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what two medications are prescribed to cancer patients to eradicate the cancer or for prophylaxis
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the definitions of a best medical record for a RADV audit is
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| Question | Answer |
|---|---|
| what two medications are prescribed to cancer patients to eradicate the cancer or for prophylaxis | tamoxifen, anastrozole |
| the definitions of a best medical record for a RADV audit is | documentation validates the CMS requested HCC's and contains all the necessary documentation elements and has additional HCC's not requested by CMS |
| what is reported by a provider for beneficiaries in medicare advantage plan | nature of presenting problem, all chronic conditions |
| retrospective audits should include | provider signatures, supporting documentation of pts dx, DOS |
| what type of audit evaluates appropriate risk score of pts | RADV |
| what info is required when submitting documentation to support a dx for a RADV/IVA | single DOS for outpatient records and the full inpatient set for hospital records |
| how often should a provider see and assess a pt in a calendar year to validate amputation status | once a year |
| a peg tube is | percutaneous endoscopic gastrostromy, g tube, gastrostomy |
| Conditions listed on the problem list for dm pt are coded as complications of the dm: True or false | false |
| what info is usually documented by provider during pt hx | pts response to current treatment, reason for encounter, providers observation of pts mood |
| which organs are in thoracic cavity | heart, lungs |
| what is true regarding hierarchies | utilized by some private payers |
| the star ratings program monitors | performance of medicare advantage plans |
| what risk adjustment model is used by medicaid | CDPS |
| quality measures like Star ratings and HEDIS have no correlation with the medical record information that is collected in support of risk adjustment. True or False | False |
| which medical records can be submitted for HCC validation | physicians office progress note, outpatient hospital, critical access hospital |
| what elements would not be taken into consideration for risk adjustment | the number of years pt has been covered under medicare advantage |
| what is purpose of RADV audit | verify accuracy of dx submitted for payment |
| when in outpatient setting would you code an uncertain dx | code as sign or symptom |
| when do you code for coexisting conditions | at the time of the encounter |
| medicare funding is allocated | previous years known dxs |
| what data elements are used in predictive modeling | DME claims, rx events, physicians claims data, facility claims data |
| what are domains in PQRS | community population health, effective clinical care, efficiency and cost reduction, patient safety |
| what info is verified during RADV audit | all dx codes reported are supported in medical record |
| what is reported when the provider documents arrow up HTN | query physician |
| what is acceptable signature | hand written |
| which organization is the coding clinic associated with | AHA |
| what is the guidelines for probable, suspected, possible, questionable, in inpatient setting | code the condition as if it was established |
| when can hemiparesis be coded | documentation states weakness on one side of body, weakness on one side of body due to stroke |
| and addendum is used to include info about what was done to pt and should be added in a reasonable time frame, which is usually capped at a mx of X days | 60 days |
| when does medicare require the provider to sign the medical record | timely basis |
| when are cancer dx's coded as current | when receiving treatment |
| what is the goal when coding for risk adjustment purposes | code all current dx a pt has |
| funding is allocated base on what for commercial plans | current years known dx's |
| how many records are submitted per pt in a RADV audit | five |
| what is true regarding the star quality rating system | quality bonus payments are made to medicare advantages plans who score at least four stars |
| what is the goal of HEDIS | allow pts to compare health plans |
| which of the following payment models are used for payment year 2014 | blended 25% of 2013 and 75% of 2014 |
| what element of the medical record is NOT used to capture current dx | radiology report |
| what is the purpose of collecting dx's in risk adjustment coding | risk adjustment factor |
| what element of the documentation includes the providers objective findings | exam |
| what is acronym for risk adjustment coding | HCC |
| what is the purpose of risk adjustment values | budget care of pt for the following year |
| medicare defaults much of its risk adjustment dx coding guidance to | official coding guidelines and coding clinic |
| what is reporting period for risk adjustment coding | jan to dec |
| what is the impact on reimbursement under the risk adjustment model if chronic conditions are not coded | failure to code for chronic conditions the pt has may result in inaccurate RAF |
| in Star program which measure is given the highest weight | outcomes |
| what is the purpose for capturing codes in an HCC model | determine the combined risk adjustment factor |
| when is added value factored into the RAF for the HC model for disease interaction | when two chronic illnesses paired together are complex to treat |
| what would lead to an underpayment | failing to report all the dx's supported in the medical record |
| what is true regarding the star program | states can either use the federal methodology or propose an alternative for certification by HHS |
| what is the lowest rating a plan must achieve to avoid penalties | three |
| what is the next step after predictive modeling identifies a dx gap | perform a retrospective audit to confirm proper dx code selection |
| which of the following is a quality review measure | PQRS |
| how is predictive modeling used in risk adjustment | determine suspected dx based on data elements |
| how are PQRS measure reported to CMS | claims data, GPRO |
| under the health and human services hierarchial condition category model which plan has the hightest out of pocket expense once premium is paid | bronze |
| what is true regarding HCC's | not all dx codes are assigned an HCC |
| which is not to be taken into consideration for risk adjustment | frequency of office visits |
