CRC Exam Questions with 100% Correct Answers | Verified | Updated 2024, Exams of Advanced Education

Download CRC Exam Questions with 100% Correct Answers | Verified | Updated 2024 and more Exams Advanced Education in PDF only on Docsity! CRC Exam Questions with 100% Correct Answers | Verified | Updated 2024 Risk Adjustment (a prospective payment system) - Correct Answer-The process of increasing or reducing payments to health plans to reflect higher or lower than expected spending. Risk adjusting is designed to compensate health plans that enroll an older and sicker population as a way to discourage plans from selecting only healthier enrollees. What is the goal when coding for risk adjustment? - Correct Answer-code ALL current dx What is the purpose of collecting dx in risk adjustment coding? - Correct Answer-Adjust potential risk measure & eval all Pts on an equal scale levels the playing field of age, race, gender, & socioeconomics What is the acronym for risk adjustment coding? - Correct Answer-HCC (Hierarchical Condition Category) pg. 1 professoraxe l What elements would NOT be taken in to consideration for risk adjustment? - Correct Answer-number of years Pt. has been covered under medicare advantage Which medical records can be submitted for HCC validation? - Correct Answer-+MD office progress note +Outpatient hospital +Critical access hospital What is the purpose of risk adjustment values? - Correct Answer-to budget care of a patient for the following year What are risk adjustment models used for? - Correct Answer- To determine projected costs of healthcare based on the conditions of patients Which is NOT to be taken into consideration for risk adjustment? - Correct Answer-Frequency of office visits How is predictive modeling used in risk adjustment? - Correct Answer-determine suspected dx based on data elements pg. 2 professoraxe l All conditions listed on the problem list for DM patients are coded as complications of DM: True or False? - Correct Answer-False What is true regarding hierarchies? - Correct Answer-Utilized by some private payers Quality Measures like Star Ratings and HEDIS have NO correlation with the medical record that is collected to support risk adjustment. TRUE or FALSE? - Correct Answer- FALSE Is HEDIS a division of CMS or Medicaid? - Correct Answer-NO Who developed HEDIS? - Correct Answer-NCQA (National Committee for Quality Assurance) How is HEDIS data collected? - Correct Answer-+surveys +medical chart reviews +insurance claims pg. 5 professoraxe l What is the goal of HEDIS (Health Plan Employer Data Info Set)? - Correct Answer-for consumers to compare health plans How often are HEDIS measures revised? - Correct Answer- Annually Which payers uses HEDIS measures? - Correct Answer-a variety RADV - Correct Answer-Risk Adjustment Data Validation What is the purpose of a RADV audit? - Correct Answer-Verify accuracy of dx submitted for payment When submitting records for RADV audit, will additional current dx that were not originally reported by considered when documentation is submitted for the audit? - Correct Answer-Yes! additional current dx not included on claims data may be approved during the audit. The submission of all dx (w/HCCs) are cumulative, so there may be a neg. or a pos. outcome overall from a $ perspective pg. 6 professoraxe l What info is verified during RADV audit? - Correct Answer-All dx codes are supported in the medical record Which of the following criteria would be components of an acceptable medical record in a RADV? - Correct Answer- +encounter must be a face-to-face visit +encounter must be from an acceptable provider type +condition(s) must be documented in the medical rec. +encounter must include a signature or attestation How many records are submitted per Pt. in a RADV audit? - Correct Answer-5 Definition of the best record for a RADV audit - Correct Answer-documentation validates the CMS requested HCCs, contains all the necessary documentation elements, & has ADDITIONAL HCCs not requested by CMS What info is required when submitting documentation to support a dx for a RADV/IVA - Correct Answer-outpatient - single DOS hospital - full inpatient set pg. 7 professoraxe l Meds for CA to eradicate or for prophylaxis - Correct Answer- Tamoxifen, Anastrozole When is it appropriate to use Hx of malignancy? - Correct Answer-+it has been excised, +no evidence of any existing primary malignancy +there is no further tx directed to the site Funding is allocated based on what for COMMERCIAL plans - Correct Answer-Current year's dx The Star Ratings program monitors? - Correct Answer- Performance of Medicare Advantage Plans Ratings are published by CMS in Oct. What is True about the Star Quality Rating system? - Correct Answer-Quality bonus payments are made to medicare advantage plans who score 5 or 4 stars BONUS= 5 or 4 In the Star Program what