HCC Coding Risk Adjustment Test With Complete Solution

HCC Coding Ri sk Adjustment Te st With Co mplete Solutio n Risk Adjustment Model - ANSWER Calculates risk scores for all beneficiaries with available data What are the three submission deadlines? - ANSWER 1. First Friday in September = Initial Risk Score 2. First Friday in March = Mid-year Update 3. January 31 after the payment year = Final reconcilation Medicare risk adjustment model is prospective. This means? - ANSWER Diagnoses reported in the prior year and demographic information are utilized to "predict" future costs and adjust payments accordingly Risk Scores. - ANSWER Measures individual beneficiaries' relative risk and are used to adjust payments for each beneficiary's expected expenditures. FERAS Response Report. - ANSWER Rejected data after it has been processed through FERAS is recorded in this report. RAPS Return File - ANSWER This is a daily report that shows all records approved and where errors occurred. RAPS Transaction Error Report - ANSWER Displays records on which errors occurred. RAPS Transaction Summary Report - ANSWER A report sent to the MA organization daily and identifies data that have been finalized in RAPS database Duplicate Diagnosis Cluster Report - ANSWER Shows diagnosis clusters submitted with information that duplicates a stored cluster. RAPS Monthly Plan Activity Report and Cumulative Plan Activity Report - ANSWER Provides a summary of all diagnoses stored for a given time period. Error Frequency Report - ANSWER This report is distributed monthly and quarterly. Provides an overview of all errors associated with files submitted in test and production. RAPS database - ANSWER Stores all finalized diagnosis clusters Risk Adjustment System (RAS) - ANSWER Executes the risk adjustment model and calculates the risk score using the SAS model. Medicare Advantage Prescription Drug System (MARx) - ANSWER Processes payments to plans and issues the MMR (Monthly Membership Report) and MOR (Model Output Report). How often does CMS conduct data validation audits and for what purpose? - ANSWER Audits are done annually on selected plans that may have to request medical record documentation from the providers to support the submitted diagnoses. What types of data are checked in FERAS? - ANSWER File-level, batch-level and first and last detailed records RAPS Return file - ANSWER Daily reports that shows all records approved and where errors occurred. What does File-level information identified? - ANSWER Submitter What does Batch-level information identify? - ANSWER MA organization What does Detail- level information identify? - ANSWER Beneficiary Define Reconciliation - ANSWER The completion of the implementation of payments with CMS calculating final risk adjustment factors and beneficiary stats based on complete data. Necessary adjustments for institutional status and demographic data for enrollees is considered. CMS continues to allow a period (approximately 13 months after the data collection year) for submitting final RAPS data for the appropriate data collection period. Is this condition a Probably Forever/Almost ALLS (still has condition even though mediation or device is covering up symptoms), Forever/ALLS, or a Chronic condition? Septicemia (Category 380) - ANSWER Probably Forever/Almost ALLS Is this condition a Probably Forever/Almost ALLS (still has condition even though mediation or device is covering up symptoms), Forever/ALLS, or a Chronic condition? Heart Failure (Category 428) - ANSWER Probably Forever/Almost ALLS Is this condition a Probably Forever/Almost ALLS (still has condition even though mediation or device is covering up symptoms), Forever/ALLS, or a Chronic condition? Disease of Pulmonary Circulation (Categories 415-47) -Regional - ANSWER Probably Forever/Almost ALLS Is this condition a Probably Forever/Almost ALLS (still has condition even