CRC Exam, top Questions with accurate answers, 100% Accurate, graded A+ to determine suspected diagnosis based on data elements. - ✔✔-How is predictive modeling used in risk adjustment? d. I... , II, III, and IV - ✔✔-Which of the following data elements are used in predictive modeling? I. DME claims II. Prescription drug events III. Physician claims data IV. Facility claims data a. III and IV b. I, II, and IV c. I, II, and III d. I, II, III, and IV a. Disease management programs - ✔✔-What might happen as a result of predictive modeling? a. Disease management programs b. Concurrent audits c. Transporation benefits d. Reduction in case management a. Outcomes - ✔✔-In the CMS Star Ratings program, which measure is given the highest weight? a. Outcomes b. Patient experience c. Customer service d. Accurate RAF scores d. Annually - ✔✔-How often are HEDIS measures revised? a. As needed b. Monthly c. Bi-annually d. Annually b. Quality bonus payments are made to Medicare Advantage plans who score at least four stars. - ✔✔- Which statement is TRUE regarding the CMS Stars quality rating system? a. Quality bonus payments are made to physician who score at least four stars. b. Quality bonus payments are made to Medicare Advantage plans who score at least four stars. c. Quality bonus payments are made to physician who score at least five stars. d. Quality bonus payments are made to Medicare Advantage plans who score at least five stars. c. I, II, III, and V - ✔✔-Merit-based Incentive Payment System (MIPS) includes which performance categories? I. Promoting Interoperability II. Cost III. Improvement Activities IV. Quantity V. Quality a. I and II b. I, III, and V c. I, II, III, and V d. I, II, III, IV, and V c. I, II, III, IV and V - ✔✔-Which of the following are domains in CMS Part C & D Stars Rating? I. Staying Healthy II. Managing Chronic Conditions III. Member Experience with Health Plans IV. Member Complaints, Problems Getting Services, and Improvement in the Health Plan's Performance V. Health Plan Customer Service a. I, II and III b. I, III, and V c. I, II, III, IV and V d. I, II, III and V c. I and III - ✔✔-What are the participation tracks available through Medicare Access and CHIP Reauthorization Act (MACRA)? I. Merit-based Incentive Payment Systems II. Sustainable Growth System III. Advanced Alternative Payment Models a. I b. II and III c. I and III d. I, II and III a. An analytical review of known data elements to establish a hypothesis related to the future health of patients. - ✔✔-What is predictive modeling? a. An analytical review of known data elements to establish a hypothesis related to the future health of patients. b. An analytical review of payments to health plans to determine the cost of future healthcare. c. An average of costs associated with diagnoses used to determine which providers to contract with for a health plan. d. An average payment associated with diagnoses used to determine which health plans providers should contract with. d. NCQA - ✔✔-Who developed and maintains HEDIS? a. CMS b. OIG c. BCBS d. NCQA a. Top performing health plans based on quality - ✔✔-What do the Star Ratings identify? a. Top performing health plans based on quality b. Top performing doctors based on quality c. Cost of healthcare in facilities d. Cost of healthcare by provider b. Allow patients to compare health plans. - ✔✔-What is the goal of HEDIS? a. Allow for patients to rate their physicians. b. Allow patients to compare health plans. c. Allow patients to schedule appointments online. d. Allow patients to access their medical records. c. October of each year. - ✔✔-When are Star Ratings are publicly published? a. January of each year. b. January and June of each year. c. October of each year. d. April and October of each year b. Determine suspected diagnoses based on data elements. - ✔✔-How is predictive modeling used in risk adjustment? a. Determine the RAF score in HCC compared to FFS. b. Determine suspected diagnoses based on data elements. c. Determine the correct enrollment process. d. Determine the return on investment for hiring coders. b. Asthma - ✔✔-If you were using predictive modeling and the results were: • Rx Claim: Albuterol (quick-relief inhaler) • Medical Claim: Pulmonary Function Test • DME claim: Home Nebulizer a. Diabetes mellitus b. Asthma c. Osteoporosis d. Hypertension d. Osteoporosis - ✔✔-If you were using a predictive model and the results were: • The member had a DME claim for a cane. • The member had an Rx Claim for a Fosamax. • The member had a medical claim for a bone density scan.Which diagnosis would you predict this member has? a. Osteoarthritis b. Degenerative joint disease of the knee c. Spinal Stenosis d. Osteoporosis b. Health plans often use predictive modeling to anticipate potential future diagnoses for an individual patient. - ✔✔-Which statement is TRUE regarding predictive modeling? a. Predictive models are only used to identify patients who develop comorbidities due to a lack of care. b. Health plans often use predictive modeling to anticipate potential future diagnoses for an individual patient. c. Predictive modeling identifies needs a patient had in the past that was not provided. d. Providers can use predictive modeling to identify when additional staff is required. all of the above - ✔✔-How is HEDIS data collected? I. Surveys II. Medical chart reviews III. Insurance claims All of the above d. I, II, and III - ✔✔-Predictive modeling can use many data elements. Which are beneficial for identifying a person with diabetes? I. Rx claims II. Medical claims III. DME claims a. I only b. I and II only c. II and III only d. I, II, and III a. Inpatient admission note - ✔✔-Which type of documentation can be used to support diagnoses reported under risk adjustment models? a. Inpatient admission note b. CT scan results c. CBC lab test d. Comprehensive problem list c. not all diagnosis codes are assigned an HCC - ✔✔-Which statement is TRUE regarding diagnosis codes and assigned HCCs? a. all diagnosis are assigned an HCC. b. all chronic illness are assigned an HCC. c. not all diagnosis codes are assigned an HCC. d. all acute exacerbations of an acute illness are assigned an HCC. b. CMS website. - ✔✔-Where can a list of diagnosis mappings to HCCs