Exam 1

Question 1

HCQIP stands for what?

Who was it introduced by and when?

Answer 1

Health Care Quality Improvement Program

The CMS introduced the HCQIP initiative in 1992

Question 2

HCQIP is a national program…

Answer 2

designed to foster partnerships among Quality Improvement Organizations and members of the health care communities in which they work

Question 3

What does QIO stand for?

Who do they contract with?

Answer 3

Quality Improvement Organization

CMS contracts with one organization in each region as well as the District of Columbia, Puerto Rico, and the U.S. Virgin Islands to serve as that state/jurisdiction’s Quality Improvement Organization (QIO) contractor.

QIOs are private, mostly not-for-profit organizations, staffed by professionals,

Question 4

Why does CMS have QIOs?

Answer 4

CMS relies on QIOs to improve the quality of health care for all Medicare beneficiaries.

Question 5

What do QIOs do?

Answer 5

The QIO program is one of the largest federal programs dedicated to improving quality healthcare to Medicare beneficiaries

Part of the DHHS National Quality Strategy to provider better care and better health at a lower cost

Mission of the QIO program is to improve the effectiveness, efficiency, economy, and quality of services delivered

Question 6

CMS identifies the core functions of the QIO Program as:

Answer 6

Improving quality of care for beneficiaries

Protecting the integrity of the Medicare Trust Fund

Protecting beneficiaries by expeditiously addressing individual complaints, such as beneficiary complaints; provider-based notice appeals; violations

Question 7

CMS has two types of QIOs:

Answer 7

• Beneficiary and Family Centered Care (BFCC) QIO
• Handles beneficiary complaints, quality of care reviews, EMTALA, complaint, appeals and other types of case review.
• The BFCC ensures consistency in the case review process while taking into consideration local factors and local needs for general quality of care, medical necessity and readmissions

Quality Innovation Network (QIN) QIO
•Works with health care providers, suppliers and the community on data-driven projects to improve patient safety, make communities healthier, better coordinate post-hospital care and improve clinical quality.
•The QINs improve service through education, outreach, sharing best practices and using data to measure improvement for targeted health conditions and to reduce incidence of healthcare acquired conditions

Question 8

Telligen…What do they do?

Answer 8

•We support CMS in their efforts to achieve better care, better health for people and communities and more affordable care through quality improvement.

• Telligen’s mission as a QIN-QIO is to improve the effectiveness, efficiency and value of services delivered to people with Medicare through healthcare quality improvement initiatives that
• Increase patient safety
• Make communities healthier
• Better coordinate post-hospital care
• Improve healthcare quality

Question 9

Telligen Works With…

Answer 9

• Home Health Agencies
• Hospitals
• Nursing Homes
• Outpatient Settings
• Patients and Families
• Pharmacies
• Physician Offices

Question 10

IQR

Answer 10

The Hospital Inpatient Quality Reporting (IQR)/Value- Based Purchasing (HVBP)program was initially developed as a result of the Medicare Prescription Drug, Improvement and Modernization Act of 2003. The Deficit Reduction Act of 2005 set out new requirements for the IQR program, which build on the ongoing voluntary Hospital Quality Initiative.

Question 11

HVBP

Answer 11

The HVBP initiative requires hospitals to submit data for specific quality measures for health conditions common among people with Medicare, and which typically result in hospitalization.

Question 12

HVBP voluntary..

Answer 12

Hospitals that do not participate in the IQR initiative will receive a reduction in their Medicare Annual Payment Update.

Question 13

HCAHPS

Answer 13

(Hospital Consumer Assessment of Healthcare Providers and Systems) is a national, standardized survey of hospital patients.

Question 14

ENCODING

Answer 14

Computer based application used for routine code assignment. This technology allows the coder to use technology and software assistance to find and assign codes correctly.

Question 15

ADVANTAGES OF USING AN ENCODER

Answer 15

•Productivity

•Built in references
 –Coding Clinic for ICD-10-CM/PCS
–CPT Assistant
–Medical Dictionary
–Drug Reference
–Pharmacology Reference
–Lab values
–NCCI edits

Question 16

CAC

Answer 16

Computer Assisted Coding

•“The use of computer software that automatically generates a set of medical codes for review/validation and/or use based upon clinical documentation provided by healthcare practitioners.”

