AAPC CRC study guide Exam 2025-2026
Questions And Answers
if you were using predictive modeling and the results were:
-the member had a DME claim for oxygen
-the member had an rx claim for pulmicort flehaler
-the member had a medical claim which included airway obstruction treatment
what diagnosis would you predict this member had - >>COPD
ANSWER
in the medical record review, the dr has documentation in a single encounter of an eye
exam, a BUN test, and HbA1c testing. which area of HEDIS measures are most likely
satisfied in this encounter - ANSWER >>diabetic
care
which statements are TRUE regarding HEDIS
I - HEDIS was designed to allow consumers to compare health plan performance to
national or regional benchmarks
II - HEDIS results are used to track year-to-year performances
III - HEDIS was developed and is maintained by NCQA
IV - CMS requires HMOs to submit Medicare HEDIS data to be a Medicare Advantage
Organization - >>I, II, III, IV
ANSWER
how is HEDIS data collected
I - insurance claims
II - surveys
III - medical chart reviews
IV - provider reporting - ANSWER >>II, III,
IV
which of the following are considered collection types for Merit-based incentive payment
system (MIPS) data
,I - administrative measures
II - qualified clinical data registry (QCDR)
III - MIPS clinical quality measures (CQMs)
IV - electronic clinical quality measures (eCOMs)
V - medicare part b claims measures
VI - consumer assessment of healthcare providers & systems (CAHPS) for MIPS survey
VII - CMS web interface measures - >>I, IV, V, VII
ANSWER
which MIPS performance category promotes the secure exchange of health information
and the use of certified electronic health record technology (CEHRT) for coordination of
care - >>promoting
ANSWERinteroperability
what is an alternative payment model (APM) - ANSWER >>a group of clinicians who
have created a medicare advantage organization that utilizes only providers affiliated
with their group
for a RADV audit, which records are sent from the health plan to CMS - ANSWER
>>the
5 best records to support the diagnosis submitted for that beneficiary
true or false: many diagnoses are missed in physician coding because diagnoses are
reported from the assessment portion of a visit instead of throughout the medical record
for that visit - ANSWER
>>true
what are the documentation standards when sending in medical records for a RADV
audit
I - legible
II - complete
III - face-to-face encounter
IV - provided by an approved provider - ANSWER >>I, II, III,
IV
what is an IVA and what is the IVAs function - ANSWER >>initial validation auditor;
a
third-party vendor, chosen by the health plan, to conduct a coding review and an
enrollment review
, when does CMS RADV typically occur - ANSWER >>2 to 3 years after payment
when does HHS HRADV typically occur - ANSWER >>6-months after year-
end
what were accountable care organizations designed for - >>improve
ANSWERthe
quality of healthcare and lower costs
true or false: CMS RADV uses a stratified sample of three strata - >>true
ANSWER
true or false: risk adjustment scores should not be used as a driver for provider behavior
>>true
ANSWER
-
which interaction options enable an added value in the CMS HCC model
I - a high-risk disease
II - 2 diseases
III - 3 diseases
IV - disability alone
V - disability and a disease - ANSWER >>II, III,
V
true or false: inpatient records are not required to be face-to-face encounters -
ANSWER
>>false
what must be included on a discharge summary submitted as a physician provider type
>>the discharge
ANSWERdate
-
true or false: diagnoses listed in a diagnostic report should be reported when
documented as relevant by the provider in the documentation for face-to-face encounter
>>true
ANSWER
-
Questions And Answers
if you were using predictive modeling and the results were:
-the member had a DME claim for oxygen
-the member had an rx claim for pulmicort flehaler
-the member had a medical claim which included airway obstruction treatment
what diagnosis would you predict this member had - >>COPD
ANSWER
in the medical record review, the dr has documentation in a single encounter of an eye
exam, a BUN test, and HbA1c testing. which area of HEDIS measures are most likely
satisfied in this encounter - ANSWER >>diabetic
care
which statements are TRUE regarding HEDIS
I - HEDIS was designed to allow consumers to compare health plan performance to
national or regional benchmarks
II - HEDIS results are used to track year-to-year performances
III - HEDIS was developed and is maintained by NCQA
IV - CMS requires HMOs to submit Medicare HEDIS data to be a Medicare Advantage
Organization - >>I, II, III, IV
ANSWER
how is HEDIS data collected
I - insurance claims
II - surveys
III - medical chart reviews
IV - provider reporting - ANSWER >>II, III,
IV
which of the following are considered collection types for Merit-based incentive payment
system (MIPS) data
,I - administrative measures
II - qualified clinical data registry (QCDR)
III - MIPS clinical quality measures (CQMs)
IV - electronic clinical quality measures (eCOMs)
V - medicare part b claims measures
VI - consumer assessment of healthcare providers & systems (CAHPS) for MIPS survey
VII - CMS web interface measures - >>I, IV, V, VII
ANSWER
which MIPS performance category promotes the secure exchange of health information
and the use of certified electronic health record technology (CEHRT) for coordination of
care - >>promoting
ANSWERinteroperability
what is an alternative payment model (APM) - ANSWER >>a group of clinicians who
have created a medicare advantage organization that utilizes only providers affiliated
with their group
for a RADV audit, which records are sent from the health plan to CMS - ANSWER
>>the
5 best records to support the diagnosis submitted for that beneficiary
true or false: many diagnoses are missed in physician coding because diagnoses are
reported from the assessment portion of a visit instead of throughout the medical record
for that visit - ANSWER
>>true
what are the documentation standards when sending in medical records for a RADV
audit
I - legible
II - complete
III - face-to-face encounter
IV - provided by an approved provider - ANSWER >>I, II, III,
IV
what is an IVA and what is the IVAs function - ANSWER >>initial validation auditor;
a
third-party vendor, chosen by the health plan, to conduct a coding review and an
enrollment review
, when does CMS RADV typically occur - ANSWER >>2 to 3 years after payment
when does HHS HRADV typically occur - ANSWER >>6-months after year-
end
what were accountable care organizations designed for - >>improve
ANSWERthe
quality of healthcare and lower costs
true or false: CMS RADV uses a stratified sample of three strata - >>true
ANSWER
true or false: risk adjustment scores should not be used as a driver for provider behavior
>>true
ANSWER
-
which interaction options enable an added value in the CMS HCC model
I - a high-risk disease
II - 2 diseases
III - 3 diseases
IV - disability alone
V - disability and a disease - ANSWER >>II, III,
V
true or false: inpatient records are not required to be face-to-face encounters -
ANSWER
>>false
what must be included on a discharge summary submitted as a physician provider type
>>the discharge
ANSWERdate
-
true or false: diagnoses listed in a diagnostic report should be reported when
documented as relevant by the provider in the documentation for face-to-face encounter
>>true
ANSWER
-