is the lowest rating a plan must achieve to avoid penalties? - Correct Answer-4 pg. 10 professoraxe l No Penalities = 5 > 4 Penalities = 1,2,3 *Pts enrolled in a poorly performing plan can switch an a 5- star plan at ANY time In the Star program which measure is given the highest weight? - Correct Answer-Outcomes What is true regarding the Star Program? - Correct Answer- States can either use the federal methodology OR Propose an alternative for certification of HHS What do the star ratings identify? - Correct Answer-top perfoming health plans based on quality What element of the medical record is NOT used to capture current dx? - Correct Answer-Radiology report Medicare defaults much of its risk adjustment dx coding guidelines to: - Correct Answer-Official Coding Guidelines, & Coding Clinic pg. 11 professoraxe l Coding Clinic is associated with? - Correct Answer-AHA (American Hosp. Assoc.) What is the purpose of collecting dxs in risk adjustment coding? - Correct Answer-Risk adjustment factor (RAF) What is the impact on reimbursement under the risk adjustment model if chronic conditions are not coded? - Correct Answer-Failure to code for ALL chronic conditions may result in an inaccurate RAF What is the purpose of capturing codes in an HCC model? - Correct Answer-determine the combined RAF When is "added value" factored into the RAF for the HC model for disease interaction? - Correct Answer-when two chronic illness paired together are complex to treat What would lead to an underpayment? - Correct Answer- failing to report all the dxs supported in the medical record pg. 12 professoraxe l +claims data elements (procedure codes, place of service codes) +special Pt.-specific conditions (ESRD, hospice) +HCCs focus on illnesses that affect the LT-care of Pt Where can a list of dx-mappings to HCCs be located? - Correct Answer-CMS website For the HHS HCC model, who is included in the adult model? - Correct Answer-those aged 21 + child model = 2-20yrs infant model= birth-1yrs What is the purpose of the coding intensity adjustment? - Correct Answer-+determine different coding pttns in HCC compared to INPATIENT claims covered by Part A +determine different coding pttns in HCC compared to OUTPATIENT claims covered by Part B Each year, Medicare normalizes risk scores to maintain an avg of? - Correct Answer-1.0 pg. 15 professoraxe l When are retrospective reviews usually performed? - Correct Answer-AFTER the dx and risk factor data has been reported to CMS How is FFS data used for the purpose of risk adjustment? - Correct Answer-used to determine the FFS normalization adjustment In CDPS risk adjustment models, where do heart attacks fall? - Correct Answer-Medium (VH=heart transplant/valves, Low=heart dis, ExLow=HTN) Under the ACA, can health plans set the premium rate based on Pt's health status? - Correct Answer-NO! health plans can NOT charge different premiums based on health status What are extra risk adjustment values/factors added when a patient has more than one major significant dx identified in the model? - Correct Answer-Interactions When are prospective reviews performed? - Correct Answer- BEFORE the dx & risk factor data is submitted to CMS pg. 16 professoraxe l What type of fracture is considered traumatic? - Correct Answer-compound fracture When code for External Causes? - Correct Answer-Causes of injury or health condition Which structure in the urinary system differs in position/length between males & females? - Correct Answer- Urethra urine is transported from kidneys to bladder via - Correct Answer-ureter Where is bile produced? - Correct Answer-produced =liver stored= gall bladder What belongs to the appendicular skeleton? - Correct Answer- pelvic girdle which membrane is found lining the interior walls of the digestive system? - Correct Answer-mucous pg. 17 professoraxe l respiratory structure composed of cartilage & ligaments - Correct Answer-trachea structure that lies on top of the dermis and has access to rich supply of blood - Correct Answer-stratum germinativum what's an MI - Correct Answer-lack of O2 to heart tissue, resulting in tissue death What is a sentinel lymph node? - Correct Answer-first lymph node to which cancer cells are most likely to spread from a primary tumor ABN cost estimate should be within what range? - Correct Answer-$100 or 25% What document assists provider offices with development of compliance manuals - Correct Answer-OIG compliance plan guidance According to the OIG, internal monitoring and auditing should be performed by what means? - Correct Answer-Periodic audits pg. 20 professoraxe l Which document is referenced when looking for potential problem areas identified by the government indicating scrutiny of the services? - Correct Answer-OIG work plan (MONTHLY the OIG releases work plans outlining its priorities for the fiscal year ahead) The OIG recommends