Question 17

NLP

Answer 17

Natural Language Processing (NLP)

• Natural Language Processing (NLP) is the technology behind computer-assisted coding
• Software that can ‘read’ Dictation/ Transcription/ Speech Recognition (Voice/Text/ Speech) systems., identify key clinical facts and map those facts to codes
• There are multiple technologies used for NLP within the industry

Question 18

HOW DOES CAC WORK?

Answer 18

• CAC solutions use either structured data input, NLP engines, or both.
• NLP engines use artificial intelligence to identify concepts in the unstructured text data and to associate medical codes from controlled vocabularies to relevant phrases in the text.
• NLP engines must be able to interpret and combine concepts in terms of morphology, syntax, semantics, and real-world knowledge.
• The accuracy of the NLP engines is, perhaps, the most important feature in a CAC solution. The NLP engine must minimize coding errors (the wrong code has been selected), false positives (the code is selected for which there is no documentary evidence), and false negatives (documentary evidence exists but the code was not selected.)Analysis of context and interaction of words within a sentence /paragraph
• Rules out numerous possible meanings before forming a conclusion on the intended meaning of the word (this is the key and where many CAC systems differ)

Question 19

IMPACT OF CAC ON CODING PROFESSIONALS

Answer 19

Computer-Assisted Coding
•Will change the role of coders. They will become more of an auditor of NLP output
•Will not replace coders but will be a tool to help improve their productivity, accuracy, and quality
•Will still require coders to review handwritten documents in the patient record as CAC cannot read most

Coder’s role in CAC is critical to it’s success
•Ultimate responsibility to validate and accept codes recommended by NLP
•Crucial to the auditing of each case before finalizing coding prior to billing

Question 20

BENEFITS OF CAC

Answer 20

Increased Coder Productivity
•Reduce coding backlogs, overtime and contract coding services dependenciesImproved

Coding Accuracy
•Identify and capture codes base on clinical documentation
•Decrease external audit dependency and costs

More Consistency
•Less room for coder interpretation
•Improve quality of less experienced coders bridging the coder experience gap

Question 21

What is Medical Necessity?

Answer 21

• Defines the clinical circumstances under which a procedure or service is considered to be:
• Reasonable
• Necessary
• Appropriate
• Safe and non-experimental

Question 22

What is a MAC?

Answer 22

Medicare Administrative Contractors

•Private insurance companies that serve as Medicare’s agent in the administration of the Medicare program, including the payment of claims.

Question 23

What does a MAC do?

Answer 23

• Process Medicare FFS claims
• Make and account for Medicare FFS payments
• Enroll providers in the Medicare FFS program

Establish, review and coordinate

Question 24

Jurisdiction 6 (J6)

Answer 24

Illinois, Minnesota, and Wisconsin

J6 processes FFS Medicare Part A and Part B claims for Illinois, Minnesota, and Wisconsin

Question 25

Jurisdiction #6 MAC contract awarded to

Answer 25

National Government Services (NGS)

Question 26

NCD

Answer 26

National Coverage Determinations

•NCDs originate from the Center for Medicare & Medicaid Services (CMS) Central Office and apply to all Medicare jurisdictions.

Identifies items and services covered or not covered by Medicare nationally—all beneficiaries regardless of where they live

Question 27

LCD

Answer 27

Local Coverage Determinations

These are MAC developed coverage policies, pertaining to services or items notaddressed in NCDs or program manuals. LCDs usually define “medical necessity” (1862a[A]), that is to say under what circumstances (i.e., diagnoses) a service(s) is covered. LCDs contain coding and utilization guidelines as well as descriptive passages.

• Each MAC may develop LCDs that expand on but do not contradict the NCD guidelines.
• They may also develop LCDs for services where there are no NCD guidelines.

Question 28

All LCDs must be written in a standard format and include:

Answer 28

• Indications
• Limitations of coverage
• Applicable CPT, HCPCS and ICD-10-CM codes

Question 29

Medical Necessity Software

Answer 29

• Many larger facilities use Medical Necessity software to screen for MN
• Software allows for reduction in costly errors for the facility
• Software also speeds up the process and makes it less labor intensive
• MN software applications are available through a variety of vendors and are quite costly
• Examples: 3M, Craneware, DCS Global, etc.

Question 30

Advance Beneficiary Notice

Answer 30

The Advanced Beneficiary Notice of Noncoverage (ABN), is issued by providers to Medicare beneficiaries in situations where Medicare payment is expected to be denied.