HCC Coding/Risk Adjustment _ Q’s & A’s
Risk Adjustment Model Correct Ans - Calculates risk scores for all
beneficiaries with available data
What are the three submission deadlines? Correct Ans - 1. First Friday
in September = Initial Risk Score
2. First Friday in March = Mid-year Update
3. January 31 after the payment year = Final reconcilation
Medicare risk adjustment model is prospective. This means? Correct Ans
- Diagnoses reported in the prior year and demographic information are
utilized to "predict" future costs and adjust payments accordingly
Risk Scores. Correct Ans - Measures individual beneficiaries' relative
risk and are used to adjust payments for each beneficiary's expected
expenditures.
FERAS Response Report. Correct Ans - Rejected data after it has been
processed through FERAS is recorded in this report.
RAPS Return File Correct Ans - This is a daily report that shows all
records approved and where errors occurred.
RAPS Transaction Error Report Correct Ans - Displays records on
which errors occurred.
RAPS Transaction Summary Report Correct Ans - A report sent to the
MA organization daily and identifies data that have been finalized in RAPS
database
Duplicate Diagnosis Cluster Report Correct Ans - Shows diagnosis
clusters submitted with information that duplicates a stored cluster.
RAPS Monthly Plan Activity Report and Cumulative Plan Activity Report
Correct Ans - Provides a summary of all diagnoses stored for a given time
period.
,Error Frequency Report Correct Ans - This report is distributed
monthly and quarterly. Provides an overview of all errors associated with files
submitted in test and production.
RAPS database Correct Ans - Stores all finalized diagnosis clusters
Risk Adjustment System (RAS) Correct Ans - Executes the risk
adjustment model and calculates the risk score using the SAS model.
Medicare Advantage Prescription Drug System (MARx) Correct Ans -
Processes payments to plans and issues the MMR (Monthly Membership
Report) and MOR (Model Output Report).
How often does CMS conduct data validation audits and for what purpose?
Correct Ans - Audits are done annually on selected plans that may have to
request medical record documentation from the providers to support the
submitted diagnoses.
What types of data are checked in FERAS? Correct Ans - File-level,
batch-level and first and last detailed records
RAPS Return file Correct Ans - Daily reports that shows all records
approved and where errors occurred.
What does File-level information identified? Correct Ans - Submitter
What does Batch-level information identify? Correct Ans - MA
organization
What does Detail-level information identify? Correct Ans - Beneficiary
Define Reconciliation Correct Ans - The completion of the
implementation of payments with CMS calculating final risk adjustment
factors and beneficiary stats based on complete data. Necessary adjustments
for institutional status and demographic data for enrollees is considered.
CMS continues to allow a period (approximately 13 months after the data
collection year) for submitting final RAPS data for the appropriate data
collection period.
, Is this condition a Probably Forever/Almost ALLS (still has condition even
though mediation or device is covering up symptoms), Forever/ALLS, or a
Chronic condition?
Septicemia (Category 380) Correct Ans - Probably Forever/Almost
ALLS
Is this condition a Probably Forever/Almost ALLS (still has condition even
though mediation or device is covering up symptoms), Forever/ALLS, or a
Chronic condition?
Heart Failure (Category 428) Correct Ans - Probably Forever/Almost
ALLS
Is this condition a Probably Forever/Almost ALLS (still has condition even
though mediation or device is covering up symptoms), Forever/ALLS, or a
Chronic condition?
Disease of Pulmonary Circulation (Categories 415-47) -Regional Correct
Ans - Probably Forever/Almost ALLS
Is this condition a Probably Forever/Almost ALLS (still has condition even
though mediation or device is covering up symptoms), Forever/ALLS, or a
Chronic condition?
Enteris and Ulcerative Colitis (Categories 555-557) Correct Ans -
Probably Forever/Almost ALLS
Is this condition a Probably Forever/Almost ALLS (still has condition even
though mediation or device is covering up symptoms), Forever/ALLS, or a
Chronic condition?
