Certified Medical Coding Specialist Risk Assessment & Management 2

Question 1

Which HCC (Hierarchical Condition Category) model is primarily used for Medicare Advantage risk adjustment?

Accepted Answer

CMS-HCC Model

Answer

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?

Accepted Answer

Code only the signs and symptoms, not the uncertain diagnosis

Answer

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?

Accepted Answer

To predict future healthcare costs based on diagnosis coding

Answer

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?

Accepted Answer

Physician self-attestation alone

Answer

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?

Accepted Answer

Yes, chronic conditions that affect care should be reported even if not treated that visit

Answer

Chronic conditions that are monitored, evaluated, or affect patient management should be reported per ICD-10-CM guidelines.

Certified Medical Coding Specialist Practice Test