Certified Medical Coding Specialist Risk Assessment & Management 4 — Questions and Answers
Question 1: When a patient is seen for management of congestive heart failure and is also noted to have COPD that is monitored, which ICD-10-CM guidelines apply?
- Code only the principal diagnosis of CHF
- Code CHF as principal and COPD as additional diagnosis since it affects management (Correct answer)
- Code COPD first as it is a chronic condition
- Do not code COPD unless it was treated with medication changes
Correct answer: Code CHF as principal and COPD as additional diagnosis since it affects management
Both conditions should be coded when coexisting conditions affect patient management or require clinical evaluation during the encounter.
Question 2: A Medicare Advantage member's risk score is calculated annually. What happens if a chronic condition is NOT documented in an encounter within the data collection year?
- The condition continues to count toward the risk score from prior years
- The HCC associated with that condition is not included in that year's risk score (Correct answer)
- CMS automatically carries forward all chronic conditions
- The payer can estimate the score based on drug utilization
Correct answer: The HCC associated with that condition is not included in that year's risk score
HCC-mapped diagnoses must be documented in a qualifying encounter within each payment year to be included in risk score calculations.
Question 3: Which of the following is an example of a 'coding gap' in risk adjustment?
- A code assigned without physician documentation
- A chronic condition known from the record that was not coded in claims for the current year (Correct answer)
- A procedure code missing a required modifier
- A mismatch between ICD-9 and ICD-10 codes
Correct answer: A chronic condition known from the record that was not coded in claims for the current year
A coding gap occurs when a clinically valid chronic condition exists but was not captured in claims data for the applicable risk adjustment period.
Question 4: Which federal law imposes civil monetary penalties for knowingly submitting false risk adjustment data to Medicare Advantage?
- HIPAA Privacy Rule
- The False Claims Act (FCA) (Correct answer)
- The Affordable Care Act Section 1557
- The Stark Law
Correct answer: The False Claims Act (FCA)
The False Claims Act allows the government to pursue civil penalties and treble damages for knowingly submitting false or fraudulent claims, including risk adjustment data.
Question 5: A patient with morbid obesity (BMI 42) is seen. The physician documents 'obesity' without specifying morbid obesity. What should the coder do?
- Assign morbid obesity code based on the BMI documentation
- Assign only the 'obesity, unspecified' code based on the physician's documentation
- Query the physician to clarify the obesity classification (Correct answer)
- Assign both obesity and morbid obesity codes
Correct answer: Query the physician to clarify the obesity classification
Coders should query the physician for clarification rather than making clinical determinations; the physician must document the specific obesity type.
Question 6: In risk adjustment, what does 'risk score normalization' accomplish?
- It adjusts average risk scores so they equal 1.0 across the enrolled population (Correct answer)
- It converts ICD-9 codes to ICD-10 codes
- It removes outlier high-cost patients from calculations
- It standardizes coding across all providers
Correct answer: It adjusts average risk scores so they equal 1.0 across the enrolled population
Normalization calibrates risk scores so that the average risk score across the Medicare population equals 1.0, ensuring budget neutrality.
Question 7: Which of the following clinical scenarios would result in assignment of an HCC for major depression?
- Patient reports feeling sad occasionally with no formal diagnosis
- Physician documents 'major depressive disorder, moderate' and prescribes an antidepressant (Correct answer)
- Billing department adds depression based on antidepressant prescription alone
- Patient's PHQ-9 score indicates depression without physician diagnosis
Correct answer: Physician documents 'major depressive disorder, moderate' and prescribes an antidepressant
An HCC is assigned only when a qualified provider documents the diagnosis in a medical record from a valid clinical encounter.
Certified Medical Coding Specialist Risk Assessment & Management 4
When a patient is seen for management of congestive heart failure and is also noted to have COPD that is monitored, which ICD-10-CM guidelines apply?