| which provider is not an approved provider for dx code capture under the medicare HCC model | anesthesiology assistant |
| when are retrospective reviews usually performed | after the dx and risk factor data has been reported to CMS |
| under the HHS and HCC model which plan has the lowest out of pocket expense once the premium is paid | platinum |
| how is FFS data used for the purposes of risk adjustment | used to determine the FFS normalization adjustment |
| what does the abbreviation CDPS indicate | Chronic Disability Payment System |
| what is risk adjustment models used for | to determine projected costs of healthcare based on the conditions of patients |
| in CDPS risk adjustment models where do heart attacks fall | medium |
| what are extra risk adjustment values or factors added when a patient has more then one major significant dx identified in the model | interactions |
| when are prospective reviews performed | prior to the dx and risk factor data being reported to CMS |
| what fx is considered traumatic | compound |
| in which circumstances would an external cause be reported | causes of injury or health condition |
| when provider documents urosepsis what do you do | query |
| which structure in the urinary system differs in position/length between male and femal | urethra |
| where is bile produced | liver |
| what belongs to the appendicular skeleton | pelvic girdle |
| which membrane is found lining the interior walls of digestive system | mucous |
| layer in the middle of the eyeball | choroid |
| term for first portion of the small intestine | duodenum |
| term for draining pus out of ear | otopyorrhea |
| long bone | metacarpals |
| gland that secretes thyroid hormone and calitonin | thyroid gland |
| another term for great toe | hallux |
| glaucoma means | abnormally high intraocular pressure |
| not considered part of the skin | hypodermis |
| bowmans capsule | c shaped structure partically surrounding the glomerulus |
| in order starting with innermost layer for walls of digestive tract | mucosa, submucosa, muscle, serosa |
| auditory ossicles | stapes and incus |
| carries sperm out of the epididymis | vas deferens |
| bone that have trochanters | femur |
| does not contribute to refraction of the eye | aqueous |
| pneumomediastinum | presence of air in mediastinum |
| does not circulate fluids thru body | endocrine |
| tympanic membrane does what | separate external ear from middle ear |
| leaving stomach nutrients move thru what order | duodenum, jejunum, ileum |
| urine transported from kidneys to bladder by what | ureter |
| respiratory structure comprised of cartilage and ligaments | trachea |
| lies on top of the dermis and has access to rich supply of blood | stratum germinativum |
| what is MI | lack of O2 to heart tissue, resulting in tissue death |
| sentinel vs lymp nodes | sential first lymph node to be reached by mets CA cells |
| ABN cost estimate should be within which range | $100 or 25% |
| what document assists provider offices with development of compliance manuals | OIG compliance Plan guidance |
| what is not considered a covered entity under HIPAA | patients |
| which document is reference when looking for potential programs areas identified by the government indicating scrutiny of the serves with the coming year | OIG work plan |
| which act was enacted a part of the american recovery and reninvestment acot of 2009 | HITECH |
| what information is not maintained in medical record | financial record |
| what will the scope of a compliance program depend on | the size and resources of the providers practice |
| what year was AAPC founded | 1988 |
| when did HIPAA become law | 1996 |
| when did HITECH enacted | 2009 |
| according to OIG internal monitoring and auditing should be performed by waht | periodic audits |
| which medicare program part is affected by centers for medicare and Medicaid services | part C |
| what is not covered under HIPAA | workers comp |
| a covered entity may obtain consent from an individual to use or disclose protected health info except for | reasearch |
| what medicare part covers provider fees without the use of private insurance | part B |
| what is the value of remittance advice | states what will be paid and why any changes to charges were made |
| who is responsible for enforcing HIPAA | OCR |
| what can result from improper use of cut and past in EHR | dx's that are not relevant for DOS |
| which payer uses HEDIS measures | a variety |
| RADV means | risk adjustment data validation |
| how are HCC's categorized | disease groups |
| Do HCC category hierarchies play a role in which medical record is submitted for RADV | will accept lower or higher HCC to validate an HCC within the same category and can be a financial gain by submitting a higher hierarchy HCC |
| Retrospective audits provide companies ability to scrub/correct data what does this accomplish | opportunity to increase revenue, compare claims to documentation submit deletions if not supported |
| example of fraud | setting a policy to report all pts w/DM and CKD as a dm manifestation in order to elevate risk scores |
| Risk adjustment is | prospective payment system |
| The purpose of RADV audit is to validate submitted HCC data. True or false | True |
| how can MA plan improve their revenue | develop prospective and restrospective reviews to make sure all accurate dx's are captured |
| An AV Fistula connects | artery to vein |
| Chronic and acute conditions from the prev year that risk adjust are used to establish reimbursement for pt care provided by the MA plan. | health reisk is redetermined every year/document all clinical findings in the medical record/HCCs must be captured every 12 months |
| what do you need to code for vascular ulcer | location and type |
| what is the function of thyroid gland | secrete hormones regulating body metabolism and blood calcium |
| which cells produce hormones to regulate blood sugar | pancreatic islets |
| excessive potassium | hyperkalemia |
| what is predictive modeling | analysis of data to determine hypothesis related to the future health care needs of patients |
| in risk adjustment models, risk scores are used to adjust payments for each beneficiary's expected expenditures. True or false | true |
| what can affect RAF score | disease interactions, age, manifestations of chronic illness |
| Is HEDIS a division of the centers of medicare and Medicaid services | no |
| RAPS is | Risk adjustment processing system |
| what risk adjustment model incorporates high, medium and low risk in the numeric value | CDPS |
Created by:
Thollie