CRC FINAL EXAM NEWEST 2024-2025 ACTUAL EXAM COMPLETE 250 QUESTIONS AND CORRECT DETAILED AN, Exams of Advanced Education

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CRC FINAL EXAM NEWEST 2024 - 2025 ACTUAL

EXAMCOMPLETE 250 QUESTIONS AND

CORRECT DETAILED ANSWERS (VERIFIED

ANSWERS)

ALREADY GRADED A+.

How is predictive modeling used in risk adjustment? - ANSWER >to determine suspected diagnosis based on data elements. Which of the following data elements are used in predictive modeling? I. DME claims II. Prescription drug events III. Physician claims data IV. Facility claims data a. III and IV b. I, II, and IV c. I, II, and III d. I, II, III, and IV - ANSWER >d. I, II, III, and IV What might happen as a result of predictive modeling? a. Disease management programs b. Concurrent audits c. Transporation benefits d. Reduction in case management - ANSWER >a. Disease management programs In the CMS Star Ratings program, which measure is given the highest weight? a. Outcomes

b. Patient experience c. Customer service d. Accurate RAF scores - ANSWER >a. Outcomes How often are HEDIS measures revised? a. As needed b. Monthly c. Bi-annually d. Annually - ANSWER >d. Annually Which statement is TRUE regarding the CMS Stars quality rating system? a. Quality bonus payments are made to physician who score at least four stars. b. Quality bonus payments are made to Medicare Advantage plans who score at least four stars. c. Quality bonus payments are made to physician who score at least five stars. d. Quality bonus payments are made to Medicare Advantage plans who score at least five stars. - ANSWER >b. Quality bonus payments are made to Medicare Advantage plans who score at least four stars. Merit-based Incentive Payment System (MIPS) includes which performance categories? I. Promoting Interoperability II. Cost III. Improvement Activities IV. Quantity V. Quality a. I and II b. I, III, and V

c. I, II, III, and V d. I, II, III, IV, and V - ANSWER >c. I, II, III, and V Which of the following are domains in CMS Part C & D Stars Rating? I. Staying Healthy II. Managing Chronic Conditions III. Member Experience with Health Plans IV. Member Complaints, Problems Getting Services, and Improvement in the Health Plan's Performance V. Health Plan Customer Service a. I, II and III b. I, III, and V c. I, II, III, IV and V d. I, II, III and V - ANSWER >c. I, II, III, IV and V What are the participation tracks available through Medicare Access and CHIP Reauthorization Act (MACRA)? I. Merit-based Incentive Payment Systems II. Sustainable Growth System III. Advanced Alternative Payment Models a. I b. II and III c. I and III d. I, II and III - ANSWER >c. I and III What 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. - ANSWER >a. An analytical review of known data elements to establish a hypothesis related to the future healthof patients. Who developed and maintains HEDIS? a. CMS b. OIG c. BCBS d. NCQA - ANSWER >d. NCQA What 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 - ANSWER >a. Top performing health plans based on quality What 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. - ANSWER

b. Allow patients to compare health plans. When are Star Ratings are publicly published? a. January of each year. b. January and June of each year. c. October of each year.

d. April and October of each year - ANSWER >c. Octoberof each year. How is predictive modeling used in risk adjustment? a. Determine the RAF score in HCC compared to FFS. b. Determine suspected diagnoses based on data elements. c. Determine the correct enrollment process. d. Determine the return on investment for hiring coders. - ANSWER >b. Determine suspected diagnoses based on data elements. If you were using predictive modeling and the results were:

• Rx Claim: Albuterol (quick-relief inhaler)
• Medical Claim: Pulmonary Function Test
• DME claim: Home Nebulizer a. Diabetes mellitus b. Asthma c. Osteoporosis d. Hypertension - ANSWER >b. Asthma If you were using a predictive model and the results were:
• The member had a DME claim for a cane.
• The member had an Rx Claim for a Fosamax.
• The member had a medical claim for a bone density scan.Which diagnosis would you predict this member has? a. Osteoarthritis b. Degenerative joint disease of the knee c. Spinal Stenosis d. Osteoporosis - ANSWER >d. Osteoporosis Which statement is TRUE regarding predictive modeling?

