Medicare Risk Adjustment and Coding, Exams of Nursing

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which medicare part is reimbursed based on the risk adjustment models Answer- part c who typically employs risk adjustment coders Answer- health plans is a health plan required to follow the minimum necessary rule Answer- yes, health plans are covered entities and are therefore required to follow the minimum necessary rule what is an example of fraud Answer- reporting a diagnosis or co-morbidity that does not exist to obtain higher reimbursement which part of medicare is also called medicare advantage Answer- part c which health insurance assistance program is sponsored by federal and state governments Answer- medicaid what OIG document should a medicare advantage participant review for potential problem areas that will receive special scrutiny in the upcoming year Answer- OIG work plan which code set is used by risk adjustment coders Answer- icd-10-cm which regulation strengthens HIPAA rules by addressing privacy and security concerns associated with the electronic transmission of health information Answer- Health Information Technology for Economic and Clinical Health Act (HITECH) what is coding Answer- translating a written or dictated medical record into a series of alphanumeric codes which organ is in the thoracic cavity Answer- lungs what does the term distal indicate Answer- farther from the point of attachment blood is received back into the left atrium of the heart through.... Answer- pulmonary veins the root of the nail is also known as what Answer- 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 Answer- personal history of breast cancer the documentation states: soft druse, some calcified what system would have this documentation Answer- ocular which organ does pulmonary refer to Answer- lungs what is a PEG tube Answer- a tube inserted into the stomach for long term feeding angina pectoris refers to which system Answer- cardiovascular what is cholelithiasis Answer- stones in the gallbladder a patient with diabetes type 2 presents with ED. after examination, the provider diagnosis the patient with ED due to diabetic autonomic neuropathy. Answer- e11.43, n52. a patient is transported from the nursing home for facial drooping, slurred speech, and dizziness. the patient was admitted for testing. after an MRI, the provider diagnosed the patient with a TIA Answer- g45. the physician was called to the hospital floor for the medical management of a patient admitted one day ago with a reduced oxygen level due to aspiration pneumonia and COPD. no chest pain at present, but still SOB and some swelling in his lower extremities. patient was tachypneic yesterday; lungs reveal course crackles in both bases, right worse than left. the physician writes instructions to continue with intravenous antibiotic treatment and respiratory support with ventilator management. he reviewed the chest X-ray which shows gastric contents in the lungs and labs. patient is improving and a pulmonary consultation has been requested Answer- j69.0, t17.810a, j44. a patient with chronic DVT in the lower leg requires heparin to maintain therapeutic anticoagulation levels. he has regular PTTs drawn to monitor his level of anticoagulation Answer- i82.5z1, z79. ch. 3, question 5 diagnosis with severe exacerbation of chi, poorly controlled hon, and worsening ckd and acute renal failure Answer- i13.0, i50.9, n17.9, n18. a patient suffering an abdominal aortic aneurysm involving the renal undergoes endovascular repair deploying a fenestrated visceral autograft using 2 visceral artery endoprostheses Answer- 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 Answer- n18.6, z99. ch. 3 question 8

Pneumonia due to Streptococcus pneumoniae; Alzheimer disease, unspecified; Dementia in other diseases classified elsewhere without behavioral disturbance. Answer- j13, g30.9, f02. ch.3 question 9 the provider's assessment states the patient has acute bronchitis, and elevated blood pressure Answer- 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 Answer- e78.5, d64.9, n18. which risk adjustment model is typically used for medicaid patients Answer- 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 Answer- 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 Answer- 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 Answer- d true or false: retrospective reviews are performed after the face to face visit but before the visit is finalized Answer- 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 V - socioeconomic status Answer- I, II, III, V true or false: the CMS national average risk score varies each year Answer- false which type of review includes a review of current year combined with the prior year's dates of service Answer- concurrent review which risk adjustment model is typically used for patients enrolled in a commercial plan through a healthcare exchange? Answer- Health and Human Services Hierarchical Condition Category (HHS HCC) which risk adjustment model is used for patients enrolled in medicare advantage plan Answer- Medicare Hierarchal Condition Category (CMS HCC-C) the affordable care act set a requirement for CMS to make quality bonus payments to medicare advantage plans based on the plans quality rating. the publicly available rating used for this is Answer- STARS what is predictive modeling in risk adjustment Answer- an analytical review of known data elements to establish a hypothesis related to the future needs of patients data elements used for predictive modeling include I - claims data II - prescription drug events III - procedures coded IV - durable medical équipement Answer- I, II, III, IV if you were using predictive modeling and the results were: -the member had a DME claim for oxygen -the member had an rx claim for pulmicort flehaler -the member had a medical claim which included airway obstruction treatment what diagnosis would you predict this member had Answer- 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 Answer- 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 Answer- I, II, III, IV how is HEDIS data collected I - insurance claims II - surveys III - medical chart reviews IV - provider reporting Answer- 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 Answer- 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 Answer- promoting interoperability what is an alternative payment model (APM) Answer- 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 Answer- 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 Answer- true what are the documentation standards when sending in medical records for a RADV audit I - legible II - complete III - face-to-face encounter IV - provided by an approved provider Answer- I, II, III, IV what is an IVA and what is the IVAs function Answer- initial validation auditor; a third- party vendor, chosen by the health plan, to conduct a coding review and an enrollment review when does CMS RADV typically occur Answer- 2 to 3 years after payment

