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aapc crc exam 9 with correct answers 2025
purpose of risk adjustment - CORRECT ANSWERS ✔✔allows CMS to pay plans for the risk of the beneficiaries they enroll, instead of an average amount for Medicare beneficiaries adjusting payment plans - CORRECT ANSWERS ✔✔CMS able to make appropriate and accurate payments for enrollees with differences in expected costs risk scores - CORRECT ANSWERS ✔✔measure individual beneficiaries' relative risk and are used to adjust payments for each beneficiary's expected expenditures risk scores - CORRECT ANSWERS ✔✔allows CMS to use standardized bids as base payments to plans acceptable data sources - CORRECT ANSWERS ✔✔hospital inpatients, hospital outpatient facilities, and physicians capturing codes - CORRECT ANSWERS ✔✔unique diagnoses at least once during risk adjustment data-reporting period final risk score calculation - CORRECT ANSWERS ✔✔providers may request recalculation of payment once error of inaccurate diagnosis submitted for calculating risk scores have been discovered and have an effect on final payment
risk adjustment models - CORRECT ANSWERS ✔✔use to calculate risk scores which predicts healthcare expenditures. PACE - CORRECT ANSWERS ✔✔program of all-inclusive care for the elderly: PACE - CORRECT ANSWERS ✔✔frail and elderly individuals eligible for nursing home placement based on state medicaid criteria CMS center for beneficiary choices - CORRECT ANSWERS ✔✔develops and implements ra payment methodology for MM program. monitors plans to improve data quality CMS regional office - CORRECT ANSWERS ✔✔provide assistance to ra organization and beneficiaris palmetto government benefits admin (palmetto gba) - CORRECT ANSWERS ✔✔manages front-end ra system (FERAS) and customer service and support center (CSSC) RAPS - CORRECT ANSWERS ✔✔risk adjustment processing system multiple chronic diseases - CORRECT ANSWERS ✔✔risk adjusted payment based on assignment of dx to disease groups,
RAPS - CORRECT ANSWERS ✔✔risk adjustment processing system; process ra data RAS - CORRECT ANSWERS ✔✔risk adjustment system; calculates risk score common UI - CORRECT ANSWERS ✔✔maintains medicare beneficiary eligibility data HPMS - CORRECT ANSWERS ✔✔health plan management system; CMS MA information system that contains health plan- level data required diagnosis - CORRECT ANSWERS ✔✔diagnosis codes required to be submitted for the CMS-HCC model and future model development ra data - CORRECT ANSWERS ✔✔ra data must be submitted at least quarterly; processed through RAPS ra data requirements - CORRECT ANSWERS ✔✔health insurance claim (HIC) #, diagnosis code, service date from, service date through, provider type
ra data requirements diagnosis - CORRECT ANSWERS ✔✔diagnosis codes must be reported at least once per enrollee within data collection period ra data flow - CORRECT ANSWERS ✔✔**hospital/physician submits data to MA organization **MA organization submits data at least quarterly to Palmetto GBA **MA organization submits data via Direct Data Entry or in RAPS format **data sent to FERAS for processing where file-level data, batch- level data, and first and last detail records are checked **any data rejected, report on FERAS Response Report **passing FERAS checks, file submitted to RAPS where detail editing performed **RAPS return file is returned daily ; shows approved and errors **RAPS transaction error report displays records on errors **RAPS distributed monthly and quarterly **RAPS database stores all finalized diagnosis clusters **RAS calculates RAF by executing the CMS-HCC model ra data processing time - CORRECT ANSWERS ✔✔1 to 2 days dx codes importance to ra - CORRECT ANSWERS ✔✔drives risk scores, which drives ra reimbursement from CMS to MA organizations
