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CRC FINAL EXAM. NEWEST 202 5 ACTUAL EXAM
COMPLETE 250 QUESTIONS AND CORRECT DETAILED
ANSWERS (VERIFIED CORRECT ANSWER)
ALREADY GRADED A+.
How is predictive modeling used in risk adjustment? - CORRECT 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 eventsIII.
Physician claims data IV. Facility claims data a. III and IV b. I, II, and IVc. 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. Client 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 qualityrating system?
a. Quality bonus payments are made to physician who scoreat least four
stars.
b. Quality bonus payments are made to Medicare Advantageplans who
score at least four stars.
I. Staying Healthy
II. Managing Chronic Conditions
III. Member Experience with Health Plans
IV. Member Complaints, Problems Getting Services, andImprovement
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 - CORRECT 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 SystemsII. Sustainable Growth System III. Advanced Alternative Payment Modelsa. I b. II and III c. I and III d. I, II and III - CORRECT 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 clients.
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. - CORRECT ANSWER:->>> >>>>a. An analytical review of known data elements to establish a hypothesis related to the future health of clients. Who developed and maintains HEDIS?a. CMS b. OIG c. BCBS d. NCQA - CORRECT 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 - CORRECT ANSWER:->>> >>>>a. Top
ANSWER:->>> >>>>b. Determine suspected diagnoses based ondata 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 mellitusb. 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 kneec. Spinal Stenosis d. Osteoporosis - CORRECT ANSWER:->>> >>>>d. Osteoporosis
Which statement is TRUE regarding predictive modeling?
DME claims
a. I only
b. I and II only c. II
and III only d. I, II, and III - CORRECT ANSWER:->>> >>>>d. I, II, and III Which type of documentation can be used to supportdiagnoses reported under risk adjustment models? a. Inclient admission note b. CT scan resultsc. CBC lab test d. Comprehensive problem list - CORRECT ANSWER:->>> >>>>a. Inclient admission note Which statement is TRUE regarding diagnosis codes andassigned 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. - CORRECT
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. - 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 forcertification by HHS. When reporting a code for retinopathy, must the coder find documentation from an ophthalmologist in order to code thecondition as an active condition?
b. twice per yearc. 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 averageres score of 1.0. Risk adjustment models are used to:
a. Limit coverage of chronic conditions.
b. Determine projected costs of healthcare based onconditions of
clients.
c. Determine the return on investment for developingproactive
disease prevention outreach.
d. Limit the coverage of hospital admissions. - CORRECT ANSWER:->>>
b. Determine projected costs of healthcare based onconditions of clients. What are the extra risk adjustment values or factors added when a client has more than one major significant diagnosisidentified in the model?
a. interactionsb. risk factors. d. demographic variances e. exceptions - CORRECT ANSWER:->>> >>>>a. interactions Interactions are extra risk adjustment values or factors added when a client 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 diagnosestogether increase clinical risk and associated costs of care. Each year, Medicare normalizes risk scores to maintain an average of what? - CORRECT 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 - CORRECT ANSWER:->>> >>>>c.
Chronic Disability Payment System CDPS is the RA model used by Medicaid What is the purpose of the coding intensity adjustment?
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 toCMS.
b. After the diagnosis and risk factor data has been reported to CMS.
c. Once the client is enrolled in Medical Part C plan. d. Once the
provider has finalized the documentation tosubmit diagnosis codes. - CORRECT ANSWER:->>> >>>>a. Prior to thediagnosis and risk factor data being reported to CMS. Which provider is NOT an approved provider for diagnosiscode capture under the Medicare HCC model? a. Gynecologist.b. Pathologist. c. Oral surgeon. d. Registered Caregiver. - CORRECT ANSWER:->>> >>>>d. Registered Caregiver. In the CDPS risk adjustment model, what category do heartattacks fall under>
a. Low
b. Mediumc.
High
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) - CORRECT ANSWER:->>> >>>>b. CDPS Which RA model is used for commercial plans and uses metal levels to classify clients? a. CDPSb. HHS c. HCC d. Commercial plans do not use risk adjustment models - CORRECT 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 RAFscore.
b. the FFS data is used to determine which client should be enrolled in the
RA plan.
c. The average FFS expenses and rates are used todetermine the
FFS normalization adjustment.
d. The average FFS expenses and rates are used to determine the maximum
payment per RAF score. - CORRECT 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 lowestout of pocket expense once the premium is paid?
a. Silver b. Gold c. Bronze d. Platinum - CORRECT ANSWER:->>> >>>>d. Platinum What is the step after predictive modeling identifies adiagnosis gap?
a. Perform a retrospective audit to confirm proper diagnosis code
selection.
