AAPC CRC Exam 9 with 100% Correct
Answers
purpose of risk adjustment - ANS-allows CMS to pay plans for the risk of the
beneficiaries they enroll, instead of an average amount for Medicare beneficiaries
adjusting payment plans - ANS-CMS able to make appropriate and accurate payments
for enrollees with differences in expected costs
risk scores - ANS-measure individual beneficiaries' relative risk and are used to adjust
payments for each beneficiary's expected expenditures
risk scores - ANS-allows CMS to use standardized bids as base payments to plans
acceptable data sources - ANS-hospital inpatients, hospital outpatient facilities, and
physicians
capturing codes - ANS-unique diagnoses at least once during risk adjustment data-
reporting period
final risk score calculation - ANS-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 - ANS-use to calculate risk scores which predicts healthcare
expenditures.
PACE - ANS-program of all-inclusive care for the elderly:
PACE - ANS-frail and elderly individuals eligible for nursing home placement based on
state medicaid criteria
CMS center for beneficiary choices - ANS-develops and implements ra payment
methodology for MM program. monitors plans to improve data quality
CMS regional office - ANS-provide assistance to ra organization and beneficiaris
palmetto government benefits admin (palmetto gba) - ANS-manages front-end ra
system (FERAS) and customer service and support center (CSSC)
RAPS - ANS-risk adjustment processing system
,multiple chronic diseases - ANS-risk adjusted payment based on assignment of dx to
disease groups, HCC. most influenced by medicare costs associated with chronic
diseases
interactions - ANS-allow for additive factors based on chronic conditions and disabled
status to increase payment accuracy
hierarchies - ANS-allow for payment based on most serious conditions when less
serious conditions exist
new enrollee - ANS-CMS uses medicare FFS up to 12 months of data collected within
collection period to calculate risk score. If data is submitted via RAPS, CMS uses those
too.
risk score (5 demographic factors) - ANS-calculate risk score: age, sex, medicaid
status, disability and original reason for medicare entitlement
disease interactions - ANS-6 in community model; 5 in institutional model
disable interactions - ANS-5 in community; 4 institutional
FERAS - ANS-front-end risk adjustment system; ra submitters sends data to palmetto
through FERAS
RAPS - ANS-risk adjustment processing system; process ra data
RAS - ANS-risk adjustment system; calculates risk score
common UI - ANS-maintains medicare beneficiary eligibility data
HPMS - ANS-health plan management system; CMS MA information system that
contains health plan-level data
required diagnosis - ANS-diagnosis codes required to be submitted for the CMS-HCC
model and future model development
ra data - ANS-ra data must be submitted at least quarterly; processed through RAPS
ra data requirements - ANS-health insurance claim (HIC) #, diagnosis code, service
date from, service date through, provider type
ra data requirements diagnosis - ANS-diagnosis codes must be reported at least once
per enrollee within data collection period
ra data flow - ANS-**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 - ANS-1 to 2 days
dx codes importance to ra - ANS-drives risk scores, which drives ra reimbursement from
CMS to MA organizations
outpatient and physicians dos - ANS-from date and through date may be the same
inpatient dos - ANS-from date and through date must be different; reflects dates of
admission to and discharge from a facility
date span - ANS-ra; it is important to determine if reported dx cluster falls within data
reporting period
FFS - ANS-fee for service; physician pay based on specific services provided to each
patient
capitated - ANS-physician pay is fixed amount per patient per month, regardless of
types of services provided
staff model - ANS-physician are paid employees managed care plan; phyisicans
generally provide services in clinic setting
mixed services model - ANS-managed care org. use a combination of contractual
arrangements
authoratative - ANS-conservative, official, and factual; perfect grammar, spelling, and
punctuation.
current communication - ANS-recent
timely - ANS-provide information when needed and meeting deadlines
consistent - ANS-consistent messages, right the first time and every time
, practical relevant and well organized communication - ANS-no background noise, clear
and easy to read/understand
accessible communication - ANS-easy accessibility
accurate reimbursement contains - ANS-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 - ANS-informs coder which dx codes are not included in code selection
use additional code - ANS-informs coder that more than one code is needed to fully
described condition
not otherwise specified (NOS) - ANS-"unspecified"
not elsewhere classified (NEC) - ANS-used when medical record documents a condition
to a level of specificity not identified by specific ICD 9 or ICD 10 code.
V codes - ANS-represent factors that influence health status or describe contact with
health services
E codes - ANS-supplemental classification used for reporting external causes of injuries
and poisonings
co-existing/related conditions - ANS-physicians should code all documented conditions
that co-exist at time of visit, and require or affect patient care
conditions treated/cured - ANS-do not code conditions previously treated or no longer
exist
symptoms/signs - ANS-do not code if part of an integral underlying condition
"history of" - ANS-patient no longer has the condition and dx often indexes to V code
not in HCC models
"history of" error - ANS-coding past condition as active; coding active condition as
history of; impacts ra
cancer codes - ANS-HCC varies depending on whether cancer is primary site or
secondary site
cancer guidelines - ANS-if malignant status not specified, code to primary site except
for:
bone, brain, diaphragms, heart, liver, lymph nodes, mediastinum, meninges,
peritoneum, pleura, retro peritoneum, and spinal cord
Answers
purpose of risk adjustment - ANS-allows CMS to pay plans for the risk of the
beneficiaries they enroll, instead of an average amount for Medicare beneficiaries
adjusting payment plans - ANS-CMS able to make appropriate and accurate payments
for enrollees with differences in expected costs
risk scores - ANS-measure individual beneficiaries' relative risk and are used to adjust
payments for each beneficiary's expected expenditures
risk scores - ANS-allows CMS to use standardized bids as base payments to plans
acceptable data sources - ANS-hospital inpatients, hospital outpatient facilities, and
physicians
capturing codes - ANS-unique diagnoses at least once during risk adjustment data-
reporting period
final risk score calculation - ANS-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 - ANS-use to calculate risk scores which predicts healthcare
expenditures.
