CRC EXAM NEWEST 2024-2025 ACTUAL EXAM COMPLETE 190 QUESTIONS AND CORRECT DETAILED ANSWERS, Exams of Health sciences

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CRC EXAM NEWEST 2024-2025 ACTUAL EXAM

COMPLETE 190 QUESTIONS AND CORRECT

DETAILED ANSWERS (VERIFIED ANSWERS).

GRADED A

• ANSWhich of the following statements are TRUE regarding problem lists? I. In some EHRs the problem list can be carried over from a previous visit without updating the information II. Problem lists include chronic conditions III. Problem lists can include previously treated conditions. IV. In some EHRs the problem list can include conditions from previous years A. I and II B. I and III C. II, III and IV D. I, II, III, and IV 1.0 - ANSEach year, Medicare normalizes risk scores to maintain an average of what?

A. A/P: Mild CKD - ANSWhich of the following physician assessments support the correct coding of CKD stage 2, code N18.2? A. A/P: Mild CKD B. Assessment and Plan: Moderate CKD C. Assessment: Severe Chronic Kidney Disease D. A/P: ESRD a. An analytical review of known data elements to establish a hypothesis related to the future health of patients. - ANSWhat is predictive modeling? a. An analytical review of known data elements to establish a hypothesis related to the future health of patients. b. An analytical review of payments to health plans to determine the cost of future healthcare. c. An average of costs associated with diagnoses used to determine which providers to contract with for a health plan. d. An average payment associated with diagnoses used to determine which health plans providers should contract with. A. Analysis of data to determine a hypothesis related to the future health care needs of patients - ANSWhat is predictive modeling?

A. Analysis of data to determine a hypothesis related to the future health care needs of patients B. Cost comparison of health care costs generated locally versus nationally C. Comparison of money saved with risk adjustment models compared to fee-for- service models D. Chronic disease management education to prevent high health care costs a. Code the condition as if it was established If the diagnosis documented at the time of discharge is qualified as "probable," "suspected," "likely," "questionable," "possible," or "still to be ruled out" or similar terms indicating uncertainty, code the condition as if it existed or was established.

• ANSWhat is the guideline for coding "probable," "suspected," "possible," or "questionable" in the INPATIENT setting? a. Code the condition as if it was established b. Code the sign and symptoms c. Query the provider before coding d. Code with the sign and symptom and the condition A. Conditions listed on the problem list for a diabetic patient are coded as complications of the diabetes.

Conditions listed on the problem list are not coded as complications of the diabetes unless the documentation supports the causal relationship. - ANSWhich of the following is NOT true? A. Conditions listed on the problem list for a diabetic patient are coded as complications of the diabetes. B. If documentation does not state the type of diabetes but indicates the patient uses insulin report Type 2 diabetes code (E11.-). C. Documentation that indicates a cause and effect relationship includes "due to," "caused by," "with" and "secondary to." D. A causal relationship is assumed between diabetes and a complication when the term "with" links the two together in the Alphabetic Index. a. Diabetes and hypertension Rationale: The guidelines state not to code resolved conditions. - ANSA patient is seen for diabetes and hypertension. The patient had pneumonia which was resolved three months ago. What diagnoses would be coded? a. Diabetes and hypertension b. Pneumonia c. Diabetes, hypertension and pneumonia d. Diabetes

a. Disease management programs - ANSWhat might happen as a result of predictive modeling? a. Disease management programs b. Concurrent audits c. Transporation benefits d. Reduction in case management A. Documentation validates the CMS requested HCCs, contains all the necessary documentation elements and has an additional HCC not requested by CMS. - ANSThe definition of a best medical record for a RADV audit is: A. Documentation validates the CMS requested HCCs, contains all the necessary documentation elements and has an additional HCC not requested by CMS B. Documentation that validates all the requested HCCs C. Documentation that validates the requested HCC, but there is no provider signature D. Documentation that validates the requested HCC plus validates an additional HCC, contains all the necessary documentation elements, but is missing the provider signature, for which a signed CMS attestation was provided but not signed by the provider

a. Dominant - ANSAccording to ICD-10-CM guidelines, what is the default code selection to use when a patient has hemiparesis affecting the right side of the body? a. Dominant b. Non-Dominant c. Both Dominant and non-dominant d. You are unable to code it A. Eases the transition from one year's model to the next because of potential lost values. The blended methodology was chosen to ensure ease of transition from one model to the next because of their vast differences and potential lost values. - ANSWhich statement is TRUE regarding the HCC blended model? A. Eases the transition from one year's model to the next because of potential lost values B. Requires additional resources to code records working under two different models C. Allows for fee-for-service model incorporation into the risk adjustment factor score D. Results in loss of revenue in the first year which can be recouped the following year

A. HCC - ANSWhich risk adjustment model is most commonly used by Medicare? A. HCC B. CDPS C. Blended D. Fee for service a. Highest level of specificity - ANSDiagnosis codes are to be coded to the ___________ based on the documentation. a. Highest level of specificity b. Unspecified code for the condition c. Code found on the superbill/encounter form d. Code selected by pick list a. Hypertension and epilepsy Rationale: The plan for hypertension and epilepsy is consistent with a current diagnosis. The plan for prostate cancer is more consistent with a history of cancer.