when does HHS HRADV typically occur Answer- 6-months after year-end what were accountable care organizations designed for Answer- improve the quality of healthcare and lower costs true or false: CMS RADV uses a stratified sample of three strata Answer- true true or false: risk adjustment scores should not be used as a driver for provider behavior Answer- true which interaction options enable an added value in the CMS HCC model I - a high-risk disease II - 2 diseases III - 3 diseases IV - disability alone V - disability and a disease Answer- II, III, V true or false: inpatient records are not required to be face-to-face encounters Answer- false what must be included on a discharge summary submitted as a physician provider type Answer- 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 Answer- 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 Answer- true ch. 7 question 5 Epistaxis; congestive heart failure; Long term (current) use of anticoagulants Answer- r04.0, i50.9, z79. ch 7 question 6 the provider documents a history of old chronic pulmonary embolism Answer- 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 Answer- i50. ch. 7 question 8 the neurologist documents a history of TIA, patient to start aspirin daily Answer- z86.

ch. 7 question 9 Adhesive capsulitis of left shoulder; Personal history of malignant melanoma of skin; Other specified postprocedural states Answer- 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. Answer- f41.9, f32.a, n32.89, i49.9, e11.9, i10, n95.9, z79. true or false: attestations are not required for inpatient records Answer- 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 Answer- g30.0, f02. a patient is seen for exercise induced syncope. after examination, the provider suspects atrial fibrillation and refers the patient to cardiology Answer- 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 Answer- 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 Answer- r06.02, r07.9, r the provider documents a diagnosis of symptomatic right carotid stenosis, right ICA occlusion Answer- i65. ch.8 question 7 Atherosclerotic heart disease of native coronary artery without angina pectoris;Hyperlipidemia, unspecified; Personal history of nicotine dependence Answer- i25.10, e78.5, z87. ch. 8 question 8 Abdominal aortic aneurysm, without mention of rupture;Occlusion and stenosis of left carotid artery. Answer- i71.4, i65. ch. 8 question 9 Other benign neoplasm of skin of scalp and neck ;Family history of malignant neoplasm of other organs or systems. Answer- d23.4, z80.

ch. 8 question 10 Urinary tract infection, site not specified;Chronic obstructive pulmonary disease, unspecified ; Atherosclerotic heart disease of native coronary artery without angina pectoris; Essential (primary) hypertension; Personal history of transient ischemic attack (TIA), and cerebral infarction without residual deficits; Personal history of nicotine dependence Answer- n39.0, j44.9, i25.10, i10, z86.73, z87. a patient visits the provider to follow-up for her coronary atherosclerosis due to lipid rich plaque of the arterial bypass graft Answer- i25.810, i25. 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 Answer- 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 Answer- i63.22, i63. a patient is seen for follow-up of dvt in the left saphenous vein. there is no med list Answer- i82. ch.9 question 5 assessment; -htn - continue current meds -left heart failure w LVEF 31-40%, would continue current med therapy Answer- i11.0, i50. ch. 9 question 6 IMPRESSION: hypertension, hyperlipidemia, coronary artery disease, congestive heart failure Answer- 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 Answer- 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 Answer- 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 Answer- 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 Answer- 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 Answer- a record from a pathologist that did not see the patient medicare recognizes that certain conditions are chronic and ongoing conditions usually treated by ongoing medication management. these conditions have the potential for acute exacerbation if not treated properly. which of the options below are examples of these types of conditions I - COPD II - Chronic heart failure III - pneumonia IV - urinary tract infection Answer- I and II what is a RADV audit Answer- a cms audit of part c HCCs to verify the diagnoses in the risk scores are supported by the documentation what does the acronym IVA stand for Answer- Initial Validation Auditor true or false: retrospective reviews are typically the prior year's date of service Answer- true categories assigned for diagnoses that are costly to manage from a prescription drug treatment perspectives are called Answer- RxHCCs which type of review affect the following year instead of the current year Answer- prospective

