Certified Medical Coding Specialist Risk Assessment & Management 3

Question 1

Under CMS risk adjustment, which type of encounter is NOT typically used to capture diagnosis codes for HCC mapping?

Accepted Answer

Lab result reports without a face-to-face encounter

Answer

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?

Accepted Answer

Use the combination code for Type 2 diabetes with diabetic CKD, plus a code for CKD stage 3

Answer

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?

Accepted Answer

Coding diagnoses to a higher severity or complexity than documented

Answer

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?

Accepted Answer

RADV (Risk Adjustment Data Validation)

Answer

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?

Accepted Answer

As old myocardial infarction using the appropriate personal history code

Answer

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.

Certified Medical Coding Specialist Practice Test