• ANSWhich condition(s) is/are coded as current documented in the assessment provided below? Assessment:

HTN: continue meds Epilepsy: check Dilantin levels. Refill med Prostate cancer: return to oncologist for yearly screening a. Hypertension and epilepsy b. Hypertension c. Hypertension, epilepsy, and prostate cancer d. Epilepsy A. I and II Retrospective chart audits have been commonly used to increase revenue, but for companies that want to do the "right" thing and to decrease the financial risk during RADV audits, comparing the claims to the documentation and where there are discrepancies submit deletes (remove ICD-10-CM code from CMS data base) and to submit additional codes is the best use of the retrospective chart audits. - ANSRetrospective audits provide insurance companies with ability to scrub/correct their data which accomplishes which of the following? I. Provides opportunities to increase revenue by submitting additional codes II. Provides opportunities to compare claims data to the documentation and submit deletions if the documentation does not support what was on the claim III. Provides opportunities to correct coding errors prior to data being submitted

A. I and II B. I C. II D. II and III A. I and II These audits can mandate that insurance companies repay CMS for past revenues which will decrease the bottom line for the stock holders. Billing compliance issues might come into play and a deeper dive might be warranted for specific provider offices which will cause abrasion with the providers. - ANSRetrospective audits generally include finding additional diagnoses, CMS has stated that the deletion of conditions needs to be part of these audits; why is it so hard for companies to follow CMS directives? I. There is a potential of loss of revenue II. Billing compliance issues might come too light III. All companies follow CMS directives A. I and II B. I C. I and III D. III

A. I and II - ANSPredictive models are used to identify people who are at high risk of chronic illnesses having higher medical claims; what can a provider do with this information to decrease the medical costs? I. Develop disease management education programs II. Involve clinical staff to help with coordination of care III. Refer the patients with chronic illnesses to be treated by another provider IV. Determine the return on investment when referring to a specialist for chronic illnesses A. I and II B. III and IV C. I and III D. I, II, III, and IV A. I and II - ANSWhich of the following medications are prescribed to cancer patients to eradicate the cancer or for prophylaxis? a. I. Tamoxifen b. II. Anastrozole c. III. Januvia d. IV. Crestor

A. I, II, and III - ANSWhich medical record(s) can be submitted for HCC validation? I. Physician office progress note II. Outpatient Hospital III. Critical Access Hospital IV. Laboratory test results V. Diagnostic X-rays A. I, II, and III B. IV C. I, II, III, and IV D. I, II, III, IV, and V A. I67.2 (cerebral ateriosclerosis), Z86. I67.2 Cerebral atherosclerosis is the correct primary ICD-10-CM code. The personal history TIA code Z86.73 is reported as the second code. Memory loss (R41.3) would not be reported as it is a symptom of cerebral arteriosclerosis. - ANSPatient is here for follow up. She was seen in the ER two weeks ago where she had an MRI of the brain which showed significant cerebral arteriosclerosis. She was diagnosed with a TIA. She has been experiencing slight memory loss. Select the correct code(s). A. I67.2 (cerebral ateriosclerosis), Z86. B. G45.9 (TIA, unspecified)

C. Z86.73 (Personal Hx of TIA or cerebral infarction without residual effects), R41. (amnesia, other) D. G45.9 (TIA, unspecified), I67.2 (cerebral ateriosclerosis), R41.3 (amnesia, other) A. Identify data that might be related to patient risk scores - ANSData mining is performed to: A. Identify data that might be related to patient risk scores B. Look for opportunities for clinical staff incentives C. Make sure that low performing providers are penalized for poor outcomes D. To evaluate the effectiveness of compliance plans A. II and III RADV/IVA audits require the provider signature, credentials, and two patient ID's such as patient name and DOB. The printed provider name is only necessary when the signature is illegible and there is a need to identify the provider. - ANSRADV/IVA audit submissions typically require: I. Provider printed name II. Two patient identifiers III. Provider's signature IV. Must include specialist consultations

V. Must include coordination of care documentation by clinical staff A. II and III B. I, II and IV C. I, III, IV, and V D. I, II, III, IV, and V A. III - ANSWhich code set is used for HCC coding? I. CPT II. HCPCS Level II III. ICD-10-CM IV. ICD-10-PCS A. III B. III and IV C. I and III D. I, II, III and IV a. Inpatient admission note - ANSWhich type of documentation can be used to support diagnoses reported under risk adjustment models?