that provider practices enforce disciplinary actions thru their guidelines to ensure actions that are CONSISTENT & APPROPRIATE According to the OIG, internal monitoring & auditing should be performed PERIODICALLY Which act was part of the Am. Recovery & Reinvestment Act of 2009 - Correct Answer-HITECH which was enacted a part of the American Recovery & Reinvestment Act of 2009? - Correct Answer-HITECH When was HITECH enacted? - Correct Answer-2009 pg. 21 professoraxe l What year was AAPC founded? - Correct Answer-1988 code: Integrity, respect, commitment, competence, fairness, responsibility (not efficiency) When did HIPAA become a law? - Correct Answer-1996 what info is not maintained in medical record? - Correct Answer-financial info what will the scope of a compliance program depend on? - Correct Answer-the size & resources of the provider's practice Covers inpatient hospital stays, care in a skilled nursing facility, hospice care, and some home health care. - Correct Answer-Part A Which medicare part covers provider fees without the use of private insurance - Correct Answer-Part B 1-medically necessary provider services 2-preventative services pg. 22 professoraxe l Example of fraud - Correct Answer-setting a policy to report all Pts with DM & CKD as a DM manifestation in order to elevate risk scores Purpose of RADV audit is to validate submitted HCC data - TRUE or FALSE? - Correct Answer-TRUE How can a MA plan improve their revenue? - Correct Answer- Develop prospective AND retrospective reviews to make sure all accurate dxs are captured. Medicare Advantage plans - Correct Answer-+health risk is RE- determined every year +document all clinical findings in the medical record +HCCs must be captured every 12 months Vascular ulcer - Correct Answer-Location & Type What is the function of thyroid gland - Correct Answer-secrete hormones regulating body metabolism & blood calcium pg. 25 professoraxe l Which cells produce hormones to regulate blood sugar - Correct Answer-pancreatic islets Excessive potassium in the blood is referred to as: - Correct Answer-Hyperkalemia Tx=IV glucose & insulin (to promote m'vt of potassium back into cells) What is predictive modeling? - Correct Answer-analysis of data to determine hypothesis related to the future health care needs of patients In risk adjustment models, risk scores are used to adjust payments for each beneficiary's expected expenditures - True or False? - Correct Answer-True What can affect RAF score? - Correct Answer-+Disease interactions +Age +Manifestations of chronic illnesses pg. 26 professoraxe l What is RAPS? - Correct Answer-Risk Adjustment Processing System What factor remain the same from year to year in risk adjustment? - Correct Answer-+Health plans are protected from the risk of attracting a disproportionate # of unhealthy enrolls +Health plans are discouraged from marketing to only healthier, less costly pot'l members +Risk adjustment is a permanent program The minimum necessary rule is based on sound current practice that PHI should NOT be used or disclosed when it is not necessary to satisfy a particular purpose or carry out a function. This means... - Correct Answer-Providers should develop safeguards to prevent unauthorized access to PHI Applys to covered entities taking reasonable steps to limit use of PHI What is the benefit of electronic transactions - Correct Answer-Timely submissions to the insurance carrier & proof of transmission pg. 27 professoraxe l Which of the following best describes psoriasis? - Correct Answer-A chronic condition characterized by red, dry, elevated lesions, covered by silvery scales An ectopic pregnancy - Correct Answer-implantation occurs somewhere other than the uterus What is the function of the Cowper's gland? - Correct Answer- lubricates the urethra. The mediastinum cavity contains - Correct Answer-trachea, heart, thymus How many lobes does the right lung have? - Correct Answer-3 (superior, middle, inferior) How many lobes does the left lung have? - Correct Answer-2 (superior and inferior) pg. 30 professoraxe l The corpus luteum secretes progesterone, which causes... - Correct Answer-thickening of endometrium for implantation & is necessary to sustain pregnancy Subcarinal means beneath the carina, which is located where? - Correct Answer-at the bifurcation of the trachea into two bronchi Which leukocyte is the body's 2nd line of defense against infection? - Correct Answer-Monocytes Anemia and polycythemia are disorders related to which blood cell? - Correct Answer-Erythrocytes What structure is NOT a true endocrine structure? - Correct Answer-Carotid body (but is made of glandular & non- glandular tissue) Which part is considered the foundation of a word? - Correct Answer-root Blepharoplasty is performed on which part of the body? - Correct Answer-eyelid pg. 31 professoraxe l Salpingo-oophorectomy - Correct Answer-Surgical removal of the fallopian tubes and ovaries What structure does paronychia refer to? - Correct Answer- nail Leukocytosis - Correct Answer-increase in white blood cells Choledochal cyst - Correct Answer-cystic growth of the common bile duct A cystourethroscopy is examination of what structures? - Correct Answer-bladder & urethra cystoscopy=scope of bladder Squamous cell carcinoma (SCC) & Basal cell carcinoma (BCC) affect which cells? - Correct Answer-epithelial cells Which layer of the epidermis is only found in thick skin (soles of feet/palms of hands)? - Correct Answer-stratum lucidum pg. 32 professoraxe l Incision into the chest wall - Correct Answer-thoracotomy Organs in the thoracic cavity - Correct Answer-heart and lungs Where gas is exchanged - Correct Answer-alveoli & capillaries Which suffix means breathing? - Correct Answer--pnea Which part of the LI is between the hepatic flexure & splenic flexure? - Correct Answer-transverse colon Congenital defect in which the urethra opens on the dorsum of the penis - Correct Answer-Epispadias Where are the Bartholin's glands located and that is their function? - Correct Answer-either side of the introitus (vaginal opening), lubricates vagina Which layer is the middle layer of the eyeball? - Correct Answer-Choroid pg. 35 professoraxe l +retina=innermost, +choroid=middle, +sclera=outermost What prevents the eyeball from collapsing? - Correct Answer- Aqueous humor Inner ear - Correct Answer-labyrinth +outer=ext. ear, +middle=tympanic cavity, +inner=labyrinth tympanic membrane separates - Correct Answer-outer ear from middle ear Auditory ossicles - Correct Answer-mealleus, incus, stapes What is true about the function of the cochlea? - Correct Answer-it transmits sound pg. 36 professoraxe l Which gland is larger in early life than in puberty? - Correct Answer-thymus gland Which gland is also know as the hypophysis cerebri? - Correct Answer-pituitary gland Which gland has separate structures called medulla & cortex? - Correct Answer-adrenal glands Which leukocytes protects the body from VIRAL infections - Correct Answer-lymphocytes +neutrophils =infections/antigens, +monocytes=infections, +eosinophils=allergies/parasites Excessive mononuclear leukocytes in the blood - Correct Answer-mononucleosis Study of how chemical agents affect living processes - Correct Answer-pharmacology pg. 37 professoraxe l Drug suffix -sartan is in what class? - Correct Answer- angiotensin receptor antagonists Drug with a suffix of -Zumab is in what class? - Correct Answer-humanized monocolonal antibody ex - Trastuzumab Medication that slows the progression of uterine CA - Correct Answer-Megestrol (hormone) Statin - Correct Answer-Lipitor, Lovastatin, Crestor not Tricor = Fibrate Drug to tx HTN & CHF - Correct Answer-Ace inhibitors Med to treat overweight Pts with DM2? - Correct Answer- Metformin Anticholinergics have been associated with the rare side effect of - Correct Answer-acute glaucoma pg. 40 professoraxe l Anticoagulants prevent clotting by blocking the effects of... - Correct Answer-Vit. K DMARDs (antirheumatic) reduce the level of - Correct Answer- TNF-alpha (tumor necrosis factor-alpha) DMARDS=methotrexate, ciclosporin, infliximab, rituximab DMARDS reduce the level of: - Correct Answer-symptoms (pain/inflammation) DMARD (disease-modifying antirheumatic drug)drugs? - Correct Answer-Methotrexate, Ciclosporin, Infliximab, rituximab Drug suffix -ximab is in what class? - Correct Answer-Chimeric antibody that responds to more than one antigen drug class Drug suffix -prazole is in what class - Correct Answer-proton pump inhibitor The path in which a drug is taken - Correct Answer-route of administration pg. 41 professoraxe l Which is NOT a parenteral administration route - Correct Answer-Epicutaneous parenteral=intravenous intraossesous, subcutaneous Side effect of sulphonylurea drugs - Correct Answer-decreased appetite & weight loss DM1 - Correct Answer-lack of insulin AV fistual - Correct Answer-connects artery < > vein Route of administration through a blood vessel - Correct Answer-Intra-arterial TOPICAL route of administration - Correct Answer- Epicutaneous, eye drops, ear drops What is TRUE about Coding Intensity Adjustment - Correct Answer-MA plan risk scores increase faster than FFS scores pg. 42 professoraxe l What is a default code? - Correct Answer-the code that represents the condition most commonly associated with the main term how do supplementary words in ( ) affect coding? - Correct Answer-No effect ( ) = supplementary words What do [ ] indicated? - Correct Answer-use the codes in [ ] in addition to the disease/condition to identify an associated manifestation [ ] = code also What month does the new ICD-10 codebook take effect each year? - Correct Answer-OCT What parties are responsible for providing ICD-10 