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CRC Final questions with answers.
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CRC Final questions with answers.2. ANS: A
Rationale: Prospective reviews are similar to concurrent, but are called prospective because when
considering the current year's encounters, these will affect the next year and not the current year where
payment is concerned. ANS - 2. When are prospective reviews performed?
a. Prior to the diagnosis and risk factor data being reported to CMS.
b. After the diagnosis and risk factor data has been reported to CMS.
c. Once the patient is enrolled in a Medicare Part C plan
d. Once the provider has finalized the documentation to submit diagnosis codes.
PTS: 1
3. ANS: B
Rationale: Each year, CMS publishes the list of diagnosis codes that risk adjust, and the HCC that it
adjusts to in the model. The information can be found at https://www.cms.gov/Medicare/Health-
Plans/MedicareAdvtgSpecRateStats/Risk-Adjustors-Items/Risk2018.html?
DLPage=1&DLEntries=10&DLSort=0&DLSortDir=descending ANS - 3. Where can a list of diagnosis
mappings to HCCs be located?
a. OIG website
b. CMS website
c. OCR website
d. QPP website
6. ANS: B
Rationale: From a payment perspective, risk adjustment models adjust health plan revenue to better
reflect the projected costs of the patient population and compensate plans that enroll high-cost
patients. ANS - 6. Risk adjustment models are used to:
a. Limit coverage of chronic conditions.
b. Determine projected costs of health care based on the condition(s) of patients.
,c. Determine the return on investment for developing proactive disease prevention outreach.
d. Limit the coverage of hospital admissions.
7. ANS: C
Rationale: Not all ICD codes carry value in risk adjustment models, including the Medicare model.
Typically diagnoses that are costly to manage from a medical management or prescription drug
treatment perspective are more likely to be found in risk adjustment models. Each year CMS publishes
the list of diagnosis codes that risk adjust and the HCC it adjusts to. The information can be found at
www.cms.gov/Medicare/Health-Plans/MedicareAdvtgSpecRateStats/Risk-Adjustors.html. ANS - 7.
Which statement is TRUE regarding diagnosis codes and assigned HCCs?
a. All diagnosis codes are assigned a HCC.
b. All chronic illnesses are assigned a HCC.
c. Not all diagnosis codes are assigned a HCC.
d. All acute exacerbations of an acute illness are assigned a HCC.
8. ANS: C
Rationale: CMS is required to make an adjustment to reflect "differences in coding patterns between
Medicare Advantage plans and providers under Part A and B to the extent that the Secretary has
identified such differences." ANS - 8. What is the purpose of the coding intensity adjustment?
I. Determine different coding patterns in HCC compared to inpatient claims covered by Part A.
II. Determine different coding patterns in HCC compared to outpatient claims covered by Part B.
III. Determine different coding patterns in HCC compared to claims processed under CDPS.
a. I
b. II
c. I and II
d. I, II, and III
9. ANS: C
Rationale: Any provider may validate any diagnosis, as diagnoses are not dependent upon the specialty
ANS - 9. When reporting a code for retinopathy, must the coder find documentation from an
ophthalmologist in order to code the condition as an active condition?
a. Yes, specialty specific diagnoses can only be reported by a specialist.
,b. Yes, ophthalmologists must diagnosis all eye related conditions.
c. No, any approved provider can validate any diagnosis.
d. No, only primary care providers can provide supporting documentation for reported diagnoses.
10. ANS: C
Rationale: Risk adjustment must be compared to average FFS expenses and rates. The purpose of the
FFS normalization adjustment is so that CMS payments are based on a population with an average risk
score of 1.0. This is the national average. Annually, Medicare normalizes the risk scores to maintain an
average risk score of 1.0. ANS - 10. How often is the normalization factor adjusted?
a. Monthly
b. Twice per year
c. Yearly
d. As needed
11. ANS: B
Rationale: The adult model includes those individuals 21 and over, the child model includes individuals 2
to 20 and infant includes individuals through age 1. ANS - 11. For the HHS Hierarchical Conditions
Category model, who is included in the adult model?
a. Individuals who are 18 and over.
b. Individuals who are 21 and over.
c. Individuals who are the head of household.
d. Individuals who are making more than $13,000 per year.
12. ANS: C
Rationale: MACRA also laid the framework for a new reimbursement system set to begin in 2019 called
the Quality Payment Program, which includes two tracks:
· Merit-based Incentive Payment System (MIPS)
· Advanced alternative payment models (APMs) ANS - 12. What are the participation tracks available
through MACRA?
I. Merit-based Incentive Payment Systems
II. Sustainable Growth System
, III. Advanced Alternative Payment Models
a. I
b. II and III
c. I and III
d. I, II, and III
13. ANS: C
Rationale: There are 9 domains. The 5 for Part C for Medicare Advantage only and Medicare Advantage
Prescription Drug plans and 4 for Part D measures for Medicare Advantage Prescriptions Drug plans:
· Staying Healthy: Screenings, Tests and Vaccines
· Managing Chronic (Long Term) Conditions
· Member Experience with Health Plan
· Member Complaints and Changes in the Health Plan's Performance
· Health Plan Customer Service
· Drug Plan Customer Service
· Member Complaints and Changes in the Drug Plan's Performance
· Member Experience with the Drug Plan
· Drug Safety and the Accuracy of Drug Pricing ANS - 13. Which of the following are domains in CMS
Part C Stars Rating?
I. Staying Healthy
II. Managing Chronic Conditions
III. Member Experience with Health Plans
IV. Member Complaints, Problems Getting Services, and Improvement 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, and IV
d. I, II, III, IV, and V
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