a. Predictive models are only used to identify patients who develop comorbidities due to a lack of care. b. Health plans often use predictive modeling to anticipate potential future diagnoses for an individual patient. c. Predictive modeling identifies needs a patient had in the past that was not provided. d. Providers can use predictive modeling to identify when additional staff is required. - ANSWER >b. Health plans often use predictive modeling to anticipate potential future diagnoses for an individual patient. How is HEDIS data collected? I. Surveys II. Medical chart reviews III. Insurance claims All of the above - ANSWER >all of the above Predictive modeling can use many data elements. Which are beneficial for identifying a person with diabetes? I. Rx claims II. Medical claims III. DME claims a. I only b. I and II only c. II and III only d. I, II, and III - ANSWER >d. I, II, and III Which 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 - ANSWER >a. Inpatient admission note Which statement is TRUE regarding diagnosis codes and assigned HCCs? a. all diagnosis are assigned an HCC. b. all chronic illness are assigned an HCC. c. not all diagnosis codes are assigned an HCC. d. all acute exacerbations of an acute illness are assigned an HCC. - ANSWER >c. not all diagnosis codes are assignedan HCC Where can a list of diagnosis mappings to HCCs be located? a. OIG website. b. CMS website. c. OCR website. d. QPP website. - ANSWER >b. CMS website. Which of the following is TRUE regarding the risk adjustment model by HHS? a. States are mandated to use the Medicare HCCs. b. States can either use the federal methodology or propose an alternate for certification by HHS. c. States can either use the federal methodology or exclude risk adjustment logic from reimbursement. d. States can determine their own policy for payment without a risk adjustment component. - ANSWER >b. States can either use the federal methodology or propose an alternate for certification by HHS. When reporting a code for retinopathy, must the coder find documentation from an ophthalmologist in order to code the condition as an active condition?

a. yes, speciality specific diagnosis can only be reported by a specialist. b. yes, ophthalmologist must diagnosis all eye related conditions. c. No, any approved provider can validate any diagnosis. d. No only PCP can provide supporting documentation for reported diagnoses. - ANSWER >c. No, any approved provider can validate any diagnosis. Under the Affordable Care Act(ACA), can health plans change the premium rate based on a patient's health status where patients with more complex medical issues are required to pay a higher premium than patients with less complex medical issues? a. Yes, as long as the more complex medical conditions are documented. b. Yes, as long as the patient discloses the information when enrolling in a plan on the health care exchange. c. No, health plans can not charge different premiums based on health status. d. No, health plans are prohibited from participating in the ACA risk adjustment model. - ANSWER >c. No, health plans can not charge different premiums based on health status. How often is the normalization factor adjusted? a. monthly b. twice per year c. yearly d. as needed - ANSWER >c. yearly RA must be compared to average FFS expenses and rates. The purpose of the FFS normalization adjustment issue that CMS payments are based on a population with an average

risk score of 1.0. This s the national average. Annually, Medicare normalizes the risk scores to maintain an average res score of 1.0. Risk adjustment models are used to: a. Limit coverage of chronic conditions. b. Determine projected costs of healthcare based on conditions of patients. c. Determine the return on investment for developing proactive disease prevention outreach. d. Limit the coverage of hospital admissions. - ANSWER

b. Determine projected costs of healthcare based on conditions of patients. What 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 - ANSWER >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. Each year, Medicare normalizes risk scores to maintain an average of what? - ANSWER >1. What does the abbreviation CDPS indicate? a. Chronic Disability Provider Services b. Chronic Diagnosis Processing System

c. Chronic Disability Payment System d. Chronic Disability Payment System - ANSWER >c. Chronic Disability Payment System CDPS is the RA model used by Medicaid What is the purpose of the coding intensity adjustment? I. Determine different coding patterns in HCC compared to inpatient claims covered by Part A. II. Determine different coding patterns in HCC compared to outpatient claims covered by Part B. III. Determine different coding patterns in HCC compared to claims processed under CDPS. a. I b. II c. I and II d. I, II, & III - ANSWER >c. I and II CMS is required to make an adjustment to reflect "differences in coding patterns between Medicare Advantage plans and providers under Pay A and B to the extent that the Secretary has identified such differences. Under the Health and Human Services (HHS) Hierarchial Condition Category model, which of the below plans has the highest out of pock expense once the premium is paid? a. Silver b. Gold c. Bronze d. Platinum - ANSWER >c. Bronze Which plan offers the best value for savings out of pock costs for the HHS HCC model? a. Silver

