Certified Medical Coding Specialist Risk Assessment & Management 3 — Questions and Answers
Question 1: Under CMS risk adjustment, which type of encounter is NOT typically used to capture diagnosis codes for HCC mapping?
- Annual wellness visits
- Inpatient hospital stays
- Emergency department visits
- Lab result reports without a face-to-face encounter (Correct answer)
Correct 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.
Question 2: A patient with Type 2 diabetes and diabetic chronic kidney disease stage 3 is seen. Which coding approach is correct?
- Code diabetes and CKD separately with no combination code
- Use the combination code for Type 2 diabetes with diabetic CKD, plus a code for CKD stage 3 (Correct answer)
- Code only the CKD as it is the more severe condition
- Code only the diabetes, as CKD is assumed
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.
Question 3: What is 'upcoding' in the context of risk adjustment fraud?
- Coding diagnoses to a higher severity or complexity than documented (Correct answer)
- Upgrading a code to the most current code set
- Adding secondary diagnoses to increase specificity
- Using the highest level E/M code available
Correct 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.
Question 4: Which federal program specifically audits Medicare Advantage organizations for risk adjustment data accuracy?
- OIG Work Plan
- RADV (Risk Adjustment Data Validation) (Correct answer)
- RAC (Recovery Audit Contractor) Program
- ZPIC (Zone Program Integrity Contractor)
Correct 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.
Question 5: 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?
- As a current acute MI
- As old myocardial infarction using the appropriate personal history code (Correct answer)
- It should not be coded at all
- As ischemic heart disease, unspecified
Correct 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.
Question 6: In risk adjustment, what is the significance of 'condition hierarchy' in HCC models?
- It ensures the most severe manifestation of a condition group is counted, preventing duplicate payment (Correct answer)
- It ranks physician specialties by coding authority
- It prioritizes inpatient codes over outpatient codes
- It determines which payer is primary
Correct 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.
Question 7: Which of the following best describes 'concurrent risk adjustment'?
- Adjusting payments based on the same year's diagnosis data as the payment year (Correct answer)
- Adjusting payments based on the prior year's diagnoses
- Adjusting payments after audits are completed
- Adjusting payments based on projected future diagnoses
Correct 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.
Certified Medical Coding Specialist Risk Assessment & Management 3
Under CMS risk adjustment, which type of encounter is NOT typically used to capture diagnosis codes for HCC mapping?