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CRC exam, Top Question with accurate answers, 100% Accurate, rated A+, verified. Risk Adjustment (a prospective payment system) - ✔✔-The process of increasing or reducing payments to health... plans to reflect higher or lower than expected spending. Risk adjusting is designed to compensate health plans that enroll an older and sicker population as a way to discourage plans from selecting only healthier enrollees. What is the goal when coding for risk adjustment? - ✔✔-code ALL current dx What is the purpose of collecting dx in risk adjustment coding? - ✔✔-Adjust potential risk measure & eval all Pts on an equal scale levels the playing field of age, race, gender, & socioeconomics What is the acronym for risk adjustment coding? - ✔✔-HCC (Hierarchical Condition Category) What elements would NOT be taken in to consideration for risk adjustment? - ✔✔-number of years Pt. has been covered under medicare advantage Which medical records can be submitted for HCC validation? - ✔✔-+MD office progress note +Outpatient hospital +Critical access hospital What is the purpose of risk adjustment values? - ✔✔-to budget care of a patient for the following year What are risk adjustment models used for? - ✔✔-To determine projected costs of healthcare based on the conditions of patients Which is NOT to be taken into consideration for risk adjustment? - ✔✔-Frequency of office visits How is predictive modeling used in risk adjustment? - ✔✔-determine suspected dx based on data elements What is the reporting period for risk adjustment coding? - ✔✔-Jan > Dec What risk adjustment model is used by Medicaid? - ✔✔-CDPS (Chronic Illness & Disability Payment System) What is CDPS? - ✔✔-Chronic Illness & Disability Payment System What risk adjustment model incorporates High, Medium, & Low risk in the numeric value - ✔✔-CDPS what is the default if type of DM is not specified? - ✔✔-DM2 How to code when a Pt. is seen for management of anemia d/t malignancy? - ✔✔-1st code - malignancy 2nd code - anemia How to code tobacco use AND dependence on tobacco - ✔✔-only code dependence on tobacco (F17.2-) What is the length of time for a MI to be considered "acute"? - ✔✔-4 weeks/28 days How is glaucoma reported? - ✔✔-only code stage of glaucoma What is the sequencing order when coding a sequela (late effect)? - ✔✔-1st- residual condition 2nd- cause of the late effect What is reported by a provider for beneficiaries in Medicare Advantage plans? - ✔✔-presenting problems, & all chronic conditions How often should a provider see a Pt. to validate amputation status? - ✔✔-once a year PEG Tube - ✔✔-+percutaneous endoscopic gastrostomy tube +G-tube +gastrostomy All conditions listed on the problem list for DM patients are coded as complications of DM: True or False? - ✔✔-False What is true regarding hierarchies? - ✔✔-Utilized by some private payers Quality Measures like Star Ratings and HEDIS have NO correlation with the medical record that is collected to support risk adjustment. TRUE or FALSE? - ✔✔-FALSE Is HEDIS a division of CMS or Medicaid? - ✔✔-NO Who developed HEDIS? - ✔✔-NCQA (National Committee for Quality Assurance) How is HEDIS data collected? - ✔✔-+surveys +medical chart reviews +insurance claims What is the goal of HEDIS (Health Plan Employer Data Info Set)? - ✔✔-for consumers to compare health plans How often are HEDIS measures revised? - ✔✔-Annually Which payers uses HEDIS measures? - ✔✔-a variety RADV - ✔✔-Risk Adjustment Data Validation What is the purpose of a RADV audit? - ✔✔-Verify accuracy of dx submitted for payment When submitting records for RADV audit, will additional current dx that were not originally reported by considered when documentation is submitted for the audit? - ✔✔-Yes! additional current dx not included on claims data may be approved during the audit. The submission of all dx (w/HCCs) are cumulative, so there may be a neg. or a pos. outcome overall from a $ perspective What info is verified during