b. Gold c. Bronze d. Platinum - ANSWER >a. Silver For the HHS HCC model who is included in the adult model? a. Individuals 18 years and older b. Individuals 21 and over. c. Individuals who are the head of the household. d. Individuals who are making more than $13,000 per year. - ANSWER >b. Individuals 21 and over. When 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. - ANSWER >a. Prior to the diagnosis and risk factor data being reported to CMS. Which provider is NOT an approved provider for diagnosis code capture under the Medicare HCC model? a. Gynecologist. b. Pathologist. c. Oral surgeon. d. Registered Nurse. - ANSWER >d. Registered Nurse. In the CDPS risk adjustment model, what category do heart attacks fall under> a. Low b. Medium c. High

d. Very high - ANSWER >b. Medium Which elements are considered the Medicare HCC model? a. age b. disability status c. conditions that affect the long-term treatment of the patient insurance status. d. All of the above - ANSWER >d. all of the above Which statement is TRUE regarding the Coding Intensity Adjustment? a. MA plan risk scores and FFS scores typical decrease. b. FFS scores and MA plan risk scores increase at the same rate. c. FFS scores increase faster than MA plan risk scores. d. MA plan risk scores increase faster than FFS scores. - ANSWER >d. MA plan risk scores increase faster than FFS scores. CMS is required to make an adjustment to reflect "differences in coding patterns between Medicare Advantage plans and providers under Pay A and B to the extent that the Secretary has identified such differences. To do this, CMS conducts extensive research to analyze changes inMA and original fee- for-service (FFS) Medicare risk scores, differences between those changes, and coding patterns behind these changes. CMS uses the results of this analysis to develop a factor that is applied to the risk score to account for these differences. MA plan risk score increaser faster than FFS scores. The goal of the MA coding adjustment is to maintain MA risk scores at the level they would be if MA plans coded similarity to FFS providers (not necessarily a 1.0 average). Which RA model is mostly commonly used by Medicaid?

a. HCC b. CDPS c. Blended d. Fee for Services (FFS) - ANSWER >b. CDPS Which RA model is used for commercial plans and uses metal levels to classify patients? a. CDPS b. HHS c. HCC d. Commercial plans do not use risk adjustment models - ANSWER >b. HHS How is the fee-for-services (FFS) data used for purposes of risk adjustment? a. the FFS reimbursement is used to determine the RAF score. b. the FFS data is used to determine which patient should be enrolled in the RA plan. c. The average FFS expenses and rates are used to determine the FFS normalization adjustment. d. The average FFS expenses and rates are used to determine the maximum payment per RAF score. - ANSWER

c. The average FFS expenses and rates are used to determine the FFS normalization adjustment. Under the Health and Human Services (HHS) Hierarchal Condition Category (HCC) model, which plan has the lowest out of pocket expense once the premium is paid? a. Silver b. Gold c. Bronze d. Platinum - ANSWER >d. Platinum

What 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. - ANSWER >a. Perform a retrospective audit to confirm proper diagnosis code selection. Which of the following is a quality review measure? a. APC b. DRG c. Uniform Hospital Discharge Data Set (UHDDS) d. Merit-based Incentive Payment System (MIPS) - ANSWER

d. MIPS What is the lowest star rating a plan must achieve to void penalties? a. 5 b. 4 c. 3 d. 2 - ANSWER >b. 4 When is added value factored into the RAF for the HCC model for disease interaction? a. When two or more chronic conditions are reported b. When there is an exacerbation of a chronic illness c. When two chronic illnesses paired together are complex to treat

d. When a diagnosis code has been reported for at least three years - ANSWER >c. When two chronic illnesses paired together are complex to treat What is the purpose for capturing diagnosis codes in an HCC model? a. Determine the correct fee for service payment b. Determine the combined risk adjustment factor c. Determine the QPP bonus payment d. Determine the patient premium - ANSWER >b. Determine the combined risk adjustment factor Diagnoses carry a Risk Adjustment Factor (RAF) values that: a. Are added together cumulatively for a total score b. Recognize the highest or most severe in a family or hierarchy c. Are added to a demographic score for a total score d. All of the above - ANSWER >d. All of the above Which of the following statements are TRUE: a. Diagnosis codes can only be reported for conditions documented in the assessment b. Diagnosis codes can only be reported for conditions documented in the plan c. Diagnosis codes can be reported for all conditions supported as active in the medical record d. Diagnosis codes can be reported for conditions confirmed by diagnostic tests - ANSWER >c. Diagnosis codes canbe reported for all conditions supported as active in the medical record Which of the following would lead to an underpayment? a. Reporting diagnosis codes that were not documented

