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
When a patient is seen for management of congestive heart failure and is also noted to have COPD that is monitored, which ICD-10-CM guidelines apply?
Answer: Code CHF as principal and COPD as additional diagnosis since it affects management
Both conditions should be coded when coexisting conditions affect patient management or require clinical evaluation during the encounter.
A Medicare Advantage member's risk score is calculated annually. What happens if a chronic condition is NOT documented in an encounter within the data collection year?
Answer: The HCC associated with that condition is not included in that year's risk score
HCC-mapped diagnoses must be documented in a qualifying encounter within each payment year to be included in risk score calculations.
Which of the following is an example of a 'coding gap' in risk adjustment?
Answer: A chronic condition known from the record that was not coded in claims for the current year
A coding gap occurs when a clinically valid chronic condition exists but was not captured in claims data for the applicable risk adjustment period.
Which federal law imposes civil monetary penalties for knowingly submitting false risk adjustment data to Medicare Advantage?
Answer: The False Claims Act (FCA)
The False Claims Act allows the government to pursue civil penalties and treble damages for knowingly submitting false or fraudulent claims, including risk adjustment data.
A patient with morbid obesity (BMI 42) is seen. The physician documents 'obesity' without specifying morbid obesity. What should the coder do?
Answer: Query the physician to clarify the obesity classification
Coders should query the physician for clarification rather than making clinical determinations; the physician must document the specific obesity type.
In risk adjustment, what does 'risk score normalization' accomplish?
Answer: It adjusts average risk scores so they equal 1.0 across the enrolled population
Normalization calibrates risk scores so that the average risk score across the Medicare population equals 1.0, ensuring budget neutrality.
Which of the following clinical scenarios would result in assignment of an HCC for major depression?
Answer: Physician documents 'major depressive disorder, moderate' and prescribes an antidepressant
An HCC is assigned only when a qualified provider documents the diagnosis in a medical record from a valid clinical encounter.