Certified Medical Coding Specialist Risk Assessment & Management 4

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?

Accepted Answer

Code CHF as principal and COPD as additional diagnosis since it affects management

Answer

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?

Accepted Answer

The HCC associated with that condition is not included in that year's risk score

Answer

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?

Accepted Answer

A chronic condition known from the record that was not coded in claims for the current year

Answer

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?

Accepted Answer

The False Claims Act (FCA)

Answer

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?

Accepted Answer

Query the physician to clarify the obesity classification

Answer

Coders should query the physician for clarification rather than making clinical determinations; the physician must document the specific obesity type.

Certified Medical Coding Specialist Practice Test

Certified Medical Coding Specialist Practice Test

Certified Medical Coding Specialist Risk Assessment & Management 4