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CRC EXAM 2024 | ALL QUESTIONS AND
CORRECT ANSWERS WITH RATIONALES
(VERIFIED ANSWERS) | GRADED A+ |
UPDATED VERSION
Which of the following statements support reporting the condition as a current diagnosis? a. Patient has a history of DVTs. b. Patient presents for a follow up for resolved pneumonia. c. Patient has a history of COPD which is stable with current medication regimen. d. Patient appears to have an early onset of dementia. ------CORRECT ANSWER---------------c. Patient has a history of COPD which is stable with current medication regimen. Rationale: Although COPD is documented as history, by the current regimen it is clear it is a current diagnosis. What is the purpose of collecting diagnoses in risk adjustment coding? a. Reimbursement validation b. Statistics c. Risk adjustment factor d. DRGs ------CORRECT ANSWER---------------c. Risk adjustment factor Rationale: Collecting these diagnoses is not for the purpose of submitting a claim, but rather to send the diagnoses in a supplemental file or updated claim to account for all the conditions the patient has documented as a current diagnosis each year. These diagnosis codes are converted to a risk adjustment factor (for example, HCC value or CDPS value) and the patient's risk score is steadily and yearly adjusted according to those risk adjustment- associated diagnosis codes. What is the reporting period for risk adjustment coding?
a. October to September b. January to October c. January to December d. June to May ------CORRECT ANSWER---------------c. January to December Rationale: When coding diagnoses for risk adjustment purposes, the goal is to honestly report all current diagnoses a patient has in face- to-face encounters by approved provider types during each calendar year (January-December) Medicare defaults much of its risk adjustment diagnosis coding guidance to the _______? a. CPT coding guidelines b. Official ICD- 10 - CM coding guidelines and Coding Clinic c. 1995 and 1197 documentation guidelines d. Official ICD- 10 - CM coding guidelines ------CORRECT ANSWER------------ ---b. Official ICD- 10 - CM coding guidelines and Coding Clinic Rationale: Medicare defaults much of its risk adjustment diagnosis coding guidance to the official coding guidelines and American Hospital Association (AHA) Coding Clinic® determinations. When selecting a diagnosis code, which statement is TRUE? a. Report the code found in the Alphabetic Index b. Report the code with the highest RAF score c. Select the code with the highest level of specificity confirmed in the Tabular List. d. Report the condition they were first diagnosed with ------CORRECT ANSWER---------------c. Select the code with the highest level of specificity confirmed in the Tabular List. Which of the following statements is TRUE concerning where in the documentation diagnoses can be pulled for HCC coding? a. Codes can only be assigned from documentation in the assessment and plan.
b. Patient with a history of MI sixth months ago. c. Patient with breast cancer receiving chemotherapy. d. Patient with a history of HIV. ------CORRECT ANSWER---------------b. Patient with a history of MI sixth months ago. Rationale: Asthma and HIV are conditions that cannot be cured. If the patient is receiving active treatment for cancer it is coded with an active cancer code. If a patient has a MI which is not requiring treatment this is coded as a "history of" or "old" MI code. This code would be used after the 4 week timeframe for a MI. What is the Joint Commission rule concerning entries in the medical record? a. Medical record needs to be signed only b. Medical record needs to be signed and dated c. Medical record needs to be signed, dated, and timed d. Joint Commission has no requirement ------CORRECT ANSWER---------- -----c. Medical record needs to be signed, dated, and timed Which of the following are NOT allowable for coding in the outpatient setting? a. Consistent with b. Use of the up and down arrows c. ICD code instead of a written description d. All options are not appropriate ------CORRECT ANSWER---------------d. All options are not appropriate Patient is seen for right lower quadrant abdominal pain, fever, and nausea. The physician diagnosed the patient with R/O appendicitis and sends the patient for further testing. Select the diagnosis code(s). a. K37 (unspecified appendicitis) b. R10.31 (fever) c. R10.31, R50.9 (RLQ Pain), R11.0 (Nausea) d. R10.31, R50.9, R11.0, K37 ------CORRECT ANSWER---------------c. R10.31, R50.9 (RLQ Pain), R11.0 (Nausea)
Which organization is the Coding Clinic associated with? a. ICD b. CPT c. AHA d. CMS ------CORRECT ANSWER---------------c. AHA When in the outpatient setting, how would you code an uncertain diagnosis according to ICD- 10 - CM coding guidelines? a. Code as a confirmed diagnosis. b. Code as a sign or symptom. c. Code as an unspecified diagnosis. d. Do not code until diagnosis is confirmed. ------CORRECT ANSWER------- --------b. Code as a sign or symptom. In an OUTPATIENT setting, uncertain diagnoses cannot be coded. Instead the signs and symptoms are coded. Refer to ICD- 10 - CM coding guideline IV.H. When does Medicare require the provider to sign the medical record? a. 30 days b. 60 days c. Timely basis d. No requirement ------CORRECT ANSWER---------------c. Timely basis What is the guideline for coding "probable," "suspected," "possible," or "questionable" in the INPATIENT setting? a. Code the condition as if it was established b. Code the sign and symptoms c. Query the provider before coding d. Code with the sign and symptom and the condition ------CORRECT ANSWER---------------a. Code the condition as if it was established
