Risk Adjustment Terms
_______ determines which ICD 10 codes that will be part of the HCC model each year.
What is CMS?
Acronym commonly used to ensure complete documentation of HCC diagnosis.
What is M.E.A.T? (Monitor, Evaluate, Assess, Treat)
Which outpatient E&M level requires 30 - 39 minutes?
What is 99214?
True or False. Depression, unspecified carries risk value.
What is False?
A statistical process that takes into account the underlying health status and health spending of the enrollees in an insurance plan
What is Risk Adjustment?
True or False. A general statement such as "I reviewed all of the following diagnoses and discussed them with the patient" is sufficient for Risk Adjustment documentation.
What is False? Each diagnosis must contain "M.E.A.T"
True or False. Time spent documenting on the same Date of Service as a patients office visit can be counted towards the providers total billing time.
What is True?
True or False. Smoker's Cough carries risk value.
What is true? (0.192)
_____ coding is a risk-adjustment model designed to estimate future health care costs for patients
Hierarchical condition category (HCC)
True or False. CVA not during acute phase and no late effects should be coded as “history of”.
What is True?
True or False. When performing a telehealth visit, VIDEO is not required to bill a 99213/99214/99215.
What is False? In order to bill for a full "face to face " visit the patient must be seen via synchronous audio and video technology.
Audio only visits are reimbursed at a lower rate.
True or False. Nicotine dependence, cigarettes, uncomplicated F17. 210 carries risk value.
What is False? Nicotine Dependence does not currently carry any risk value.
_____ are assigned based on the patient's diagnosis codes and map to a Hierarchical Condition Category (HCC) and demographic factors.
What are RAF scores?
True or False. Patient following up for history of prostate cancer two years ago. He completed radiation one year ago. Patient is doing well. Prostate specific antigen (PSA) level is normal.
The correct Diagnosis for this encounter would be C61 (Malignant neoplasm of prostate).
What is False? The Correct diagnosis codes would be
Z08: Encounter for follow-up examination after completed treatment for malignant neoplasm. Z85.46: Personal history of malignant neoplasm of prostate.
True or False. A patient is in for a wellness visit and complains of bilateral knee pain in the morning. Tenderness and swelling are found on exam. The patient is given a nonsteroidal anti-inflammatory drug prescription. The provider should charge a 99213 in addition to the Wellness Visit Code.
What is True?
Diagnosis for a patient with a BMI greater than 35 with at least 1 comorbidity.
What is Morbid Obesity or Class 2 Obesity with Comorbidity?
"Although many HCC coding audits performed by the ____ are focused on MA organizations (like Humana with $197.7 million in overpayments), the DOJ has filed lawsuits against health care providers in violation of the False Claims Act for “unsupported” HCC diagnosis codes."
CMS risk-adjusts the capitated payments to Medicare Advantage plans based on an enrollee’s “risk score” – a measure of the expected costs associated with a person’s care. An enrollee with a risk score of ____ is expected to incur costs equal to those of the average Medicare beneficiary.
What is 1.0?
True or False. A patient comes in for a suspicious lesion, the provider evaluates and removes the lesion at that visit. The provider should charge a 99213 in addition to the procedure code.
What is False? The E&M level is included in the procedure and should not be billed separately.
True or False? Senile Purpura D69.2 carries risk value.
What is True? (0.192)