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