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CRC FINAL EXAM NEWEST 2024 ACTUAL EXAM
COMPLETE 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
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.
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 health of 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.
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
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 assigned an 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?
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.
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 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. 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