a. Inpatient admission note b. CT scan results c. CBC lab test d. Comprehensive problem list a. interactions Interactions are extra risk adjustment values or factors added when a patient has more than one major significant diagnosis identified in the model. These interactions add value because it is understood that having a combination of some diagnoses together increase clinical risk and associated costs of care. - ANSWhat are the extra risk adjustment values or factors added when a patient has more than one major significant diagnosis identified in the model? a. interactions b. risk factors. d. demographic variances e. exceptions A. It secretes hormones regulating body metabolism and blood calcium - ANSWhat is the function of the thyroid gland? A. It secretes hormones regulating body metabolism and blood calcium B. It secretes hormones regulating the secretion of insulin and hemoglobin

C. It secretes hormones regulating mood and growth hormones D. It secretes hormones regulating the immune system and blood calcium A. Location and type of ulcer must be described for vascular ulcers. The treating provider must call it an ulcer and must include a description of the location and type of ulcer in order to code a vascular ulcer. - ANSIn order for a coder to properly code for a vascular ulcer, which of the following must be included by the treating provider in the documentation? A. Location and type of ulcer must be described for vascular ulcers B. Size and location of ulcer must be described for vascular ulcers C. Size and type of ulcer must be described for vascular ulcers D. Only the location of the ulcer must be described for vascular ulcers a. Outcomes - ANSIn the CMS Star Ratings program, which measure is given the highest weight? a. Outcomes b. Patient experience c. Customer service d. Accurate RAF scores

a. Perform a retrospective audit to confirm proper diagnosis code selection. - ANSWhat is the step after predictive modeling identifies a diagnosis gap? a. Perform a retrospective audit to confirm proper diagnosis code selection. b. Develop a process to capture more accurate diagnosis going forward. c. Change the diagnosis if it results in higher risk adjustment. d. Change the diagnosis regardless of the risk adjustment. A. Performance of Medicare Advantage plans - ANSWhat does CMS' Star Ratings program monitor? A. Performance of Medicare Advantage plans B. Fraud and abuse C. Adherence to state scope of practice D. Performance of Medicare providers a. Previous year's known diagnoses Rationale: In Medicare, each current year's financial funding is allocated based on the previous year's known diagnoses (or medical problems). - ANSFor Medicare, funding is allocated based on: a. Previous year's known diagnoses b. Current year's known diagnoses

c. Projected diagnosis codes d. Audited diagnosis codes a. Prior to the diagnosis and risk factor data being reported to CMS. - ANSWhen are prospective reviews performed? a. Prior to the diagnosis and risk factor data being reported to CMS. b. After the diagnosis and risk factor data has been reported to CMS. c. Once the patient is enrolled in Medical Part C plan. d. Once the provider has finalized the documentation to submit diagnosis codes. A. Prospective payment system - ANSRisk Adjustment is a: A. Prospective payment system B. Retrospective payment system C. Fee-for-service payment system D. Case rate payment system A. Reporting a diabetic manifestation to increase the risk score. - ANSWhich of the following is an example of fraud? A. Reporting a diabetic manifestation to increase the risk score.

B. Submitting a record for a RADV audit which includes diagnoses that were not previously reported. C. Training physicians to document causal relationships for manifestations for chronic illnesses when present. D. Setting a policy to report all patient's with DM and CKD as a diabetic manifestation. a. Silver - ANSWhich plan offers the best value for savings out of pock costs for the HHS HCC model? a. Silver b. Gold c. Bronze d. Platinum A. The diagnosis is included in the CMS-Hierarchical Condition Category (CMS- HCC) A current model diagnosis code must meet the following criteria:

1. The diagnosis is included in the CMS-Hierarchical Condition Category (CMS- HCC), Prescription Drug (CMS-RxHCC) or End Stage Renal Disease (CMS-HCC ESRD) risk adjustment models.

2. The diagnosis must be received from one of the three provider types (hospital inpatient, hospital outpatient, and physician) covered by the risk adjustment requirements.
3. The diagnosis must be collected according to the risk adjustment data collection instructions. - ANSIn order for a code to be counted as part of the current CMS HCC model, what is the criteria a diagnosis code must meet? A. The diagnosis is included in the CMS-Hierarchical Condition Category (CMS- HCC) B. The diagnosis is a history code C. The diagnosis has never been reported D. The diagnosis is an acute condition A. The number of years a patient has been covered under Medicare Advantage All risk adjustment programs utilize diagnosis codes to "adjust" potential risks for patients, there are additional elements taken into consideration, including: Age Gender Socioeconomic status Insurance status (Medicare, Medicaid, dual-eligible, etc.) Procedure codes Place of service codes

