CRC Exam with 100% Correct Answers
Risk Adjustment (a prospective payment system) - ANSWER-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? - ANSWER-code ALL current dx
What is the purpose of collecting dx in risk adjustment coding? - ANSWER-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? - ANSWER-HCC (Hierarchical
Condition Category)
What elements would NOT be taken in to consideration for risk adjustment? -
ANSWER-number of years Pt. has been covered under medicare advantage
Which medical records can be submitted for HCC validation? - ANSWER-+MD office
progress note
+Outpatient hospital
+Critical access hospital
What is the purpose of risk adjustment values? - ANSWER-to budget care of a patient
for the following year
What are risk adjustment models used for? - ANSWER-To determine projected costs of
healthcare based on the conditions of patients
Which is NOT to be taken into consideration for risk adjustment? - ANSWER-Frequency
of office visits
How is predictive modeling used in risk adjustment? - ANSWER-determine suspected
dx based on data elements
What is the reporting period for risk adjustment coding? - ANSWER-Jan > Dec
What risk adjustment model is used by Medicaid? - ANSWER-CDPS (Chronic Illness &
Disability Payment System)
,What is CDPS? - ANSWER-Chronic Illness & Disability Payment System
What risk adjustment model incorporates High, Medium, & Low risk in the numeric value
- ANSWER-CDPS
what is the default if type of DM is not specified? - ANSWER-DM2
How to code when a Pt. is seen for management of anemia d/t malignancy? -
ANSWER-1st code - malignancy
2nd code - anemia
How to code tobacco use AND dependence on tobacco - ANSWER-only code
dependence on tobacco (F17.2-)
What is the length of time for a MI to be considered "acute"? - ANSWER-4 weeks/28
days
How is glaucoma reported? - ANSWER-only code stage of glaucoma
What is the sequencing order when coding a sequela (late effect)? - ANSWER-1st-
residual condition
2nd- cause of the late effect
What is reported by a provider for beneficiaries in Medicare Advantage plans? -
ANSWER-presenting problems, &
all chronic conditions
How often should a provider see a Pt. to validate amputation status? - ANSWER-once a
year
PEG Tube - ANSWER-+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? - ANSWER-False
What is true regarding hierarchies? - ANSWER-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? - ANSWER-FALSE
Is HEDIS a division of CMS or Medicaid? - ANSWER-NO
Who developed HEDIS? - ANSWER-NCQA (National Committee for Quality Assurance)
, How is HEDIS data collected? - ANSWER-+surveys
+medical chart reviews
+insurance claims
What is the goal of HEDIS (Health Plan Employer Data Info Set)? - ANSWER-for
consumers to compare health plans
How often are HEDIS measures revised? - ANSWER-Annually
Which payers uses HEDIS measures? - ANSWER-a variety
RADV - ANSWER-Risk Adjustment Data Validation
What is the purpose of a RADV audit? - ANSWER-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? -
ANSWER-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? - ANSWER-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? - ANSWER-+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? - ANSWER-5
Definition of the best record for a RADV audit - ANSWER-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 -
ANSWER-outpatient - single DOS
hospital - full inpatient set
How is Medicare Funding allocated? - ANSWER-Based on previous years known dx
(retrospective)
Risk Adjustment (a prospective payment system) - ANSWER-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? - ANSWER-code ALL current dx
What is the purpose of collecting dx in risk adjustment coding? - ANSWER-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? - ANSWER-HCC (Hierarchical
Condition Category)
What elements would NOT be taken in to consideration for risk adjustment? -
ANSWER-number of years Pt. has been covered under medicare advantage
Which medical records can be submitted for HCC validation? - ANSWER-+MD office
progress note
+Outpatient hospital
+Critical access hospital
What is the purpose of risk adjustment values? - ANSWER-to budget care of a patient
for the following year
What are risk adjustment models used for? - ANSWER-To determine projected costs of
healthcare based on the conditions of patients
Which is NOT to be taken into consideration for risk adjustment? - ANSWER-Frequency
of office visits
How is predictive modeling used in risk adjustment? - ANSWER-determine suspected
dx based on data elements
What is the reporting period for risk adjustment coding? - ANSWER-Jan > Dec
What risk adjustment model is used by Medicaid? - ANSWER-CDPS (Chronic Illness &
Disability Payment System)
,What is CDPS? - ANSWER-Chronic Illness & Disability Payment System
What risk adjustment model incorporates High, Medium, & Low risk in the numeric value
- ANSWER-CDPS
what is the default if type of DM is not specified? - ANSWER-DM2
How to code when a Pt. is seen for management of anemia d/t malignancy? -
ANSWER-1st code - malignancy
2nd code - anemia
How to code tobacco use AND dependence on tobacco - ANSWER-only code
dependence on tobacco (F17.2-)
What is the length of time for a MI to be considered "acute"? - ANSWER-4 weeks/28
days
How is glaucoma reported? - ANSWER-only code stage of glaucoma
What is the sequencing order when coding a sequela (late effect)? - ANSWER-1st-
residual condition
2nd- cause of the late effect
What is reported by a provider for beneficiaries in Medicare Advantage plans? -
ANSWER-presenting problems, &
all chronic conditions
How often should a provider see a Pt. to validate amputation status? - ANSWER-once a
year
PEG Tube - ANSWER-+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? - ANSWER-False
What is true regarding hierarchies? - ANSWER-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? - ANSWER-FALSE
Is HEDIS a division of CMS or Medicaid? - ANSWER-NO
Who developed HEDIS? - ANSWER-NCQA (National Committee for Quality Assurance)
, How is HEDIS data collected? - ANSWER-+surveys
+medical chart reviews
+insurance claims
What is the goal of HEDIS (Health Plan Employer Data Info Set)? - ANSWER-for
consumers to compare health plans
How often are HEDIS measures revised? - ANSWER-Annually
Which payers uses HEDIS measures? - ANSWER-a variety
RADV - ANSWER-Risk Adjustment Data Validation
What is the purpose of a RADV audit? - ANSWER-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? -
ANSWER-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? - ANSWER-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? - ANSWER-+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? - ANSWER-5
Definition of the best record for a RADV audit - ANSWER-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 -
ANSWER-outpatient - single DOS
hospital - full inpatient set
How is Medicare Funding allocated? - ANSWER-Based on previous years known dx
(retrospective)
