CRC EXAM QUESTIONS AND ANSWERS

Risk Adjustment Data Element Age, Gende, Socioeconomic status, Disability status, Insurance status(Medicaid, dual-eligible,) Claims data elements such as procedure codes, place of service codes, special patient-specific conditions hospice, ESRD RAF Risk Adjustment Factor Scores Three main types of reviews Retrospective, Concurrent and prospective Retrospective reviews are performed after the information has been reported and in risk adjustment these are prior years dos Concurrent reviews performed ongoing as patients are seen prior to reporting and in risk adjustment the current year Prospective reviews will effect the next year and not the current year where payment is concerned. They are used to forcast Types of Risk Adjustment Models(HHS) HHS hEALTH AND HUMAN SERVICES hIERARCHICAL CONDITION(Commercial, individual and small grooup Types of Risk Adjustment Modles(CDPS) Chronic Illness and Disability payment systems(Medicaid) Types of Risk Adjustment Models(HCC-C) Hierarchical Condition Category, Part C Types of Risk Adjustment model (DRG) Diagnosis Related Group (Inpatient) Types of Risk Adjustment model (ACG) Adjusted Clinical Groups(Outpatient) Prescription based program risk adjustment examples:UCSD Medicaid Rx(UCSD) Prescription based program risk adjustment examples(Dxcg) RxGroups(DxCG) Prescription based program risk adjustment examples(HCC-D) Hierarchical Condition Category, Part D(HCC-D Trump List Families or hierarchies set a value base on severity of illness with more severe diagnoses carrying the overall risk score for that family. Stage 1 Pressure Ulcer Persistent focal erythema stage 2 pressure ulcer Partial thickness skin loss involving epidermis, dermis, or both Stage 3 pressure ulcer Full Thickness skin loss extending through subcutaneous tissue Stage 4 Pressure ulcer Necrosis of soft tissue extending to muscle and bone Unstageable Ulce is covered in eschar or slough it cannot be determine how deep Pathologic Fractures Broken bone that occures in an area of weakened bone. The cause typically due to another disease such as neoplasm or osteoporosis Stress Fractures repeated force or overuse. these fractures are considered non-traumatic malunion fracture a healed fracture in a undesirable position resulting in a deformity or crooked limb. nonunion fracture fracture is not healing New bone tissure is not growing to bridge the gap between the broken bones FFS Normalization adjustment CMS payments are based on a population with an average risk score Special population for normalization factores Pace Mode, ESRD and Part D History of CDPS Began using RA in 1996 utilizing claims from disabled beneficiaries information from the disability payment system from Colorado, Michiganm Missouri, New York, and Ohio Star Ratings Medicare Advantage plan would received a bonus if they receive 4 or more stars in 5 star quality ratings 5 star Excellent performance 4 star Above Average Performance 3 star average performance 2 star Below average performance 1 star Poor Performance Part C Plan Domain 1 Staying Helathy Screenings, test, and vaccines (7 measures Domain 2 Managing Chronic (Long Term) Conditions (12Measures) Domain 3 Member Experience with Health Plan (6 measures) Domain 4: Member complaints, problems getting service and improvement in the Health Plan's Performance (4 measures) Domain 5 Health Plan customer service (3 measures Part D Plans Domain 1Drug plan customer service (3 measures) Domain 2 Member Complaints, Problems Getting Services, and improvement in the Drug Plan's Performance (4 measures) Domain 3 Member Experience with Drug Plan (2 measures) Domain 4 Patient afety and drug pricing (6measures) Star Rating penalize when plans are not obtaining four stars or better PQRS Physician Quality Reporting System PQRS 2 A Reporting program using a combination of incentive payments and payment adjustments to promote reporting of quality information by eligible professionals (EP) Valued-Based Payment Modifier Program Provide Performance information to physicians as part of Medicare's efforts to improve the quality and efficiency of medical care HEDIS The Healthcare Effectiveness Data and Information Set) HEDIS 3 Tract year to year performance 81 HEDIS Measures DIVIDED into five domains of care 1. Effectiveness of Care 2. Access/Availability of Care 3. Experience of Care 4. Utilization and relative resource use 5. Health Plan Descriptive Information Major Reason for RA To identify all current diagnoses to highest specificity. Annual RA Audits CMS conducts audits of the risk adjustment data submitted by or on behalf of health plans to ensure program integrity Error in RA Audits once error determine will then be applied to the premiums for the entire patient population for that health plan RADV(Risk Adustment Data Validation) CMS identifies a random stratified sample of patients audit. Only Part C HCC'S are audited in a RADV