Quality of Care Measures Flashcards
6 cards from real CRC practice questions. Tap to flip, then mark Knew It or Still Learning — missed cards come back until you master them.
Read the first 6 Quality of Care Measures flashcards as text
Which scenario demonstrates ideal alignment between risk adjustment accuracy and quality measure performance?
Answer: Accurate coding that simultaneously supports correct quality denominators and appropriate payment
Accurate coding serves both objectives simultaneously. These are complementary when the foundation is coding accuracy.
How does CMS use risk adjustment in calculating certain Star Rating measures?
Answer: Certain outcome measures are risk-adjusted to account for member health status differences across plans
CMS risk-adjusts outcome-based measures like readmissions to ensure fair comparison across plans serving different populations.
A plan's diabetic retinopathy screening rate is 72% vs 58% national average, but only 60% of diabetic members are properly coded. What is the true rate?
Answer: Cannot be determined without data on uncoded members' screening status
The true rate depends on how many uncoded members received screening, which is unknown.
What role does Social Determinants of Health coding play in risk adjustment and quality?
Answer: SDOH Z-codes provide supplemental data for quality stratification with limited current HCC value
Z-codes for social determinants support care management and health equity initiatives, with growing importance in future models.
An MA plan achieves a 4.5 Star Rating with 5% quality bonus. How does coding accuracy contribute to maintaining this rating?
Answer: Accurate coding maintains reliable denominators, prevents audit penalties, and ensures risk-adjusted measures are calibrated
Maintaining ratings requires consistent performance, which depends on reliable measurement infrastructure supported by accurate coding.
A CRC notices many outpatient encounters are missing procedure codes while diagnosis codes are present. How does this affect quality measurement?
Answer: Missing procedures prevent verification of services rendered, potentially excluding members from quality numerators
Many HEDIS measures use procedure codes to verify services were delivered. Missing them can make it appear care was not provided.