RADV audit? - ✔✔-All dx codes are supported in the medical record Which of the following criteria would be components of an acceptable medical record in a RADV? - ✔✔- +encounter must be a face-to-face visit +encounter must be from an acceptable provider type +condition(s) must be documented in the medical rec. +encounter must include a signature or attestation How many records are submitted per Pt. in a RADV audit? - ✔✔-5 Definition of the best record for a RADV audit - ✔✔-documentation validates the CMS requested HCCs, contains all the necessary documentation elements, & has ADDITIONAL HCCs not requested by CMS What info is required when submitting documentation to support a dx for a RADV/IVA - ✔✔-outpatient - single DOS hospital - full inpatient set How is Medicare Funding allocated? - ✔✔-Based on previous years known dx (retrospective) What data elements are used in predictive modeling? - ✔✔-+DME claims +RX events +MD claims data +Facility claims data What are the domains in PQRS (Physician Quality Reporting System)? - ✔✔-+community population health +effective clinical care +efficiency & cost reduction +patient safety What is reported when the provider documents arrow up HTN - ✔✔-query MD What is an acceptable signature? - ✔✔-Handwritten INPATIENT setting - how would you code uncertain dx? (uncertain = probable, suspected, possible, questionable) - ✔✔-Code the condition as if it was established dx OUTPATIENT setting - how would you code an uncertain dx? - ✔✔-code as a sign or symptom or abnormal labs When can hemiparesis be coded? - ✔✔-+weakness on one side of body +weakness on one side of body s/p CVA How long can an addendum be added to documentation? - ✔✔-"reasonable time frame"/ 60 days When does Medicare require the provider to sign the medical record? - ✔✔-"timely" basis When are CA dx coded as "current"? - ✔✔-When receiving treatment Meds for CA to eradicate or for prophylaxis - ✔✔-Tamoxifen, Anastrozole When is it appropriate to use Hx of malignancy? - ✔✔-+it has been excised, +no evidence of any existing primary malignancy +there is no further tx directed to the site Funding is allocated based on what for COMMERCIAL plans - ✔✔-Current year's dx The Star Ratings program monitors? - ✔✔-Performance of Medicare Advantage Plans Ratings are published by CMS in Oct. What is True about the Star Quality Rating system? - ✔✔-Quality bonus payments are made to medicare advantage plans who score 5 or 4 stars BONUS= 5 or 4 In the Star Program what is the lowest rating a plan must achieve to avoid penalties? - ✔✔-4 No Penalities = 5 > 4 Penalities = 1,2,3 *Pts enrolled in a poorly performing plan can switch an a 5-star plan at ANY time In the Star program which measure is given the highest weight? - ✔✔-Outcomes What is true regarding the Star Program? - ✔✔-States can either use the federal methodology OR Propose an alternative for certification of HHS What do the star ratings identify? - ✔✔-top perfoming health plans based on quality What element of the medical record is NOT used to capture current dx? - ✔✔-Radiology report Medicare defaults much of its risk adjustment dx coding guidelines to: - ✔✔-Official Coding Guidelines, & Coding Clinic Coding Clinic is associated with? - ✔✔-AHA (American Hosp. Assoc.) What is the purpose of collecting dxs in risk adjustment coding? - ✔✔-Risk adjustment factor (RAF) What is the impact on reimbursement under the risk adjustment model if chronic conditions are not coded? - ✔✔-Failure to code for ALL chronic conditions may result in an inaccurate RAF What is the purpose of capturing codes in an HCC model? - ✔✔-determine the combined RAF When is "added value" factored into the RAF for the HC model for disease interaction? - ✔✔-when two chronic illness paired together are complex to treat What would lead to an underpayment? - ✔✔-failing to report all the dxs supported in the medical record What is the next step after predictive modeling identifies a dx gap? - ✔✔-perform a retrospective audit to confirm