be located? a. OIG website. b. CMS website. c. OCR website. d. QPP website. b. States can either use the federal methodology or propose an alternate for certification by HHS. - ✔✔- Which of the following is TRUE regarding the risk adjustment model by HHS? a. States are mandated to use the Medicare HCCs. b. States can either use the federal methodology or propose an alternate for certification by HHS. c. States can either use the federal methodology or exclude risk adjustment logic from reimbursement. d. States can determine their own policy for payment without a risk adjustment component. c. No, any approved provider can validate any diagnosis. - ✔✔-When reporting a code for retinopathy, must the coder find documentation from an ophthalmologist in order to code the condition as an active condition? a. yes, speciality specific diagnosis can only be reported by a specialist. b. yes, ophthalmologist must diagnosis all eye related conditions. c. No, any approved provider can validate any diagnosis. d. No only PCP can provide supporting documentation for reported diagnoses. c. No, health plans can not charge different premiums based on health status. - ✔✔-Under the Affordable Care Act(ACA), can health plans change the premium rate based on a patient's health status where patients with more complex medical issues are required to pay a higher premium than patients with less complex medical issues? a. Yes, as long as the more complex medical conditions are documented. b. Yes, as long as the patient discloses the information when enrolling in a plan on the health care exchange. c. No, health plans can not charge different premiums based on health status. d. No, health plans are prohibited from participating in the ACA risk adjustment model. c. yearly RA must be compared to average FFS expenses and rates. The purpose of the FFS normalization adjustment issue that CMS payments are based on a population with an average risk score of 1.0. This s the national average. Annually, Medicare normalizes the risk scores to maintain an average res score of 1.0. - ✔✔-How often is the normalization factor adjusted? a. monthly b. twice per year c. yearly d. as needed b. Determine projected costs of healthcare based on conditions of patients. - ✔✔-Risk adjustment models are used to: a. Limit coverage of chronic conditions. b. Determine projected costs of healthcare based on conditions of patients. c. Determine the return on investment for developing proactive disease prevention outreach. d. Limit the coverage of hospital admissions. a. interactions Interactions are extra risk adjustment values or factors added when a patient has more than one major significant diagnosis identified in the model. These interactions add value because it is understood that having a combination of some diagnoses together increase clinical risk and associated costs of care. - ✔✔-What are the extra risk adjustment values or factors added when a patient has more than one major significant diagnosis identified in the model? a. interactions b. risk factors. d. demographic variances e. exceptions 1.0 - ✔✔-Each year, Medicare normalizes risk scores to maintain an average of what? c. Chronic Disability Payment System CDPS is the RA model used by Medicaid - ✔✔-What does the abbreviation CDPS indicate? a. Chronic Disability Provider Services b. Chronic Diagnosis Processing System c. Chronic Disability Payment System d. Chronic Disability Payment System c. I and II CMS is required to make an adjustment to reflect "differences in coding patterns between Medicare Advantage plans and providers under Pay A and B to the extent that the Secretary has identified such differences. - ✔✔-What is the purpose of the coding intensity adjustment? I. Determine different coding patterns in HCC compared to inpatient claims covered by Part A. II. Determine different coding patterns in HCC compared to outpatient claims covered by Part B. III. Determine different coding patterns in HCC compared to claims processed under CDPS. a. I b. II c. I and II d. I, II, & III c. Bronze - ✔✔-Under the Health and Human Services (HHS) Hierarchial Condition Category model, which of the below plans has the highest out of pock expense once the premium is paid? a. Silver b. Gold c. Bronze d. Platinum a. Silver - ✔✔-Which plan offers the best value for savings out of pock costs for the HHS HCC model? a. Silver b. Gold c. Bronze d. Platinum b. Individuals 21 and over. - ✔✔-For the HHS HCC model who is included in the adult model? a. Individuals 18 years and older b. Individuals 21 and over. c. Individuals who are the head of the household. d. Individuals who are making more than $13,000 per year. a. Prior to the diagnosis and risk factor data being reported to CMS. - ✔✔-When are prospective reviews performed? a. Prior to the diagnosis and risk factor data being reported to CMS. b. After the diagnosis and risk factor data has been reported to CMS. c. Once the patient is enrolled in Medical Part C plan. d. Once the provider has finalized the documentation to submit diagnosis codes. d. Registered Nurse. - ✔✔-Which provider is NOT an approved provider for diagnosis code capture under the Medicare HCC model? a. Gynecologist. b. Pathologist. c. Oral surgeon. d. Registered Nurse. b. Medium - ✔✔-In the CDPS risk adjustment model, what category do heart attacks fall under> a. Low b. Medium c. High d. Very high d. all of the above - ✔✔-Which elements are considered the Medicare HCC model? a. age b. disability status c. conditions that affect the long-term treatment of the patient insurance status. d. All of the above d. MA plan risk scores increase faster than FFS scores. CMS is required to make an adjustment to reflect "differences in coding patterns between Medicare Advantage plans and providers under Pay A and B to the extent that the Secretary has identified such differences. To do this, CMS conducts extensive research to analyze changes inMA and original fee-forservice (FFS) Medicare risk scores, differences between those changes, and coding patterns behind these changes. CMS uses the results of this analysis to develop a factor that is applied to the risk score to account for these differences. MA plan ri [Show More]
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