CDIP Regulatory and Payer Requirements 3

Question 1

The Hierarchical Condition Category (HCC) risk adjustment model is primarily used by which Medicare payment program?

Accepted Answer

Medicare Advantage (Part C)

Answer

HCC risk adjustment is used by Medicare Advantage to adjust capitation payments to plans based on the predicted health costs of enrolled members.

Question 2

Which condition is classified as a Hospital-Acquired Condition (HAC) under CMS policy that can result in reduced payment when not documented as present on admission?

Accepted Answer

Catheter-associated urinary tract infection (CAUTI)

Answer

CAUTI is one of CMS's designated HACs; if not present on admission, the hospital may not receive additional payment for treating this complication.

Question 3

The Present on Admission (POA) indicator is required for all diagnoses on inpatient claims. Which POA indicator code means the condition was present at the time of inpatient admission?

Accepted Answer

Y

Answer

POA indicator 'Y' (Yes) means the condition was present at the time of inpatient admission.

Question 4

Under the Affordable Care Act's Value-Based Purchasing (VBP) program, hospital payments are adjusted based on:

Accepted Answer

Performance on quality and patient experience measures

Answer

Hospital VBP adjusts Medicare payments up or down based on hospitals' performance on quality, safety, and patient experience measures.

Question 5

Which Medicare claim type is used for outpatient hospital services, including emergency department visits and clinic visits?

Accepted Answer

UB-04 (CMS-1450)

Answer

The UB-04 (CMS-1450) form is used by institutional providers, including hospitals billing for outpatient services under OPPS.

(CDIP) Certified Documentation Improvement Practitioner Practice Test

(CDIP) Certified Documentation Improvement Practitioner Practice Test

CDIP Regulatory and Payer Requirements 3