authoratative - CORRECT ANSWERS ✔✔conservative, official, and factual; perfect grammar, spelling, and punctuation. current communication - CORRECT ANSWERS ✔✔recent timely - CORRECT ANSWERS ✔✔provide information when needed and meeting deadlines consistent - CORRECT ANSWERS ✔✔consistent messages, right the first time and every time practical relevant and well organized communication - CORRECT ANSWERS ✔✔no background noise, clear and easy to read/understand accessible communication - CORRECT ANSWERS ✔✔easy accessibility accurate reimbursement contains - CORRECT ANSWERS ✔✔ICD 9 CM & ICD 10 CM basis of ra models accurate dx codes are a result of clear, consistent, and complete documentation CMS verifies accuracy exclude notes - CORRECT ANSWERS ✔✔informs coder which dx codes are not included in code selection
use additional code - CORRECT ANSWERS ✔✔informs coder that more than one code is needed to fully described condition not otherwise specified (NOS) - CORRECT ANSWERS ✔✔"unspecified" not elsewhere classified (NEC) - CORRECT ANSWERS ✔✔used when medical record documents a condition to a level of specificity not identified by specific ICD 9 or ICD 10 code. V codes - CORRECT ANSWERS ✔✔represent factors that influence health status or describe contact with health services E codes - CORRECT ANSWERS ✔✔supplemental classification used for reporting external causes of injuries and poisonings co-existing/related conditions - CORRECT ANSWERS ✔✔physicians should code all documented conditions that co- exist at time of visit, and require or affect patient care conditions treated/cured - CORRECT ANSWERS ✔✔do not code conditions previously treated or no longer exist symptoms/signs - CORRECT ANSWERS ✔✔do not code if part of an integral underlying condition
physician documentation/communication tips - CORRECT ANSWERS ✔✔**document and report co-existing diagnoses **communicate issues regarding inadequate documentation **adhere to proper methods for appending (late entries) or correcting inaccurate data entries: lab/radiology results, strike through, initial, and date. **use only standard abbreviations *identify patient and date on each page of record SOAP Notes - CORRECT ANSWERS ✔✔Subjective: describes patient problem/illness Objective: physician observation Assessment: patient's current conditions and status Plan: treatment, referrals, prescriptions, referrals, education RADV purpose - CORRECT ANSWERS ✔✔ensure risk adjusted payment integrity and accuracy ra rule - CORRECT ANSWERS ✔✔all ra diagnosis codes submitted must be supported by medical record documentation RADV primary objectives - CORRECT ANSWERS ✔✔verify enrollee CMS-HCCs used for payment *identify risk adjustment discrepancies *calculate enrollee-level payment error *estimate national and contract-level payment errors
implement contract-level payment adjustments RADV submitted code guideline - CORRECT ANSWERS ✔✔face to face encounter *code accordance to ICD 9 CM/ICD 10 CM *dos within collection period acceptable RA provider type and physician specialty RADV core process - CORRECT ANSWERS ✔✔stage 1: sampling and medical record request *stage 2: medical record review (MRR) *stage 3: MRR findings and cotract-level payment adjustments *stage 4: documentation dispute *stage 5: post documentation dispute payment adjustments stage 6: appeals sampling selection - CORRECT ANSWERS ✔✔national sample: estimate national annual payment error. consists of continuously and non-continuously enrolled beneficiaries with at least one ra codes (CMS-HCC) *contract specific sample: estimate annual payment error at contract level; CMS will target or randomly select contracts; medical record request once sampling completed - CORRECT ANSWERS ✔✔request defined by 3 segments:
*ONE best medical record to submit with completed coversheet *dos may include consecutive range of dates for inpatient record; one dos if outpatient or physician provider one coversheet for each HCC being validated medical records - CORRECT ANSWERS ✔✔submit via electronic media, fax, hardcopy. do not email medical record receipt - CORRECT ANSWERS ✔✔administrative check: confirms beneficiary demographic information, name, HIC number and service date within or outside of collection period clinical check:verify record dated and signed, appropriate provider type, consist of pertinent components CMS reimbursement - CORRECT ANSWERS ✔✔each medical record submitted per beneficiary HCC *if one record supports more than one beneficiary HCC, will receive reimbursement for one record *rule applies regardless of method chosen for medical record submission medical record review - CORRECT ANSWERS ✔✔validate risk adjusted payments *service provided by an acceptable ra provider type and physician specialty *dos within collection period
