Deck 15: Introduction to the Mechanics of Hierarchical Condition Categories From a CMS Perspective

Question 1

The goal of ____________ is to have a process in place that will help insurance carriers provide coverage to individuals with pre-existing conditions.

A) Accountable Care Organizations
B) third-party administration
C) Medicare and Medicaid
D) reinsurance and risk corridor programs

Answer 1

D

Question 2

By providing risk-adjusted payments, CMS can make more accurate and appropriate payments for beneficiaries with differences in:

A) admission diagnoses.
B) expected costs.
C) discharge disposition.
D) expected revenues.

Answer 2

B

Question 3

To ensure the accuracy and integrity of data submitted to CMS, all diagnoses codes must be documented in the medical record a result of:

A) a discharge note.
B) a face-to-face visit.
C) a virtual visit.
D) None of these is correct.
E) both a discharge note and a virtual visit.

Answer 3

B

Question 4

According to the risk adjustment program, diagnosis codes need to be reported:

A) monthly.
B) quarterly.
C) semi-annually.
D) annually.

Question 5

The HCC model is used to calculate risk scores that predict:

A) outcomes.
B) costs for an individual patient.
C) costs for a pool of patients.
D) case-mix index.

Question 6

Selected Significant Disease (SSD) Model considers ____________ manifestations of a condition.

A) non-urgent
B) serious
C) elective
D) a patient's history of

Question 7

A Prospective Model uses diagnostic information from _________ to predict Medicare benefit costs for the following year.

A) a base year
B) a prior year
C) two prior years
D) All of these are correct.

Question 8

The HCC model is a Prospective Model that uses diagnostic sources because the model recognizes diagnoses from:

A) hospital inpatient settings.
B) hospital outpatient settings.
C) physician settings.
D) None of these is correct.
E) All of these are correct.

Question 9

Multiple chronic diseases are considered part of the risk-adjusted payment model based on the assignment of diagnoses to disease groups, also known as:

A) condition categories.
B) primary diagnoses.
C) diagnosis-related groups.
D) None of these is correct.

Question 10

Hierarchies are comprised of condition categories, reflecting severity and:

A) cost dominance.
B) admission diagnoses.
C) discharge disposition.
D) case-mix index.

Question 11

The HCC risk adjustment model is used to adjust the payments that are made for ________________ benefits that are offered by Medicare Advantage plans and PACE organizations.

A) Part B
B) Part C
C) Part A
D) both Part A and Part B

Question 12

When CMS looks at recalculating the risk adjustment model, it looks back on _________________ claims for the prior year to forecast the following year's costs.

A) outpatient
B) fee-for-service
C) inpatient
D) None of these is correct.

Question 13

The determination for payment in the long-term institutional program is based on the minimum 90-day assessment by the nursing home. The tool used for this measurement is the:

A) Minimum Data Set.
B) Diagnosis-Related Grouper.
C) Resource-Based Relative Value Scale.
D) None of these is correct.

Question 14

Which of the following demographic factors influence risk scores?

A) Sex of the beneficiary
B) Disability status
C) Original reason for entitlement
D) All of these are correct.
E) None of these is correct.

Question 15

According to CMS, disease hierarchies address situations when there are _______________ for a particular disease and _____________________, and these data have been reported for a beneficiary.

A) several options, Medicare eligibility
B) multiple levels of severity, discharge disposition
C) the admission diagnosis, discharge diagnosis
D) multiple levels of severity, varying degrees of associated costs
E) None of these is correct.

Question 16

According to CMS, certain combinations of ____________________ for an individual can increase the overall medical costs for a beneficiary more than what the CMS HCC model reflects.

A) coexisting diagnoses
B) multiple procedures
C) admissions
D) duplicate diagnoses

Question 17

When a patient has a status of receiving dialysis and is actively receiving or compliant to the regimen of dialysis, the Dialysis Center will submit information on form _________, and the information contained on this form will supply information to CMS.

A) CMS 1500
B) CMS ABN
C) CMS-2278
D) UB04
E) None of these is correct.

Question 18

________________________ was developed to cover Medicare Advantage enrollees and any programs that were part of a stand-alone prescription drug plan (PDP).

A) Part A RxHCC
B) Part D RxHCC
C) Part C RxHCC
D) Part B RxHCC

Question 19

Which of the following is a similarity between the CMS HCC and the RxHCC models?

A) They use diagnosis codes.
B) They do not use a regression model to predict expenditures.
C) They do not use relative weights to calculate payments.
D) They use data to adjust fee-for-service payments.

Question 20

The difference between the CMS HCC and the RxHCC models is in the potential expenditure. Each model calculates total expenditures, which in the CMS-HCC model are medical services, and in the RxHCC model, the expenditures are reflective of:

A) medical expenditures.
B) prescription drug costs.
C) comorbid conditions.
D) complexity of diagnoses.

Question 21

A ____________________ is a tool that can smooth out or normalize data over a period of time.

A) normalization factor
B) frailty adjustment
C) low-income status
D) None of these is correct.

Question 22

Which of the following data are used in calculating the risk scores for both the MA plans and the FFS plans?

A) Demographic data capture
B) Frailty adjustment
C) Diagnostic data
D) Normalization factor

Question 23

Which of the following is the beneficiary's insurance identification that is issued by the Social Security Administration or the Railroad Retirement Board?

A) Provider type
B) Service from and to dates
C) Diagnosis code
D) Health insurance claim number

Question 24

Which of the following describes the clinical details or a patient's reason for seeking care from a provider?

A) Diagnosis code
B) Health insurance claim number
C) Provider type
D) Service from and to dates

Question 25

Which of the following clearly identifies when a patient received care from the organization?

A) Admission date and procedure date
B) Admission date
C) Discharge date and discharge status
D) Service from and to dates

Question 26

Which of the following identifies the reason for the risk adjustment based on the place of care?

A) Diagnosis code
B) Health insurance claim number
C) Provider type
D) Service from and to dates

Question 27

Insurance by another insurer of all or part of a risk previously assumed by an insurance company is called reinsurance.

Question 28

The second goal of the reinsurance and risk programs is to destabilize the premium structure.

Question 29

Risk adjustment is driven from ICD-10-CM diagnosis codes that are derived from the medical records and documentation in the primary care physician's office.

Question 30

In an acute setting, where inpatient services are reimbursed, we see that a system called Diagnosis-Related Group (DRG) reimburses inpatient facilities based on like patients with like resource consumption.