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
Under CMS risk adjustment, which type of encounter is NOT typically used to capture diagnosis codes for HCC mapping?
Answer: Lab result reports without a face-to-face encounter
Lab results alone without an associated face-to-face clinical encounter do not qualify as valid sources for risk adjustment diagnosis capture.
A patient with Type 2 diabetes and diabetic chronic kidney disease stage 3 is seen. Which coding approach is correct?
Answer: Use the combination code for Type 2 diabetes with diabetic CKD, plus a code for CKD stage 3
ICD-10-CM provides combination codes for diabetes with related complications; CKD stage should also be coded for specificity.
What is 'upcoding' in the context of risk adjustment fraud?
Answer: Coding diagnoses to a higher severity or complexity than documented
Upcoding means assigning codes that reflect greater severity or complexity than what is supported by medical record documentation.
Which federal program specifically audits Medicare Advantage organizations for risk adjustment data accuracy?
Answer: RADV (Risk Adjustment Data Validation)
CMS uses the RADV audit program to validate that diagnoses submitted by Medicare Advantage plans are supported by medical record documentation.
A provider documents 'history of MI' for a patient who had a myocardial infarction two years ago with no current symptoms. How should this be coded?
Answer: As old myocardial infarction using the appropriate personal history code
An MI that occurred more than four weeks ago is coded as old or healed MI using the personal history or old MI code, not as acute.
In risk adjustment, what is the significance of 'condition hierarchy' in HCC models?
Answer: It ensures the most severe manifestation of a condition group is counted, preventing duplicate payment
Condition hierarchy in HCC models prevents duplicate risk score credit by selecting only the highest-severity HCC within a disease category.
Which of the following best describes 'concurrent risk adjustment'?
Answer: Adjusting payments based on the same year's diagnosis data as the payment year
Concurrent risk adjustment uses the current payment year's diagnosis data to adjust payments within that same year.