CCDS TRAINING STUDY SHEET 2026
UPDATED QUESTIONS AND ANSWERS
◉The social security act requires what from CMS?. Answer: Protect
the Medicare trust fund against inappropriate payments that pose
the greatest risk to the trust fund and take corrective actions in
response to any inappropriate payments.
◉What are MACs and what do they do?. Answer: Medicare
Administrative Contractors. They perform clinical review of medical
records to ensure that payment is made only for services that need
Medicare coverage, coding, and medical necessity requirements.
◉Medicare defines medical necessity as follows. Answer: No
payment may be made under Part A or Part B for expenses incurred
for items or services which are not reasonable and necessary for the
diagnosis and treatment of illness or injury to improve the
functioning of a malformed body member.
◉What is CERT?. Answer: Comprehensive error rate testing. It
examines a statistically valid, random sample of claims to determine
whether they were paid properly under Medicare coverage, coding,
and billing rules.
,◉What is the 2 midnight rule?. Answer: CMA will reimburse
hospitals for inpatient admissions if the admitting practitioner
expects the patient to require a hospital stay that crossed two
midnights and if the medical record supports that reasonable
expectation.
◉A physician's medial decision making process of whether a patient
should be admitted as an inpatient is based on what factors?.
Answer: Severity of signs and symptoms exhibited by the patient
Medical probability of an adverse outcome for the patient
The need and availability of diagnostic studies
◉Where does CMS discuss inpatient admission requirements?.
Answer: Medicare benefit policy manual
◉What is medical necessity?. Answer: A legal doctrine by which
evidence based clinical standards of care are used to determine
whether treatment or a procedure is reasonable, necessary, and/or
appropriate.
◉Services and items ordered or deliver d by providers should be
ensured to have these three factors. Answer: Provided economically
and only when they are medically necessary
Of a sufficient level of quality to meet professionally recognized
standards of care
,Supported by evidence of medical necessity and quality capable of
satisfying the Medicare utilization and quality control peer review
organization programs
◉Which employees are responsible for monitoring the medical
record to support physician compliance with accepted screening
criteria, federal regulations and guidance, other physicians opinions
and community standards of care?. Answer: Utilization management
committee and case managers
◉According to Medicare's conditions of participation. Answer: The
hospital must have in effect a utilization management plan that
provided for review of services furnished by the institution by
members of the medical staff to patients entitled to benefits under
the Medicare and Medicaid programs.
◉What are RAs and when/how did they start?. Answer: Recovery
Audit program. 2003 under the Medicare Prescription Drug
Improvement and Modernization Act
◉What do RAs do?. Answer: Identify and correct improper
payments through post payment review of medical records.
◉Common Public report cards. Answer: Leapfrog, US News and
World Report, Hospital Compare, Physician compare
, ◉Where does info on Physician Compare come from?. Answer:
Provider enrollment, chain, and overshoot system (PECOS) and
other sources.
◉What 7 measures is CMS required to include for public reporting?.
Answer: 1. Measures collected under the Physician Quality
Reporting System
2. An assessment of patient health outcomes and functional status of
patients
3. An assessment of the continuity and coordination of care and care
transitions, including episodes of care and risk-adjusted resource
use
4. An assessment of efficiency
5. An assessment of patient experience and patient caregiver, and
family engagement
6. An assessment of safety, effectiveness, and timeliness of care
7. Other information as determined appropriate
◉The Institute for Healthcare Improvement's "Triple Aim" approach
calls for what three goals?. Answer: 1. Improving the patient
experience of care (including quality and satisfaction)
2. Improving the health of populations
3. Reducing the per capita cost of healthcare
UPDATED QUESTIONS AND ANSWERS
◉The social security act requires what from CMS?. Answer: Protect
the Medicare trust fund against inappropriate payments that pose
the greatest risk to the trust fund and take corrective actions in
response to any inappropriate payments.
◉What are MACs and what do they do?. Answer: Medicare
Administrative Contractors. They perform clinical review of medical
records to ensure that payment is made only for services that need
Medicare coverage, coding, and medical necessity requirements.
◉Medicare defines medical necessity as follows. Answer: No
payment may be made under Part A or Part B for expenses incurred
for items or services which are not reasonable and necessary for the
diagnosis and treatment of illness or injury to improve the
functioning of a malformed body member.
◉What is CERT?. Answer: Comprehensive error rate testing. It
examines a statistically valid, random sample of claims to determine
whether they were paid properly under Medicare coverage, coding,
and billing rules.
,◉What is the 2 midnight rule?. Answer: CMA will reimburse
hospitals for inpatient admissions if the admitting practitioner
expects the patient to require a hospital stay that crossed two
midnights and if the medical record supports that reasonable
expectation.
◉A physician's medial decision making process of whether a patient
should be admitted as an inpatient is based on what factors?.
Answer: Severity of signs and symptoms exhibited by the patient
Medical probability of an adverse outcome for the patient
The need and availability of diagnostic studies
◉Where does CMS discuss inpatient admission requirements?.
Answer: Medicare benefit policy manual
◉What is medical necessity?. Answer: A legal doctrine by which
evidence based clinical standards of care are used to determine
whether treatment or a procedure is reasonable, necessary, and/or
appropriate.
◉Services and items ordered or deliver d by providers should be
ensured to have these three factors. Answer: Provided economically
and only when they are medically necessary
Of a sufficient level of quality to meet professionally recognized
standards of care
,Supported by evidence of medical necessity and quality capable of
satisfying the Medicare utilization and quality control peer review
organization programs
◉Which employees are responsible for monitoring the medical
record to support physician compliance with accepted screening
criteria, federal regulations and guidance, other physicians opinions
and community standards of care?. Answer: Utilization management
committee and case managers
◉According to Medicare's conditions of participation. Answer: The
hospital must have in effect a utilization management plan that
provided for review of services furnished by the institution by
members of the medical staff to patients entitled to benefits under
the Medicare and Medicaid programs.
◉What are RAs and when/how did they start?. Answer: Recovery
Audit program. 2003 under the Medicare Prescription Drug
Improvement and Modernization Act
◉What do RAs do?. Answer: Identify and correct improper
payments through post payment review of medical records.
◉Common Public report cards. Answer: Leapfrog, US News and
World Report, Hospital Compare, Physician compare
, ◉Where does info on Physician Compare come from?. Answer:
Provider enrollment, chain, and overshoot system (PECOS) and
other sources.
◉What 7 measures is CMS required to include for public reporting?.
Answer: 1. Measures collected under the Physician Quality
Reporting System
2. An assessment of patient health outcomes and functional status of
patients
3. An assessment of the continuity and coordination of care and care
transitions, including episodes of care and risk-adjusted resource
use
4. An assessment of efficiency
5. An assessment of patient experience and patient caregiver, and
family engagement
6. An assessment of safety, effectiveness, and timeliness of care
7. Other information as determined appropriate
◉The Institute for Healthcare Improvement's "Triple Aim" approach
calls for what three goals?. Answer: 1. Improving the patient
experience of care (including quality and satisfaction)
2. Improving the health of populations
3. Reducing the per capita cost of healthcare
