AAPC CRC study guide with 100% correct answers

which medicare part is reimbursed based on the risk adjustment models part c who typically employs risk adjustment coders health plans is a health plan required to follow the minimum necessary rule yes, health plans are covered entities and are therefore required to follow the minimum necessary rule what is an example of fraud reporting a diagnosis or co-morbidity that does not exist to obtain higher reimbursement which part of medicare is also called medicare advantage part c which health insurance assistance program is sponsored by federal and state governments medicaid what OIG document should a medicare advantage participant review for potential problem areas that will receive special scrutiny in the upcoming year OIG work plan which code set is used by risk adjustment coders icd-10-cm which regulation strengthens HIPAA rules by addressing privacy and security concerns associated with the electronic transmission of health information Health Information Technology for Economic and Clinical Health Act (HITECH) what is coding translating a written or dictated medical record into a series of alphanumeric codes which organ is in the thoracic cavity lungs what does the term distal indicate farther from the point of attachment blood is received back into the left atrium of the heart through.... pulmonary veins the root of the nail is also known as what germinal matrix the documentation states: Past Surgical history: she had a lumpectomy of the breast for DCIS 12 years ago which successfully eradicated the CA how would this be reported personal history of breast cancer the documentation states: soft druse, some calcified what system would have this documentation ocular which organ does pulmonary refer to lungs what is a PEG tube a tube inserted into the stomach for long term feeding angina pectoris refers to which system cardiovascular what is cholelithiasis stones in the gallbladder a patient with diabetes type 2 presents with ED. after examination, the provider diagnosis the patient with ED due to diabetic autonomic neuropathy. e11.43, n52.1 a patient is transported from the nursing home for facial drooping, slurred speech, and dizziness. the patient was admitted for testing. after an MRI, the provider diagnosed the patient with a TIA g45.9 the physician was called to the hospital floor for the medical management of a patient admitted one day ago with a reduced oxygen level due to aspiration pneumonia and COPD. no chest pain at present, but still SOB and some swelling in his lower extremities. patient was tachypneic yesterday; lungs reveal course crackles in both bases, right worse than left. the physician writes instructions to continue with intravenous antibiotic treatment and respiratory support with ventilator management. he reviewed the chest X-ray which shows gastric contents in the lungs and labs. patient is improving and a pulmonary consultation has been requested j69.0, t17.810a, j44.9 a patient with chronic DVT in the lower leg requires heparin to maintain therapeutic anticoagulation levels. he has regular PTTs drawn to monitor his level of anticoagulation i82.5z1, z79.01 ch. 3, question 5 diagnosis with severe exacerbation of chi, poorly controlled hon, and worsening ckd and acute renal failure i13.0, i50.9, n17.9, n18.9 a patient suffering an abdominal aortic aneurysm involving the renal undergoes endovascular repair deploying a fenestrated visceral autograft using 2 visceral artery endoprostheses i71.4, i72.2 a patient with cod, stage 5 is evaluated by the provider and receives peritoneal dialysis. the provider evaluates the patient once before dialysis begins n18.6, z99.2 ch. 3 question 8 Pneumonia due to Streptococcus pneumoniae; Alzheimer disease, unspecified; Dementia in other diseases classified elsewhere without behavioral disturbance. j13, g30.9, f02.80 ch.3 question 9 the provider's assessment states the patient has acute bronchitis, and elevated blood pressure j20.9, r03.0 ch. 3 question 10 provider documents the patient has hyperlipidemia, anemia, and ESRD. he refers the patient to nephrology for the ESRD e78.5, d64.9, n18.6 which risk adjustment model is typically used for medicaid patients chronic illness and disability payment systems (CDPS) which of the following providers are approved for diagnosis code capture under the medicare HCC model I - general surgeon II - cardiologist III - certified registered nurse anesthetist IV - massage therapist V - neuropsychiatrist I, II, III, V ch. 4 question 3 based on the tables above, if the documentation states a type 1 diabetic member has both ketoacidosis and diabetic nephropathy, which HCCs will be used in the CMS calculations HCC 17 ch. 4 question 4 using the tables above, which is true a- a patient in shock trumps a patient in respiratory arrest b- a patient in acute respiratory failure trumps a patient dependent on a respirator c- a patient in respiratory arrest trumps a patient with an infection of the tracheostomy stoma d- a patient dependent on a respirator trumps a patient in respiratory arrest d true or false: retrospective reviews are performed after the face to face visit but before the visit is finalized false all risk adjustment models use diagnosis codes to determine potential patient-level risks. what additional elements are taken into consideration I - age II - insurance status III - claims data elements IV - ethnicity V - socioeconomic status I, II, III, V true or false: the CMS national average risk score varies each year false which type of review includes a review of current year combined with the prior year's dates of service concurrent review which risk adjustment model is typically used for patients enrolled in a commercial plan through a healthcare exchange? Health and Human Services Hierarchical Condition Category (HHS HCC) which risk adjustment model is used for patients enrolled in medicare advantage plan Medicare Hierarchal Condition Category (CMS HCC-C) the affordable care act set a requirement for CMS to make quality bonus payments to medicare advantage plans based on the plans quality rating. the publicly available rating used for this is STARS what is predictive modeling in risk adjustment an analytical review of known data elements to establish a hypothesis related to the future needs of patients data elements used for predictive modeling include I - claims data II - prescription drug events III - procedures coded IV - durable medical équipement I, II, III, IV 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 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 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