Certified Medical Coding Specialist Risk Assessment & Management 2 — Questions and Answers
Question 1: Which HCC (Hierarchical Condition Category) model is primarily used for Medicare Advantage risk adjustment?
- CMS-HCC Model (Correct answer)
- RxHCC Model
- CDPS Model
- ACG Model
Correct answer: CMS-HCC Model
The CMS-HCC model is the primary risk adjustment model used for Medicare Advantage plans to calculate risk scores.
Question 2: A patient is documented with 'possible' diabetes. Under ICD-10-CM outpatient guidelines, how should this be coded?
- Code the confirmed diabetes diagnosis
- Code only the signs and symptoms, not the uncertain diagnosis (Correct answer)
- Code 'possible' diabetes as confirmed
- Query the physician before coding
Correct 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.
Question 3: What is the primary purpose of a Hierarchical Condition Category (HCC) in risk adjustment?
- To determine hospital reimbursement rates
- To predict future healthcare costs based on diagnosis coding (Correct answer)
- To categorize surgical procedures
- To assign DRG weights for inpatient stays
Correct answer: To predict future healthcare costs based on diagnosis coding
HCCs group related diagnoses to predict expected healthcare expenditures for risk-adjusted capitation payments.
Question 4: Which of the following is NOT a valid method for a payer to validate risk adjustment data accuracy?
- RADV (Risk Adjustment Data Validation) audits
- Review of medical records
- Review of claims data
- Physician self-attestation alone (Correct answer)
Correct answer: Physician self-attestation alone
Physician self-attestation alone is not an accepted validation method; medical record documentation must support reported diagnoses.
Question 5: A coder documents a chronic condition that was monitored during an encounter but not treated. Should this condition be reported?
- No, only conditions actively treated should be coded
- Yes, chronic conditions that affect care should be reported even if not treated that visit (Correct answer)
- Only if the physician specifically lists it as a diagnosis
- Only if it affects the E/M level
Correct 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.
Question 6: In risk adjustment, what does the term 'prospective' risk adjustment mean?
- Payment is adjusted based on prior year's diagnoses to set current year capitation (Correct answer)
- Payment is adjusted after reviewing current year's utilization
- Diagnoses are coded after services are rendered
- Risk scores are calculated only at year end
Correct 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.
Question 7: Which document provides the most authoritative clinical evidence to support a risk-adjusted diagnosis code?
- The insurance claim form
- The signed physician progress note or visit documentation (Correct answer)
- The patient's self-reported health history
- The pharmacy prescription record
Correct 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.
Certified Medical Coding Specialist Risk Assessment & Management 2
Which HCC (Hierarchical Condition Category) model is primarily used for Medicare Advantage risk adjustment?