b. Reporting a disease with a complication that is not supported in the medical record c. Failing to report a sign or symptom of a definitive diagnosis d. Failing to report all the diagnoses supported in the medical record - ANSWER >d. Failing to report all the diag How many records are submitted by health plans per patient in a RADV audit? a. One b. Five c. Ten d. None it is performed with claims data - ANSWER >b. Five Rationale: The health plans must submit up to five best records demonstrating diagnoses as current in the year being audited that support the HCC values that were paid. For 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 - ANSWER >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). Each record submitted for a RADV should include: I. Complete and legible records II. A complete list of all past and present diagnoses III. Credential for the rendering provider IV. Provider signature or attestation

a. I and II b. II and III c. II and IV d. I, III, and IV - ANSWER >d. I, III, and IV Rationale: When submitting medical records for a RADV audit, health plans must focus attention on established CMS recordkeeping principles.

1. Medical records should be
2. complete and legible and
3. include the identity of the provider and
4. the date of service.
5. It is important that all relevant information is included at the time of service.
6. The credential for the rendering provider must be somewhere on the medical record. If a signature is missing from a medical record, CMS will require an attestation from the provider of service. When 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. - ANSWER >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. Which of the following criteria would be components of an acceptable medical record in a RADV? I. Encounter must be a face-to-face visit. II. Encounter must be from an acceptable provider type. III. Condition(s) reported must be documented in the medical record. IV. Encounter must include a signature or attestation. V. Diagnostic radiology notes must be included. a. I, II, and III b. II, IV, and V c. I, II, III, and IV d. I, II, III, IV, and V - ANSWER >c. I, II, III, and IV Rationale: When submitting medical records for a RADV audit, health plans must focus attention on established CMS recordkeeping principles. Medical records should be complete and legible and include the identity of the provider and the date of service. It is important that all relevant information is included at the time of service. The credential for the rendering provider must be somewhere on the medical record. If a signature is missing from a medical record, CMS will require an attestation from the provider of service. Records must also be a face-to-face encounter from an acceptable provider type. Diagnostic radiology notes are not used for RADV.

What is the impact on reimbursement under the risk adjustment model if chronic conditions are not coded properly? a. Coding for a chronic condition that the patient does not have will result in a lower RAF. b. Coding for an acute condition the patient has will result in a lower RAF. c. Failure to code for a chronic condition the patient has may result in an inaccurate RAF. d. Failure to code for all history that apply to the patient encounter may result in a higher RAF. - ANSWER >c. Failure to code for a chronic condition the patient has may result in an inaccurate RAF. Rationale: Failing to code any real documented diagnoses will skew the facts on each patient profile and create a negative domino effect on the funding for the care and attention to those missed diagnoses. One of the major reasons risk adjustment was created is to identify all current diagnoses to highest specificity. Patients often are found to have many conditions during a manual chart review, which were not known or not reported previously. This leads to an underpayment and limited resources toward that patient's care, leaving health plans with a lack of appropriate funding and planning for those diagnoses when they become necessary to treat later, whether that treatment is current or happens later in the year or the following year. For commercial plans, 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 - ANSWER >b. Current year's known diagnoses

How is HEDIS data collected? I. Surveys II. Medical chart reviews III. Insurance claims a. II only b. I and II c. II and III d. I, II, and III - ANSWER >d. I, II, and III Rationale: HEDIS® data are traditionally collected through surveys, medical chart reviews, and insurance claims from hospitalizations, medical office visits, and procedures. Which of the following data elements are used in predictive modeling? I. DME claims II. Prescription drug events III. Physician claims data IV. Facility claims data a. III and IV b. I, II, and IV c. I, II, and III d. I, II, III, and IV - ANSWER >d. I, II, III, and IV Rationale: Known health information from claims data, disease management, durable medical equipment (DME) requests, prescription drug events (PDE), and similar elements are used in predictive modeling efforts. Select the conditions a coder can assume a cause and effect relationship between, when both diagnosis codes are reported for the same encounter.