what is suspect logic Answer- using known data elements to establish a hypothesis related to the future health of patients true or false: report all documented conditions that coexist at the time of the encounter Answer- true a patient is respirator dependent and has a tracheostomy in need of revision due to redundant scar tissue formation surrounding the site. under general anesthesia and establishing the airway to maintain ventilation, the scar tissue is resected and then repair is accomplished using a layered closure Answer- L90.5, z43.0, z99. 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 Answer- 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 Answer- 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 Answer- 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 Answer- t83.592a, n39.0, b96. the patient presents to her physician 10 weeks following a true posterior wall MI. the patient is still symptomatic Answer- 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 Answer- 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 Answer- t82.868a, i82.602, c nonproliferation retinopathy of the right eye in a diabetic patient Answer- 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 Answer- 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 Answer- L89.501, L89. what code is reported for subsequent type 4 MI Answer- i21.a the patient has idiopathic pulmonary fibrosis Answer- J84. true or false: if the non-pressure ulcer is documented as completely healed, no code is reported Answer- true how often must chronic conditions be assessed to be valid for HCCs Answer- 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 Answer- r50.9, m79. practice test, question 26 Acute kidney failure, unspecified ; Type 2 diabetes mellitus with diabetic CKD ; Hypertensive chronic kidney disease with stage 1 through 4 chronic kidney disease or unspecified chronic kidney disease. ; Chronic Kidney Disease stage 3 unspecified ; Hypotension, unspecified Answer- n17.9, e11.22, i12.9, n18.30, i95. practice test question 27 Other forms of dyspnea ; Essential (primary) hypertension ; Hypothyroidism, unspecified ; Nicotine dependence, cigarettes, uncomplicated Answer- r06.09, i10, e03.9, f17. practice test question 28 Type 2 diabetes mellitus With neurological complications With other multiple complications, uncontrolled ; Depression, unspecified Answer- e11.43, f32.a you are reviewing provider documentation for risk adjusted diagnosis, so you can provide feedback to the provider. you are looking to validate hypertensive heart and CKD with heart failure using the providers progress note from an office visit earlier in the year. the provider has documented, "assessment; hypertension, ckd, heart failure" in the progress note. you should inform the provider Answer- the stage of ckd and the type of heart failure must be documented for proper coding in auditing a chart, you see an entry for a phone call to refill flecainide for the patients atrial fibrillation. in reviewing the chart, you find no other documentation related to the fib within the year. which of the following is CORRECT regarding provider feedback for this scenario

a - the auditor should look further back to confirm a diagnosis of afib b - the documentation supports reporting afib for risk adjustment c - the provider must see the patient within seven days of the phone call for the diagnosis to be reportable for risk adjustment d - the diagnosis must be supported by a face-to-face encounter for the diagnosis to be reported for risk adjustment Answer- d true or false: diagnosis listed in the pmh should not be reported when they no longer exist Answer- 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 Answer- true practice test question 33 Unspecified osteoarthritis, unspecified site Answer- 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 Answer- 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 Answer- a respiratory disorder true or false: HIV/AIDS is most commonly transmitted by coughing Answer- 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 Answer- 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 Answer- 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 Answer- 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 Answer- II, III, IV practice test question 41 using the info provided above, which statements are true I - sarcoidosis of the lung trumps cystic fibrosis II - cystic fibrosis trumps copd III - bronchiectasis trums cystic fibrosis IV - emphysema trums sarcoidosis of the lung Answer- II, IV true or false: quality measures like star ratings and HEDIS have no correlation with the medical record info that is collected in support of risk adjustment Answer- false true or false: stars ratings help identify top performing health providers Answer- true commercial plans through healthcare changes use which risk adjustment model Answer- HHS HCC true or false: coders are accustomed to submitting diagnosis codes on claims for the purposes of reimbursement validation for services rendered Answer- false which statement is coded as a history of conditions a - history of heart transplant b - history of Alzheimers dementia c - history of prostate cancer, seed implant next week for radiation d - history of breast ca, no further treatment necessary Answer- d what is the rule regarding uncertain diagnosis for outpatient records Answer- conditions stated as probable, suspected, likely, questionable, possible, or still to be ruled out are not reported which of the following providers is an acceptable provider type for RADV audits a - nutritionist b - pharmacist c - dme provider

d - audiologist Answer- d true or false: to code a condition as a manifestation, the cause and effect relationship must be documented, unless the condition falls under the " with" guideline in the icd- 10-cm Answer- true what would lead to an overpayment in the medical record Answer- reporting a history of condition as active