Special patient-specific conditions (i.e. such as being enrolled in hospice or being an ESRD (end stage renal disease) patient), etc. - ANSWhich of the following elements would NOT be taken into consideration for risk adjustment? A. The number of years a patient has been covered under Medicare Advantage B. Gender C. Procedure codes D. Place of service a. The type of asthma is reported along with the COPD. - ANSWhich statement is TRUE regarding coding COPD with a specific type of asthma in ICD-10-CM? a. The type of asthma is reported along with the COPD. b. Only the COPD is reported. c. COPD with bronchitis is reported for COPD with asthma. d. Only the asthma is reported. a. Top performing health plans based on quality - ANSWhat do the Star Ratings identify? a. Top performing health plans based on quality b. Top performing doctors based on quality c. Cost of healthcare in facilities

d. Cost of healthcare by provider a. Verify accuracy of the diagnosis submitted for payment. CMS conducts Risk Adjustment Data Validation (RADV) audits to verify the accuracy of the diagnosis codes submitted for payment by the Medicare Advantage organization. - ANSWhat is the purpose of the RADV audit? a. Verify accuracy of the diagnosis submitted for payment. b. Verify accuracy of the CPT codes submitted for payment. c. Verify provider's signature/attestation. d. Verify the provider's use of quality measures. a. Work Plan - ANSMonthly, on its website, the OIG releases a ____ outlining its priorities for the fiscal year ahead. a. Work Plan b. Self-referral law c. CIA yearly review d. Compliance Plan a. Yes, additional current diagnoses not included on claims data may be approved during the audit.

Rationale: Additional diagnoses that are documented as current in those dates of services on claims for that year, but not included on the original claim, may also be approved. The submission of all diagnoses (with HCC's) are cumulative, so there may be a negative or positive outcome overall from a financial perspective in such an audit. - ANSWhen submitting records for RADV audit, will additional current diagnoses that were not originally reported be considered when documentation is submitted for the audit? a. Yes, additional current diagnoses not included on claims data may be approved during the audit. b. Yes, claims are not required to capture risk adjustment factors. c. No, the audit is performed based on the diagnoses originally submitted. d. No, because the RADV audit is prospective only predictive modeling is used. A. Yes, plans can request a recalculation if an inaccurate diagnosis will impact the final payment - ANSCan a request for recalculation from the plan be requested when inaccurate diagnosis codes are identified after the final risk score is determined? A. Yes, plans can request a recalculation if an inaccurate diagnosis will impact the final payment B. Yes, plans can request a recalculation if found within ten days C. No, plans cannot request a recalculation once a final risk score is calculated D. No, plans request for a recalculation can only occur when notified by CMS

a. Z51.89 Encounter for other specified aftercare Because it is past four weeks and the patient is still symptomatic, according to ICD-10-CM guidelines, Section 1.C.9.e.1, for encounters after the 4 week time frame and the patient is still receiving care related to the myocardial infarction, the appropriate aftercare code should be assigned, rather than a code from category I21. - ANSPatient presents to her physician 10 weeks following a true posterior wall myocardial infarction. The patient is still symptomatic and is receiving care related to the myocardial infarction. What is the correct first-listed ICD-10-CM code for this condition? a. Z51.89 Encounter for other specified aftercare b. I21.29 ST elevation (STEMI) MI involving other sites c. I22.8 Subsequent ST elevation (STEMI) MI of other sites d. I24.2 Old MI all of the above - ANSHow is HEDIS data collected? I. Surveys II. Medical chart reviews III. Insurance claims All of the above

b. 3 - ANSDrugs are generally known by ___ names. a. 1 b. 3 c. 5 d. 7 b. 4 - ANSWhat is the lowest star rating a plan must achieve to void penalties? a. 5 b. 4 c. 3 d. 2 B. A code for a rule out diagnosis can be coded in the outpatient setting only - ANSWhich of the following statements is TRUE regarding rule out diagnoses? A. A code for a rule out diagnosis can be coded when coding for HCC B. A code for a rule out diagnosis can be coded in the outpatient setting only C. The provider can document the rule out diagnosis but a code is not selected to report it D. The provider can document the rule out diagnosis and select a secondary code to report it

B. Affects the veins - ANSWhich of the following is FALSE regarding Atherosclerosis? A. Can affect the coronary (heart) arteries B. Affects the veins C. Is promoted by LDL (low density lipoprotein - bad cholesterol) and protected by HDL (high density lipoprotein - good cholesterol) D. Is a chronic disease that can remain asymptomatic for decades b. Allow patients to compare health plans. - ANSWhat is the goal of HEDIS? a. Allow for patients to rate their physicians. b. Allow patients to compare health plans. c. Allow patients to schedule appointments online. d. Allow patients to access their medical records. b. Asthma - ANSIf you were using predictive modeling and the results were:

• Rx Claim: Albuterol (quick-relief inhaler)
• Medical Claim: Pulmonary Function Test
• DME claim: Home Nebulizer