Perforated Gastric, Duodenal, Peptic, and Gastrojejunal Ulcers (Categories
531-534) Correct Ans - Probably Forever/Almost ALLS
Risk Adjustment Model Correct Ans - Calculates risk scores for all
beneficiaries with available data
What are the three submission deadlines? Correct Ans - 1. First Friday
in September = Initial Risk Score
2. First Friday in March = Mid-year Update
3. January 31 after the payment year = Final reconcilation
Medicare risk adjustment model is prospective. This means? Correct Ans
- Diagnoses reported in the prior year and demographic information are
utilized to "predict" future costs and adjust payments accordingly
Risk Scores. Correct Ans - Measures individual beneficiaries' relative
risk and are used to adjust payments for each beneficiary's expected
expenditures.
FERAS Response Report. Correct Ans - Rejected data after it has been
processed through FERAS is recorded in this report.
RAPS Return File Correct Ans - This is a daily report that shows all
records approved and where errors occurred.
RAPS Transaction Error Report Correct Ans - Displays records on
which errors occurred.
RAPS Transaction Summary Report Correct Ans - A report sent to the
MA organization daily and identifies data that have been finalized in RAPS
database
Duplicate Diagnosis Cluster Report Correct Ans - Shows diagnosis
clusters submitted with information that duplicates a stored cluster.
RAPS Monthly Plan Activity Report and Cumulative Plan Activity Report
Correct Ans - Provides a summary of all diagnoses stored for a given time
period.
,Error Frequency Report Correct Ans - This report is distributed
monthly and quarterly. Provides an overview of all errors associated with files
submitted in test and production.
RAPS database Correct Ans - Stores all finalized diagnosis clusters
Risk Adjustment System (RAS) Correct Ans - Executes the risk
adjustment model and calculates the risk score using the SAS model.
Medicare Advantage Prescription Drug System (MARx) Correct Ans -
Processes payments to plans and issues the MMR (Monthly Membership
Report) and MOR (Model Output Report).
How often does CMS conduct data validation audits and for what purpose?
Correct Ans - Audits are done annually on selected plans that may have to
request medical record documentation from the providers to support the
submitted diagnoses.
What types of data are checked in FERAS? Correct Ans - File-level,
batch-level and first and last detailed records
RAPS Return file Correct Ans - Daily reports that shows all records
approved and where errors occurred.
What does File-level information identified? Correct Ans - Submitter
What does Batch-level information identify? Correct Ans - MA
organization
What does Detail-level information identify? Correct Ans - Beneficiary
Define Reconciliation Correct Ans - The completion of the
implementation of payments with CMS calculating final risk adjustment
factors and beneficiary stats based on complete data. Necessary adjustments
for institutional status and demographic data for enrollees is considered.
CMS continues to allow a period (approximately 13 months after the data
collection year) for submitting final RAPS data for the appropriate data
collection period.
, Is this condition a Probably Forever/Almost ALLS (still has condition even
though mediation or device is covering up symptoms), Forever/ALLS, or a
Chronic condition?
Septicemia (Category 380) Correct Ans - Probably Forever/Almost
ALLS
Is this condition a Probably Forever/Almost ALLS (still has condition even
though mediation or device is covering up symptoms), Forever/ALLS, or a
Chronic condition?
Heart Failure (Category 428) Correct Ans - Probably Forever/Almost
ALLS
Is this condition a Probably Forever/Almost ALLS (still has condition even
though mediation or device is covering up symptoms), Forever/ALLS, or a
Chronic condition?
Disease of Pulmonary Circulation (Categories 415-47) -Regional Correct
Ans - Probably Forever/Almost ALLS
Is this condition a Probably Forever/Almost ALLS (still has condition even
though mediation or device is covering up symptoms), Forever/ALLS, or a
Chronic condition?
Enteris and Ulcerative Colitis (Categories 555-557) Correct Ans -
Probably Forever/Almost ALLS
Is this condition a Probably Forever/Almost ALLS (still has condition even
though mediation or device is covering up symptoms), Forever/ALLS, or a
Chronic condition?
Perforated Gastric, Duodenal, Peptic, and Gastrojejunal Ulcers (Categories
531-534) Correct Ans - Probably Forever/Almost ALLS