PACE - ANS-program of all-inclusive care for the elderly:
PACE - ANS-frail and elderly individuals eligible for nursing home placement based on
state medicaid criteria
CMS center for beneficiary choices - ANS-develops and implements ra payment
methodology for MM program. monitors plans to improve data quality
CMS regional office - ANS-provide assistance to ra organization and beneficiaris
palmetto government benefits admin (palmetto gba) - ANS-manages front-end ra
system (FERAS) and customer service and support center (CSSC)
RAPS - ANS-risk adjustment processing system
,multiple chronic diseases - ANS-risk adjusted payment based on assignment of dx to
disease groups, HCC. most influenced by medicare costs associated with chronic
diseases
interactions - ANS-allow for additive factors based on chronic conditions and disabled
status to increase payment accuracy
hierarchies - ANS-allow for payment based on most serious conditions when less
serious conditions exist
new enrollee - ANS-CMS uses medicare FFS up to 12 months of data collected within
collection period to calculate risk score. If data is submitted via RAPS, CMS uses those
too.
risk score (5 demographic factors) - ANS-calculate risk score: age, sex, medicaid
status, disability and original reason for medicare entitlement
disease interactions - ANS-6 in community model; 5 in institutional model
disable interactions - ANS-5 in community; 4 institutional
FERAS - ANS-front-end risk adjustment system; ra submitters sends data to palmetto
through FERAS
RAPS - ANS-risk adjustment processing system; process ra data
RAS - ANS-risk adjustment system; calculates risk score
common UI - ANS-maintains medicare beneficiary eligibility data
HPMS - ANS-health plan management system; CMS MA information system that
contains health plan-level data
required diagnosis - ANS-diagnosis codes required to be submitted for the CMS-HCC
model and future model development
ra data - ANS-ra data must be submitted at least quarterly; processed through RAPS
ra data requirements - ANS-health insurance claim (HIC) #, diagnosis code, service
date from, service date through, provider type
ra data requirements diagnosis - ANS-diagnosis codes must be reported at least once
per enrollee within data collection period
ra data flow - ANS-**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 - ANS-1 to 2 days
dx codes importance to ra - ANS-drives risk scores, which drives ra reimbursement from
CMS to MA organizations
outpatient and physicians dos - ANS-from date and through date may be the same
inpatient dos - ANS-from date and through date must be different; reflects dates of
admission to and discharge from a facility
date span - ANS-ra; it is important to determine if reported dx cluster falls within data
reporting period
FFS - ANS-fee for service; physician pay based on specific services provided to each
patient
capitated - ANS-physician pay is fixed amount per patient per month, regardless of
types of services provided
staff model - ANS-physician are paid employees managed care plan; phyisicans
generally provide services in clinic setting
mixed services model - ANS-managed care org. use a combination of contractual
arrangements
authoratative - ANS-conservative, official, and factual; perfect grammar, spelling, and
punctuation.
current communication - ANS-recent
timely - ANS-provide information when needed and meeting deadlines
consistent - ANS-consistent messages, right the first time and every time
, practical relevant and well organized communication - ANS-no background noise, clear
and easy to read/understand
accessible communication - ANS-easy accessibility
accurate reimbursement contains - ANS-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 - ANS-informs coder which dx codes are not included in code selection
use additional code - ANS-informs coder that more than one code is needed to fully
described condition
not otherwise specified (NOS) - ANS-"unspecified"
not elsewhere classified (NEC) - ANS-used when medical record documents a condition
to a level of specificity not identified by specific ICD 9 or ICD 10 code.
V codes - ANS-represent factors that influence health status or describe contact with
health services
E codes - ANS-supplemental classification used for reporting external causes of injuries
and poisonings
co-existing/related conditions - ANS-physicians should code all documented conditions
that co-exist at time of visit, and require or affect patient care
conditions treated/cured - ANS-do not code conditions previously treated or no longer
exist
symptoms/signs - ANS-do not code if part of an integral underlying condition
"history of" - ANS-patient no longer has the condition and dx often indexes to V code
not in HCC models
"history of" error - ANS-coding past condition as active; coding active condition as
history of; impacts ra
cancer codes - ANS-HCC varies depending on whether cancer is primary site or
secondary site
cancer guidelines - ANS-if malignant status not specified, code to primary site except
for:
bone, brain, diaphragms, heart, liver, lymph nodes, mediastinum, meninges,
peritoneum, pleura, retro peritoneum, and spinal cord
