AAPC CRC study guide QUESTIONS WITH COMPLETE 100% VERIFIED SOLUTIONS 2024/2025, Exams of Nursing

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AAPC CRC study guide QUESTIONS WITH COMPLETE 100% VERIFIED SOLUTIONS 2024/2025 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 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 how is HEDIS data collected I - insurance claims II - surveys III - medical chart reviews IV - provider reporting 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 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 interoperability what is an alternative payment model (APM) 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 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 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 I, II, III, IV what is an IVA and what is the IVAs function 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 2 to 3 years after payment when does HHS HRADV typically occur 6-months after year-end what were accountable care organizations designed for improve the quality of healthcare and lower costs true or false: CMS RADV uses a stratified sample of three strata true true or false: risk adjustment scores should not be used as a driver for provider behavior true 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 II, III, V true or false: inpatient records are not required to be face-to-face encounters false what must be included on a discharge summary submitted as a physician provider type the discharge date 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 true or false: chronic conditions reported in the past medical history can be coded for risk adjustment if there is documentation supporting current treatment true ch. 7 question 5 Epistaxis; congestive heart failure; Long term (current) use of anticoagulants r04.0, i50.9, z79.01 ch 7 question 6 the provider documents a history of old chronic pulmonary embolism z86.711 a patient arrives at the emergency department with SOB. the provider documents the patient has a known history of CHF and is currently on Bumex for the CHF i50.9 ch. 7 question 8 the neurologist documents a history of TIA, patient to start aspirin daily ch. 9 question 7 Type 1 diabetes mellitus With neurological complications Controlled ; Type 1 diabetes mellitus with foot ulcer ; Non-pressure chronic ulcer of other part of left foot with unspecified severity ; Essential (primary) hypertension ; Pure hypercholesterolemia, unspecified ; Rhabdomyolysis ; Adverse effect of antihyperlipidemic and antiarteriosclerotic drugs, sequela e10.40, e10.621, L97.529, i10, e78.00, m62.82, t46.6x5s ch. 9 question 8 Chronic respiratory failure, not elsewhere classified Type 1 [with hypoxia] ; Chronic obstructive pulmonary disease, unspecified ; Anxiety, Unspecified ; Dependence on supplemental oxygen j96.10, j44.9, f41.9, z99.81 ch. 9 question 9 Other forms of dyspnea ; Essential (primary) hypertension ; Hypothyroidism, unspecified ; Unspecified asthma, uncomplicated ; Nicotine dependence, cigarettes, uncomplicated ; Allergy status to narcotic agent r06.09, i10, e03.9, j45.909, f17.210, z88.5 ch. 9 question 10 Pneumonitis due to inhalation of food and vomit ; Chronic obstructive pulmonary disease with (acute) exacerbation ; Chronic obstructive pulmonary disease with acute lower respiratory infection ; Malignant neoplasm of unspecified part of unspecified bronchus or lung ; Type 2 diabetes mellitus without complications ; Essential (primary) hypertension ; Pure hypercholesterolemia, unspecified ; Insomnia, Unspecified ; Unspecified protein-calorie malnutrition ; Gastrostomy status ; Long term (current) use of anticoagulants ; Personal history of pulmonary embolism ; Personal history of nicotine dependence ; Personal history of antineoplastic chemotherapy ; Personal history of irradiation ; Presence of other vascular implants and grafts j69.0, j44.1, j44.0, c34.90, e11.9, i10, e78.00, g47.00, e46, z93.1, z79.01, z86.711, z87.891, z92.21, z92.3, z95.828 16 what record would cause concern during a RADV audit a record from a pathologist that did not see the patient medicare recognizes that certain conditions are chronic and ongoing conditions usually treated by ongoing medication management. these conditions have the potential for acute exacerbation if not treated properly. which of the options below are examples of these types of conditions I - COPD II - Chronic heart failure III - pneumonia IV - urinary tract infection I and II what is a RADV audit a cms audit of part c HCCs to verify the diagnoses in the risk scores are supported by the documentation what does the acronym IVA stand for Initial Validation Auditor true or false: retrospective reviews are typically the prior year's date of service true categories assigned for diagnoses that are costly to manage from a prescription drug treatment perspectives are called RxHCCs which type of review affect the following year instead of the current year prospective what is suspect logic using known data elements to establish a hypothesis related to the future