveness Data and Information Set (HEDIS®) .............................................. 42  \nBundled Payments ........................................................................................ 46  \nChapter 5  \nCoding and Reimbursement  ........................................................................ 49  \nIntroduction ............................................................................................. 49  \nResource-Based Relative Value Scale (RBRVS)................................................................ 49  \nHow to Use the RBRVS.........","cbCaiptqOlyudmwN","https://ap.wps.com/l/cbCaiptqOlyudmwN","pdf",1739366,12,"English","# Chapter 1 Purpose of Clinical Documentation Improvement\n## The Professional Side of Clinical Documentation\n# Chapter 2 Documentation Requirements\n## Introduction\n## Health Insurance Portability and Accountability Act (HIPAA)\n## The Medical Record\n## Medical Record Components\n## Sources\n# Chapter 3 Provider Communication and Compliance\n## Federal Regulations\n## Office of Inspector General (OIG)\n## Physician Queries\n# Chapter 4 Quality Measures\n## CMS Star Ratings\n## The Healthcare Effectiveness Data and Information Set (HEDIS®)\n## Bundled Payments\n# Chapter 5 Coding and Reimbursement\n## Introduction\n## Resource-Based Relative Value Scale (RBRVS)\n## How to Use the RBRVS\n## Modifiers\n## Modifier Usage with NCCI\n## Medical Necessity\n## Medical Necessity and CMS\n## Advance Beneficiary Notice\n## Risk Adjustment\n## Types of Risk Adjustment Models\n## Medicare Hierarchal Condition Categories (HCC)\n## Fee-For-Service (FFS) Normalization Adjustment\n## The Health and Human Services (HHS) Hierarchical Condition Category Model\n# Chapter 6 Clinical Conditions and Diagnosis Coding Part I: Chapters 1-11\n## Chapter 1: Certain Infectious and Parasitic Diseases (Codes A00–B99)\n## Chapter 2: Neoplasms (Codes C00–D49)\n## Chapter 3: Diseases of the Blood and Blood-Forming Organs and Certain Disorders Involving the Immune Mechanism (D50-D89)","[{\"question\":\"What is the main focus of the 2019 CDEO Documentation Expert Outpatient Study Guide?\",\"answer\":\"It focuses on clinical documentation improvement and compliant documentation practices, then links those concepts to coding and reimbursement for outpatient settings.\"},{\"question\":\"Which documentation requirements and privacy topic are covered in the guide?\",\"answer\":\"The guide includes an overview of documentation requirements and specifically covers HIPAA and medical record components and sources.\"},{\"question\":\"What coding and reimbursement areas are addressed in Chapter 5?\",\"answer\":\"Chapter 5 covers RBRVS, modifier usage (including with NCCI), medical necessity, advance beneficiary notice, risk adjustment, Medicare HCC, and HHS hierarchical condition category modeling.\"}]","CDEO - Documentation Expert Outpatient Study Guide - Chapter 1 Purpose of Clinical Documentation Improvement | PDF",1790296379]