a. Hypertension and CHF b. Diabetes and a foot ulcer c. Diabetes and CKD d. Hypertension and CKD e. All of the above - ANSWER >e. All of the above According to the ICD- 10 - CM guidelines, when should co- existing conditions be reported? I. The condition has resolved. II. The condition affects the treatment of an acute condition. III. The condition affects the management of an exacerbated chronic condition. a. I and II b. II and III c. III d. I, II, and III - ANSWER >b. II and III Rationale: According to the ICD- 10 - CM guidelines, report coexisting conditions when it affects the management and treatment of the presenting condition. Which statement from the ROS can be reported as a current diagnosis? a. Patient states she feels anemic. b. Respiratory: asthma-uses rescue inhaler once per week. c. Cardiovascular: patient notices a rapid rate at night. d. Constitutional: patient had a fever for the last two days. - ANSWER >b. Respiratory: asthma-uses rescue inhaler once per week. Rationale: Do not select diagnosis codes for what the patient describes until it is confirmed by the treating provider. The patient could present with symptoms that are consistent with a definitive diagnosis. It is appropriate to report the asthma

because the provider documents the current medical management of the condition. When selecting a diagnosis code, which of the statements is TRUE? a. Report the default code found in the Alphabetic Index. b. Select the code only after it is confirmed using the Tabular List. c. The first-listed diagnosis is the condition with the highest RAF score. d. The first-listed diagnosis is the condition with the highest RVUs assigned. - ANSWER >b. Select the code only after it is confirmed using the Tabular List. Which conditions can be reported as current in the following list? Chronic Conditions: Hepatitis B (followed by hepatologist) HTN (readings running high at home) DM (stable on current insulin dose) Breast cancer (mastectomy in 2011) a. Hypertension and diabetes b. Hypertension, diabetes, and breast cancer c. Hepatitis, hypertension, and diabetes d. Hepatitis, hypertension, diabetes, and breast cancer - ANSWER >c. Hepatitis, hypertension, and diabetes A diabetic patient presents with a laceration on the bottom of her foot. The wound requires a closure repair. Which conditions should the coder report? a. Diabetes

b. Open wound of the foot c. Open wound of the foot and diabetes d. Open wound of the foot and a diabetic manifestation - ANSWER >c. Open wound of the foot and diabetes What is the ultimate goal for risk adjustment coders? a. Code diagnoses with the highest risk adjustment score. b. Code all current conditions following ICD- 10 - CM guidelines. c. Code chronic illnesses only. d. Code all diagnoses documented on the active problem list.

• ANSWER >b. Code all current conditions following ICD- 10 - CM guidelines. Rationale: Risk adjustment coders are responsible for coding all active conditions. The ICD guidelines must be adhered to. Which of the following conditions is coded with a history of code? a. Patient with a history of hypertension managed on Cardizem. b. Patient with a history of breast cancer undergoing radiation treatment. c. Patient with a history of colon cancer resected two years ago. d. Patient with long history of oxygen dependent COPD. - ANSWER >c. Patient with a history of colon cancer resected two years ago. Which element of the medical record is NEVER allowed to be used to capture current diagnosis codes? a. Exam b. Past medical history c. Radiology report d. Assessment - ANSWER >c. Radiology report

Rationale: Information from the radiology report can not be used to report a current diagnosis until the provider reviews the report and indicates its clinical significance. Diagnosis 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 - ANSWER >a. Highest levelof specificity What is the goal when coding for risk adjustment purposes? a. Report only chronic illnesses. b. Report only the code for the main reason for the visit. c. Report a complete and accurate clinical profile of the patient. d. Report all diagnoses previously treated or no longer exist. - ANSWER >c. Report a complete and accurate clinical profile of the patient. Which of the following statements are TRUE concerning diagnoses providers should document to support each E/M visit? a. Document only for the diagnosis the provider treated for that day. b. Document for all diagnoses for all conditions that the patient has ever had. c. Document only for the main reason the patient was seen today. d. Document all diagnoses that are a part of the medical decision making (MDM) for each visit. - ANSWER >d.

Document all diagnoses that are a part of the medical decision making (MDM) for each visit. Rationale: Diagnosis coding guidelines state that providers should document all diagnoses that are a part of the medical decision making (MDM) to support each E/M visit. If the documentation is not clearly documented to code current conditions, what should be done? a. Use the unspecified code b. Query the provider c. Assume d. Don't code the condition - ANSWER >b. Query the provider What is the purpose of the risk adjustment values? a. Statistics of the diagnoses of patients. b. Budget for the care of the patient for the following year. c. Review the claims for up-coding or over-coding. d. Target providers with inappropriate coding patterns. - ANSWER >b. Budget for the care of the patient for the following year. A 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 - ANSWER >a. Diabetes and hypertension Rationale: The guidelines state not to code resolved conditions.