proper dx code selection Which of the following is a quality review measure? - ✔✔-PQRS (physician quality reporting system) How are PQRS measures reported to CMS? - ✔✔-Claims data GPRO (Group Practice Reporting Option) Which risk adjustment model is used for commercial plans & uses metal levels to classify Pts? - ✔✔-HHS The HCC risk adjustment model - ✔✔-+helps forecast anticipated health cost +adjusts payments based on dx +helps ID Pts. with higher medical needs Under the HHS hierarchical condition category model, which plan has the HIGHEST out-of-pocket expenses once premium is paid - ✔✔-Bronze Under the HHS and HCC model, which plan has the LOWEST out-of-pocket expense once the premium is paid? - ✔✔-Platinum Which plan offers the BEST Value for savings out of pocket for the HHS HCC? - ✔✔-Silver What is true regarding HCCs? - ✔✔-Not all dx codes are assigned an HCC Which provider is NOT an approved provider for dx code capture under the Medicare HCC model? - ✔✔- anesthesiology assistant Which elements are considered in the Medicare HCC model? - ✔✔-+age +gender +disability status +socioeconomic status +insurance status (medicare/medicaid/etc) +claims data elements (procedure codes, place of service codes) +special Pt.-specific conditions (ESRD, hospice) +HCCs focus on illnesses that affect the LT-care of Pt Where can a list of dx-mappings to HCCs be located? - ✔✔-CMS website For the HHS HCC model, who is included in the adult model? - ✔✔-those aged 21 + child model = 2-20yrs infant model= birth-1yrs What is the purpose of the coding intensity adjustment? - ✔✔-+determine different coding pttns in HCC compared to INPATIENT claims covered by Part A +determine different coding pttns in HCC compared to OUTPATIENT claims covered by Part B Each year, Medicare normalizes risk scores to maintain an avg of? - ✔✔-1.0 When are retrospective reviews usually performed? - ✔✔-AFTER the dx and risk factor data has been reported to CMS How is FFS data used for the purpose of risk adjustment? - ✔✔-used to determine the FFS normalization adjustment In CDPS risk adjustment models, where do heart attacks fall? - ✔✔-Medium (VH=heart transplant/valves, Low=heart dis, ExLow=HTN) Under the ACA, can health plans set the premium rate based on Pt's health status? - ✔✔-NO! health plans can NOT charge different premiums based on health status What are extra risk adjustment values/factors added when a patient has more than one major significant dx identified in the model? - ✔✔-Interactions When are prospective reviews performed? - ✔✔-BEFORE the dx & risk factor data is submitted to CMS What type of fracture is considered traumatic? - ✔✔-compound fracture When code for External Causes? - ✔✔-Causes of injury or health condition Which structure in the urinary system differs in position/length between males & females? - ✔✔- Urethra urine is transported from kidneys to bladder via - ✔✔-ureter Where is bile produced? - ✔✔-produced =liver stored= gall bladder What belongs to the appendicular skeleton? - ✔✔-pelvic girdle which membrane is found lining the interior walls of the digestive system? - ✔✔-mucous Small Intestine - ✔✔-duodenum > jejunum > ileum Large intestine - ✔✔-appendix>cecum>ascending>transverse>descending> sigmoid>rectum Term for draining pus out of ear - ✔✔-otopyorrhea Example of a long bone - ✔✔-metacarpal Gland that secretes thyroid hormone & calcitonin - ✔✔-thyroid gland Great Toe - ✔✔-Hallux Glaucoma - ✔✔-abnormally high intraocular pressure NOT part of the skin - ✔✔-hypodermis C-shaped structure surrounding the glomerulus - ✔✔-Bowman's capsule Layers of the digestive tract (inner>outermost) - ✔✔-mucosa> submucosa>muscle>serosa carries sperm out the epididymis to urethra - ✔✔-vas deferens Bone that has trochanters - ✔✔-Femur Does NOT contribute to refraction of the eye - ✔✔-does NOT contribute = Macula does contribute = cornea, lens, aqueous pneumomediastinum - ✔✔-Air entrapped with [Show More]

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