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AAPC CRC study guide
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 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. 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. 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. ch.3 question 9 the provider's assessment states the patient has acute bronchitis, and elevated blood pressure - j20.9, r03. 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. 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
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
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. ch 7 question 6 the provider documents a history of old chronic pulmonary embolism - z86. 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. ch. 7 question 8 the neurologist documents a history of TIA, patient to start aspirin daily - z86.
ch. 7 question 9 Adhesive capsulitis of left shoulder; Personal history of malignant melanoma of skin; Other specified postprocedural states - m75.02, z85.820, z98. ch. 7 question 10 Anxiety disorder, unspecified; Depression, unspecified; Other specified disorders of bladder; Cardiac arrhythmia, unspecified; Type 2 diabetes mellitus without complications; Essential (primary) hypertension; Menopausal and perimenopausal disorder, unspecified; Long term (current) use of oral hypoglycemic drugs. - f41.9, f32.a, n32.89, i49.9, e11.9, i10, n95.9, z79. true or false: attestations are not required for inpatient records - true a patient is seen by their family practitioner for confusion, depression and behavioral changes. upon examination, the patient cannot remember recent events. the provider diagnoses the patient with early onset Alzheimers disease with dementia - g30.0, f02. a patient is seen for exercise induced syncope. after examination, the provider suspects atrial fibrillation and refers the patient to cardiology - r a patient is seeing the ED for facial weakness on the right side. after workup, the provider diagnoses the patient with a stroke which caused the weakness - i69. a patient arrives at the ED with SOB, chest pain, and excessive sweating. the ED provider orders a D dimer suspecting a pulmonary embolism - r06.02, r07.9, r
a patient presents with a long history of ckd. the patient states he has been extremely tired lately and very fatigued. the provider orders lab work. the patient returns and the provider documents anemia in ckd and ckd 3 - n18.30, d63. the neurologist sees a patient in the hospital for CVA. the imaging shows occlusion of the basilar artery and the right carotid artery - i63.22, i63. a patient is seen for follow-up of dvt in the left saphenous vein. there is no med list - i82. ch.9 question 5 assessment; -htn - continue current meds -left heart failure w LVEF 31-40%, would continue current med therapy - i11.0, i50. ch. 9 question 6 IMPRESSION: hypertension, hyperlipidemia, coronary artery disease, congestive heart failure - i11.0, i50.9, e78.5, i25. 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. 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. 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. 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
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. 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. 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. 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. the patient presents to her physician 10 weeks following a true posterior wall MI. the patient is still symptomatic - z51.89, i25. 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. 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, c
nonproliferation retinopathy of the right eye in a diabetic patient - e11. 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 - c 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. what code is reported for subsequent type 4 MI - i21.a the patient has idiopathic pulmonary fibrosis - J84. 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 a 26 year old male patient sees his physician for 2 weeks of fever and muscle aches. his partner of 6 months recently tested positive for HIV. the physician orders an enzyme immunoassay to determine if any HIV antibodies are detected - r50.9, m79. practice test, question 26
true or false: diagnosis listed in the pmh should not be reported when they no longer exist - true true or false: for a condition within a problem list to be considered for a RADV purposes, it is necessary for a provider to document its relevance to the current encounter - true practice test question 33 Unspecified osteoarthritis, unspecified site - m19. dr smith is engaging with the MA regarding his approach to the using the new EHR in the office for recording diagnosis codes with no documentation. the doctor continues to only report diagnosis codes instead of a legible description of the diagnosis. in the follow-up conversation with the MA , how should this be addressed - dr smith is asked to document a legible description of the diagnosis code and is provided documentation from the coding clinic documentation states, " the patient reports worsening dyspnea on exertion over the past year. she currently can walk one-half block on a flat surface before developing SOB and up one-half flight of stairs. these symptoms are often accompanied by upper back and neck pain and relieved with rest. she denies any chest pain, PND, orthopnea, palpitations, or syncopal spells what does the acronym PND refer to in this context - a respiratory disorder true or false: HIV/AIDS is most commonly transmitted by coughing - false practice test, question 37 the above table shows the hierarchies for renal disease/condition codes
if the documentation states the member has a diagnosis that belongs in HCC 137 and another diagnosis that belongs in HCC 134; which one will CMS use in their calculation - HCC 134 data is mined from various places to give additional information as it relates to risk scores. which of the following data elements might be used for predictive modeling I - durable medical equipment requests II - claims data (CPT, HCPCS level II, icd-10-cm, etc) III - prescription drug events - 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