health of patients true or false: report all documented conditions that coexist at the time of the encounter true a patient is respirator dependent and has a tracheostomy in need of revision due to redundant scar tissue formation surrounding the site. under general anesthesia and establishing the airway to maintain ventilation, the scar tissue is resected and then repair is accomplished using a layered closure L90.5, z43.0, z99.11 while in the hospital, the patient developed an intra-muscular infection at the surgical site of a total knee replacement. the diagnosis is staphylococcus sepsis. the infectious disease provider visits the patient to discuss the diagnosis and treatment plan t81.42xa, t81.44xa, a41.2 a 71 year old presents to the outpatient clinic at the local hospital with copd, congestive heart failure, and hypertension. after a comprehensive evaluation, the physician makes adjustments to the patients hypertension medication due to the hypertension being uncontrolled. the patients other conditions were documented as stable. the patient is to follow-up in 2 weeks i11.0, i50.9, j44.9 a patient with hypertensive heart disease sees the ophthalmologist for headaches and double vision. the ophthalmologist makes a diagnosis of bilateral hypertensive retinopathy of both eyes h35.003, i11.9 a patient with a indwelling ureteral stent is treated in the emergency room for a utility due to e coli caused by the stent. aggressive antibiotic therapy was started in the ER t83.592a, n39.0, b96.20 the patient presents to her physician 10 weeks following a true posterior wall MI. the patient is still symptomatic z51.89, i25.9 practice test, question 16 Malignant neoplasm: Dorsal surface of tongue ; Malignant neoplasm of base of tongue ; Neoplasm of uncertain behavior of other specified sites of the oral cavity ; Nicotine dependence, chewing tobacco, uncomplicated c02.0, c01, d37.09, f17.220 a 50 year old patient has a port-a-cath removal due to a venous thrombosis of the left upper arm. the diagnosis documented is prostate carcinoma with left arm port-a-cath and complete venous thrombosis, left upper arm t82.868a, i82.602, c61 nonproliferation retinopathy of the right eye in a diabetic patient e11.3291 the patient is a 67 year old gentleman with a history of prostate cancer receiving brachytherapy treatment. following calculation, transrectal ultrasound guidance was provided for percutaneous placement of i-125 seeds into the prostate tissue c61 a patient sees his physician for follow-up of a stage 1 pressure ulcer of the ankle and a healing pressure ulcer of the heel L89.501, L89.609 what code is reported for subsequent type 4 MI i21.a9 the patient has idiopathic pulmonary fibrosis J84.112 true or false: if the non-pressure ulcer is documented as completely healed, no code is reported true how often must chronic conditions be assessed to be valid for HCCs within the year the HCC is reported I, II, III insurance companies use a statistical process in which historical data is analyzed using algorithms to determine the likelihood of a future event. what is this process called predictive modeling insurance companies use predictive modeling for: I - recuperate money from the provider II - uncover potential current diagnoses that have not been reported on claims III - prepare for future needs of its members IV - provider education V - pay providers for additional diagnoses that have not been reported on claims II, III, IV practice test question 41 using the info provided above, which statements are true I - sarcoidosis of the lung trumps cystic fibrosis II - cystic fibrosis trumps copd III - bronchiectasis trums cystic fibrosis IV - emphysema trums sarcoidosis of the lung II, IV true or false: quality measures like star ratings and HEDIS have no correlation with the medical record info that is collected in support of risk adjustment false true or false: stars ratings help identify top performing health providers true commercial plans through healthcare changes use which risk adjustment model HHS HCC true or false: coders are accustomed to submitting diagnosis codes on claims for the purposes of reimbursement validation for services rendered false which statement is coded as a history of conditions a - history of heart transplant b - history of Alzheimers dementia c - history of prostate cancer, seed implant next week for radiation d - history of breast ca, no further treatment necessary d what is the rule regarding uncertain diagnosis for outpatient records conditions stated as probable, suspected, likely, questionable, possible, or still to be ruled out are not reported which of the following providers is an acceptable provider type for RADV audits a - nutritionist b - pharmacist c - dme provider d - audiologist d true or false: to code a condition as a manifestation, the cause and effect relationship must be documented, unless the condition falls under the " with" guideline in the icd-10-cm true what would lead to an overpayment in the medical record reporting a history of condition as active