CCM (The Commission CCM & CDMS Exams) cheat sheet

Medicare Part A covers inpatient hospital, skilled nursing facility care after a qualifying stay, hospice, and some home health; Part B covers physician and outpatient services.

Prospective payment systems set payment in advance (DRG for acute inpatient, RUG for SNF, IRF-PAI for inpatient rehab); retrospective systems pay after services are delivered.

Capitation pays a fixed per-member-per-month amount regardless of utilization; fee-for-service pays per service; bundled payments cover a defined episode of care.

Medicare chronic care management billing generally requires two or more chronic conditions, an individualized care plan, and documented consent.

The Hospital Readmissions Reduction Program reduces Medicare payments to hospitals with excess 30-day readmissions for specified conditions.

Observation status is not an inpatient admission and can disqualify Medicare coverage of subsequent SNF care, which generally requires a 3-day inpatient stay.

Medicaid is jointly funded by federal and state governments, covers low-income populations, and has state-specific benefit packages.

Workers' compensation covers work-related injury care and commonly uses state fee schedules, utilization review, and return-to-work coordination.

Value-based purchasing adjusts reimbursement based on quality, outcomes, and cost performance rather than volume of services.

Kübler-Ross stages of grief are denial, anger, bargaining, depression, and acceptance; they are not necessarily linear and may overlap or recur.

Transtheoretical model stages are precontemplation, contemplation, preparation, action, and maintenance; interventions are matched to the person's stage.

PHQ-9 total scores are interpreted as 5-9 mild, 10-14 moderate, 15-19 moderately severe, and 20-27 severe depression.

GAD-7 scores of 5, 10, and 15 represent cut points for mild, moderate, and severe anxiety.

CAGE screening uses four yes/no items (Cut down, Annoyed, Guilty, Eye-opener); two or more positive answers suggest alcohol misuse.

Maslow's hierarchy orders needs as physiologic, safety, belonging, esteem, and self-actualization, with lower needs generally addressed first.

Motivational interviewing uses OARS: Open questions, Affirmations, Reflections, and Summaries.

Health literacy influences comprehension; teach-back and plain language are used to confirm understanding.

Cultural competence includes awareness, knowledge, skill, and humility, and affects assessment, communication, and care planning.

Donabedian's model evaluates quality through structure (resources), process (what is done), and outcomes (results).

A rate is calculated as (numerator ÷ denominator) × 100 or × 1,000, depending on the measure convention.

Reliability is consistency or reproducibility of a measure; validity is whether the measure captures the intended concept.

Sensitivity = true positives ÷ (true positives + false negatives), reflecting a test's ability to detect true disease.

Specificity = true negatives ÷ (true negatives + false positives), reflecting a test's ability to identify those without disease.

PDSA (Plan-Do-Study-Act) is a rapid-cycle method for testing small changes and then adopting, adapting, or abandoning them.

Root cause analysis is a retrospective method for adverse events; failure mode and effects analysis (FMEA) is prospective.

HEDIS is a standardized set of health plan performance measures; CMS Star Ratings summarize quality across domains.

Benchmarking compares an organization's performance with internal targets or external best-practice standards to identify gaps.

The inpatient rehabilitation 3-hour rule requires at least 3 hours of therapy per day, 5 days per week (or 15 hours per week) for Medicare IRF coverage.

The 60% rule requires at least 60% of an IRF's admissions to have one of 13 qualifying conditions, such as stroke or spinal cord injury.

The Functional Independence Measure (FIM) has 18 items scored 1-7, with total scores from 18 to 126; higher scores indicate greater independence.

The Barthel Index measures independence in activities of daily living on a 0-100 scale.

The rehab team commonly includes a physiatrist, physical therapist, occupational therapist, speech-language pathologist, rehab nurse, psychologist, and case manager.

Physical therapy addresses mobility, gait, and strength; occupational therapy addresses activities of daily living and instrumental activities of daily living.

Medicare Part A covers SNF rehabilitation after a qualifying 3-day inpatient hospital stay when skilled care is required.

Home health coverage generally requires homebound status and a skilled nursing or therapy need.

Assistive devices and durable medical equipment support function, and training in their safe use improves outcomes.

HIPAA requires minimum necessary use and disclosure of protected health information, plus privacy, security, and breach notification safeguards.

Negligence requires four elements: duty owed, breach of duty, causation, and damages.

Informed consent requires patient capacity, disclosure of risks and alternatives, voluntariness, and documentation.

Advance directives include living wills, durable power of attorney for health care, and POLST orders.

Mandated reporting applies to suspected child abuse or neglect, elder abuse, and dependent adult abuse in many jurisdictions.

Confidentiality exceptions include public health reporting, duty to warn or protect, and court orders.

Core ethical principles include autonomy, beneficence, nonmaleficence, justice, and fidelity.

EMTALA requires emergency screening and stabilization regardless of the patient's ability to pay.

Conflicts of interest and professional boundary issues must be disclosed and managed to protect the patient's interests.