guidelines? - Correct Answer-NCHS & CMS When do you code for co-existing conditions? - Correct Answer-at the time of the encounter pg. 45 professoraxe l What is the purpose of the coding intensity adjustment? - Correct Answer-+determine different coding patterns in HCC compared to inpatient claims covered by Part A +determine different coding patterns in HCC compared to outpatient claims covered by Part B What is the time frame defining when pain becomes chronic? - Correct Answer-no time frame Code Blood test for HIV that is inconclusive - Correct Answer- R75 MRSA - Correct Answer-Methicillin Resistant Staphylocccus Aureus 4th Character in DM codes indicate - Correct Answer-any complication associated w/ DM When do you code Acute Resp. Failure as a secondary dx? - Correct Answer-when it occurs after admission How to code urosepsis - Correct Answer-Query provider pg. 46 professoraxe l Is there a time limit when assigning codes as sequela? - Correct Answer-No time limit How code an acute exacerbation of a chronic condition? - Correct Answer-1st=acute 2nd=chronic How code an "impending" condition that has not occurred by d/c? - Correct Answer-check alpha index for "threatened" or "impending", if not code the existing underlying condition How code when info in the medical record provides detail, but no specific code exists? - Correct Answer-NEC Three-character ICD-10 codes represent what level of code? - Correct Answer-category How code management of anemia d/t malignancy? - Correct Answer-1st=malignancy 2nd=anemia pg. 47 professoraxe l what is the step after predicative modeling IDs a Dx gap? - Correct Answer-perform a retrospective audit to confirm proper dx code selection using predictive modeling, which would indicate the possibility of a diabetic complication? - Correct Answer- dialysis Example of a quality review measure - Correct Answer-MIPS What are the participation tracks available thru MACRA? - Correct Answer-Merit-based incentive payment system (MIPS) Advanced Alternative Payment models (APMS) When a Pt. has a condition that is both acute & chronic, how code - Correct Answer-1st=acute 2nd=chronic When are Star ratings published? - Correct Answer-Oct of each year pg. 50 professoraxe l MIPS includes which performance categories? - Correct Answer-+Promoting interoperability +Cost +Improvement Activities +Quality Which domains in CMS Part C & D Stars Ratings? - Correct Answer-+staying healthy +managing chronic conditions +member exp. w/ health plans +member c/o & problems, improvements in plan +health plan customer service How often are HEDIS measures revised? - Correct Answer- Annually How is predictive modeling used in risk adjustment? - Correct Answer-determine suspected dx based on data elements what is the purpose for capturing dx codes in an HCC model? - Correct Answer-determine the combined risk adjustment factor pg. 51 professoraxe l what would lead to an underpayment? - Correct Answer- failing to report all the dx supported in the medical rec What is TRUE about Dx codes? - Correct Answer-Dx codes can be reported for ALL conditions supported as ACTIVE in the medical record Diagnoses carry a RAF values that" - Correct Answer-+are added together cumulatively for a total score +recognize the highest or most severe in a family/hierarchy +are added to a demogrpahic score for a total score what is the purpose for capturing dx codes in an HCC model? - Correct Answer-determine the combined risk adjustment factor what would lead to an underpayment? - Correct Answer- failing to report ALL the dx supported in the med. rec. Each record submitted for a RADV should include: - Correct Answer-+complete & legible records pg. 52 professoraxe l What is the reporting period for risk adjustment - Correct Answer-January to December Where in the documentation dx can be pulled for HCC coding? - Correct Answer-codes can be assigned from documentation within the entire note (discern if active dx or hx condition) Do you code "Resolved" conditions? - Correct Answer-no Pt. seen for DM & HTN, and had resolved PNA 3 months ago - Correct Answer-code for DM & HTN only, PNA is resolved Pt. has a hx of COPD, which is stable w/ current meds - current dx? - Correct Answer-YES, cuz currently being treated Providers should document to support each E/M visit, by - Correct Answer-documenting ALL dx that are part of the medical decision making (MDM) for each visit acceptable signature - Correct Answer-Handwritten signature, electronic sig/authentification pg. 55 professoraxe l not acceptable=sig. stamp, signed by not read, dictated but not signed Pt. presents for surgical creation of an AV fistual for ESRD - Correct Answer-ESRD=N18.6, AV fistual, surgically created=z99.2 Pt. seen for Coumadin mgt for Afib - Correct Answer- encounter for drug level monitoring=z51.81 Afib=I48.91 LT use of anticoagulants=z79.01 pg. 56 professoraxe l