Risk Assessment & Management Flashcards
7 cards from real Certified Medical Coding Specialist practice questions. Tap to flip, then mark Knew It or Still Learning — missed cards come back until you master them.
Read the first 7 Risk Assessment & Management flashcards as text
Which HCC (Hierarchical Condition Category) model is primarily used for Medicare Advantage risk adjustment?
Answer: CMS-HCC Model
The CMS-HCC model is the primary risk adjustment model used for Medicare Advantage plans to calculate risk scores.
A patient is documented with 'possible' diabetes. Under ICD-10-CM outpatient guidelines, how should this be coded?
Answer: Code only the signs and symptoms, not the uncertain diagnosis
For outpatient encounters, uncertain diagnoses such as 'possible' or 'probable' are not coded; only signs and symptoms are coded.
What is the primary purpose of a Hierarchical Condition Category (HCC) in risk adjustment?
Answer: To predict future healthcare costs based on diagnosis coding
HCCs group related diagnoses to predict expected healthcare expenditures for risk-adjusted capitation payments.
Which of the following is NOT a valid method for a payer to validate risk adjustment data accuracy?
Answer: Physician self-attestation alone
Physician self-attestation alone is not an accepted validation method; medical record documentation must support reported diagnoses.
A coder documents a chronic condition that was monitored during an encounter but not treated. Should this condition be reported?
Answer: Yes, chronic conditions that affect care should be reported even if not treated that visit
Chronic conditions that are monitored, evaluated, or affect patient management should be reported per ICD-10-CM guidelines.
In risk adjustment, what does the term 'prospective' risk adjustment mean?
Answer: Payment is adjusted based on prior year's diagnoses to set current year capitation
Prospective risk adjustment uses prior year diagnosis data to set the current year's capitation payment rates.
Which document provides the most authoritative clinical evidence to support a risk-adjusted diagnosis code?
Answer: The signed physician progress note or visit documentation
Signed physician documentation in the medical record is the gold standard for supporting risk-adjusted diagnosis codes.