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
A coder reviews a record where the physician documents 'diabetic neuropathy' but does not specify the type of diabetes. What is the correct coding approach?
Answer: Default to Type 2 diabetes with diabetic neuropathy, as Type 2 is the default when type is not specified
Per ICD-10-CM guidelines, when the type of diabetes is not documented, the default is Type 2 diabetes mellitus.
Which of the following best describes the role of a 'suspect condition' in Medicare Advantage risk adjustment?
Answer: Suspect conditions cannot be submitted for risk adjustment; only confirmed diagnoses are valid
CMS requires confirmed diagnoses documented by a qualified provider; suspect or probable conditions cannot be submitted for Medicare Advantage risk adjustment.
What is the primary compliance risk associated with 'chart-chasing' in risk adjustment?
Answer: It may result in coding diagnoses not supported by the current year's medical record documentation
Chart-chasing involves retrospectively reviewing records to find additional diagnoses, which can lead to coding conditions not validly documented in qualifying encounters.
Which of the following is a key difference between HCC risk adjustment and traditional fee-for-service payment?
Answer: HCC risk adjustment pays a capitated rate adjusted by patient health status, while FFS pays per service rendered
HCC-based risk adjustment modifies per-member-per-month capitation payments based on predicted health costs from diagnosis data, unlike FFS per-procedure payment.
A health plan conducts an internal audit and finds that 15% of submitted HCC diagnoses lack adequate medical record support. What is the most appropriate next step?
Answer: Delete all unsupported HCCs and resubmit corrected data to CMS
Compliance requires proactive correction and deletion of unsupported diagnoses with resubmission of accurate data to CMS to avoid False Claims Act liability.
Which ICD-10-CM code category is used to report body mass index (BMI) as an additional code in risk-relevant obesity documentation?
Answer: Z68 (Body mass index)
Category Z68 contains BMI codes that are reported as additional codes to support obesity diagnoses documented by the provider.
Under the CMS-HCC model, atherosclerotic coronary artery disease maps to an HCC. Which documentation element is essential for a coder to capture this condition for risk adjustment?
Answer: Physician documentation of coronary artery disease (CAD) or atherosclerosis of coronary artery in a qualifying encounter
Physician documentation of the confirmed diagnosis in a valid clinical encounter is required; ancillary test results or referrals alone do not suffice.