CRC (Other exams) flashcards
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- Risk adjustment
- A method that uses diagnoses and demographic factors to predict expected healthcare costs, adjusting payments so plans caring for sicker populations receive more resources.
- Risk Adjustment Factor (RAF)
- A numeric score comparing a beneficiary's predicted cost to the average; 1.0 represents average risk, and 1.25 predicts 25 percent higher cost.
- Prospective risk adjustment
- Uses diagnoses from a prior period to predict costs and set payment for a future period, requiring annual recapture of chronic conditions.
- Concurrent risk adjustment
- Uses diagnoses from the current payment period to predict costs for that same period, often applied in Medicaid and commercial models.
- Budget neutrality
- A payment principle in which aggregate risk-adjusted payments are calibrated so that changes in risk scores do not increase total program spending.
- Hierarchical Condition Category
- A grouping of diagnosis codes with similar expected costs; within a family, only the most severe documented HCC contributes to the risk score.
- CMS-HCC model
- A Medicare Advantage risk adjustment model that combines age, sex, institutional status, Medicaid eligibility, and HCCs to predict beneficiary costs.
- HHS-HCC model
- A risk adjustment model for individual and small-group markets that uses age, sex, metal tier, enrollment duration, and diagnosis-based HCCs.
- RxHCC model
- A Part D risk adjustment model that predicts prescription drug spending using separate diagnosis groupings and hierarchies from the CMS-HCC model.
- Disease interaction coefficient
- An additional risk-score factor added when specific condition combinations occur, reflecting higher cost than the sum of individual HCC coefficients.
- Highest specificity coding
- Assigning the most detailed ICD-10-CM code supported by documentation, including site, laterality, type, severity, and complication status.
- Combination code
- A single ICD-10-CM code that captures both an underlying condition and its manifestation, such as diabetes with retinopathy.
- History code
- An ICD-10-CM Z code indicating a resolved or past condition; it generally does not map to a payment HCC.
- Principal diagnosis
- The condition established after study to be chiefly responsible for the encounter, sequenced first when required by coding guidelines.
- Laterality
- The specification of right, left, bilateral, or unspecified side in an ICD-10-CM code, requiring documentation for the highest specificity.
- MEAT documentation
- Evidence in the medical record of Monitor, Evaluate, Assess, or Treat for a condition during the encounter, supporting active status.
- Abstraction
- The structured extraction of diagnosis, encounter date, provider, and clinical support from a medical record for risk-adjustment reporting.
- Problem list limitation
- A diagnosis appearing only on a problem list without supporting encounter documentation generally cannot be validated as an active condition.
- Provider query
- A compliant written request for clarification when documentation is ambiguous, incomplete, or contradictory, without leading the provider to a diagnosis.
- Suspect condition
- An analytics-flagged diagnosis not documented by a provider; it cannot be coded until the provider documents and confirms the condition.
- HCC hierarchy
- A rule that limits payment to the most severe HCC within a condition family even when multiple related diagnoses are documented.
- Chronic condition recapture
- The annual documentation requirement for ongoing chronic conditions so they remain eligible for prospective risk-adjustment payment.
- Resolved condition
- A condition no longer active or requiring treatment; it should be coded as history rather than as a current diagnosis.
- Causal linkage
- Documentation connecting a manifestation to its underlying disease, required to support combination codes such as diabetic kidney disease.
- RADV audit
- A CMS Risk Adjustment Data Validation review comparing submitted HCC diagnoses with medical records and requiring repayment for unsupported diagnoses.
- Upcoding
- Submitting a diagnosis or severity level not supported by the medical record to increase payment, which can constitute fraud.
- False Claims Act
- A federal law imposing liability for knowingly submitting false or unsupported claims, including risk-adjustment diagnoses, to government programs.
- Compliance program
- An organization's system of policies, training, auditing, monitoring, and corrective actions designed to prevent and detect regulatory violations.
- Diabetes mellitus
- A chronic disorder of hyperglycemia caused by insulin deficiency or resistance, often producing microvascular and macrovascular complications.
- Chronic kidney disease
- Progressive loss of kidney function staged by glomerular filtration rate, with stage 5 defined as GFR below 15.
- Heart failure
- A syndrome of impaired cardiac filling or ejection, classified by ejection fraction as reduced, mildly reduced, or preserved.
- Metastatic neoplasm
- Cancer that has spread from a primary site to distant organs; coding requires identifying both the primary and secondary sites.