CRC EXAM question with 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)
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)