*provider signature and credentials on each note *acceptable documentaiton based on documentation guidance dx supported by medical record documentation inpatient medical record documentation - CORRECT ANSWERS ✔✔fact sheet *history and physcial exam *physician orders *progress notes *operative/pathology reports *consultation reports *diagnostic testing reports discharge summary outpatient medical record documentation - CORRECT ANSWERS ✔✔fact sheet *history and physical exam *physician orders *progress notes *diagnostic reports (to support documentation) consultation reports unacceptable sources of medical records - CORRECT ANSWERS ✔✔skilled nursing facility (SNF)
ra errors - CORRECT ANSWERS ✔✔*unacceptable provider type and physician specialty *dos submitted does not fall within ra data collection period *missing provider signature and credentials *incomplete: diagnosis code cannot be assigned for dos if documentation is insufficient or incomplete never sent: no medical record documentation was received diagnosis code does not match ra diagnosis at teh 3rd, 4th, or 5th digit level MRR findings/contract level payment adjustments - CORRECT ANSWERS ✔✔CMS provides MA of RADV findings documentation disputes/appeal - CORRECT ANSWERS ✔✔enrollee HCC level discrepancy findings will be allowed for dispute *MA may dispute for particular medical record dos submitted during medical record request stage *MA organizations will be given 60 days to submit a documentation dispute expert coding panel reviews every dispute; panel consists of senior medical reviewer, senior coder, physician document dispute/appeal process - CORRECT ANSWERS ✔✔does not accept first time submission of medical record *does not accept missing medical records
*medical record resulted in coding discrepancy clearly document reason for disagreement payment adjustment - CORRECT ANSWERS ✔✔findings will be recalculated based on findings and payment error will be re- estimated. MA will be notified of revised payment error estimate resulting in payment adjustment appeal stage - CORRECT ANSWERS ✔✔CMS will implement formal appeal process facilitated by CMS office of Hearings. model developed by John Hopkins in 1992 - CORRECT ANSWERS ✔✔Adjusted Clinical Groups model developed by University of California, San Diego in 1996 - CORRECT ANSWERS ✔✔Chronic-illness Disability Payment System model developed by 3M Health Information Systems in 2000 - CORRECT ANSWERS ✔✔Clinical Risk Groups model developed by Ingenix in 2001 - CORRECT ANSWERS ✔✔Episode Risk Groups
how many health categories of included in the Clinical Risk Group - CORRECT ANSWERS ✔✔ 9 how many base Clinical Risk Groups are there - CORRECT ANSWERS ✔✔ 272 how many severity of illness levels are included in the Clinical Risk Group model? - CORRECT ANSWERS ✔✔4- RAF - CORRECT ANSWERS ✔✔Risk Adjustment Factor HCC - CORRECT ANSWERS ✔✔Hierarchical Condition Category PCP - CORRECT ANSWERS ✔✔Primary Care Physician SH - CORRECT ANSWERS ✔✔Select Health ACA - CORRECT ANSWERS ✔✔Affordable Care Act PMPM - CORRECT ANSWERS ✔✔Per Member Per Month CCRR - CORRECT ANSWERS ✔✔Chronic Condition Re- Evaluation Rate
CCIIO - CORRECT ANSWERS ✔✔Center for Consumer Information & Insurance Oversight CMS - CORRECT ANSWERS ✔✔Centers for Medicare and Medicaid Services EMPI - CORRECT ANSWERS ✔✔MMI (Intermountain member identifier) RADVI - CORRECT ANSWERS ✔✔Risk Adjustment Diagnosis Validation DDC - CORRECT ANSWERS ✔✔Distributed Data Collection for RI, RA RI - CORRECT ANSWERS ✔✔Reinsurance AWV - CORRECT ANSWERS ✔✔Annual Wellness Visit - These are the CPT codes that we use to identify annual well visits: G0439, G0438. E&M codes (99385, 99386, 99387, 99395, 99396,
CWV - CORRECT ANSWERS ✔✔Comprehensive Wellness Visit EDW - CORRECT ANSWERS ✔✔Enterprise Data Warehouse