What is the purpose of the Coding Clinic®? a. Performs audits on provider documentation b. Provides guidance for proper ICD code selection. c. Provides guidance for proper CPT® code selection. d. All of the above ------CORRECT ANSWER---------------b. Provides guidance for proper ICD code selection. What is the purpose of the RADV audit? a. Verify accuracy of the diagnosis submitted for payment. b. Verify accuracy of the CPT codes submitted for payment. c. Verify provider's signature/attestation. d. Verify the provider's use of quality measures. ------CORRECT ANSWER- --------------a. Verify accuracy of the diagnosis submitted for payment. CMS conducts Risk Adjustment Data Validation (RADV) audits to verify the accuracy of the diagnosis codes submitted for payment by the Medicare Advantage organization. In ICD- 10 - CM, when can hemiparesis be coded? a. Documentation states weakness on one side of the body b. Documentation states hemiparesis c. Weakness on one side of the body due to stroke/CVA d. both b and c ------CORRECT ANSWER---------------d. both b and c If the provider documents hemiparesis or weakness on one side of the body due to stroke/CVA Patient is seen for chest pain, shortness of breath, and nausea. The patient is diagnosed with an MI. Select the diagnosis code(s). a. I22.9 (Subsequent ST elevation (STEMI) MI of unspecified site) b. I21.9 (Acute MI, unspecified) c. R07.9, R06.02 (Chest Pain unspecified, SOB) d. I21.9, R11.0 (Acute MI, unspecified; N/V) ------CORRECT ANSWER------ ---------b. I21.9 (Acute MI, unspecified)
There must be an appropriate signature for the provider. Which of the following is the appropriate signature? a. Dr. Smith b. Dr. Michael R. Smith c. Michael R. Smith, MD d. M. Smith ------CORRECT ANSWER---------------c. Michael R. Smith, MD Which statement is TRUE regarding coding COPD with a specific type of asthma in ICD- 10 - CM? a. The type of asthma is reported along with the COPD. b. Only the COPD is reported. c. COPD with bronchitis is reported for COPD with asthma. d. Only the asthma is reported. ------CORRECT ANSWER---------------a. The type of asthma is reported along with the COPD. ASSESSMENT/PLAN
- SOB and Dizziness: Related to patient's bilateral Pulmonary Embolisms; continue in Lovenox, patient has some drainage around PEG tube site, I will discuss with oncology regarding xarelto,
- High troponin: I think probably related with PE, check Echo and now WMA, no further work up at this time
- Leakage around Peg Tube: consult Dr. X he had placed PEG
- Anemia
- Consult PT/OT a. R06.02 (SOB), R42 (dizziness) b. I26.99 (other pulmonary embolism without acute or for pulmonale), Z93. (gastrostomy status) c. I26. d. I26.99, R06.02, R42 ------CORRECT ANSWER---------------b. I26. (other pulmonary embolism without acute or for pulmonale), Z93. (gastrostomy status)
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 ------CORRECT 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 ------CORRECT 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 ------CORRECT ANSWER---------------a. Outcomes How often are HEDIS measures revised? a. As needed b. Monthly c. Bi-annually d. Annually ------CORRECT 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. ------CORRECT 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 ------CORRECT 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
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 ------CORRECT 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. ------CORRECT 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 ------CORRECT ANSWER---------------c. October of 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. ------CORRECT 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 ------CORRECT 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 ------CORRECT 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. ------CORRECT 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 ------CORRECT ANSWER---------------all of the above
d. QPP website. ------CORRECT 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. ------CORRECT 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. ------CORRECT 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. ------CORRECT 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 ------CORRECT 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. ------CORRECT 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 ------CORRECT 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
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 ------CORRECT 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 ------CORRECT 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. ------CORRECT 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. ------CORRECT 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. ------CORRECT 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 ------CORRECT 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 ------CORRECT 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. ------CORRECT 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
