Certified Medical Coding Specialist Risk Assessment & Management 5

Question 1

A coder reviews a record where the physician documents 'diabetic neuropathy' but does not specify the type of diabetes. What is the correct coding approach?

Accepted Answer

Default to Type 2 diabetes with diabetic neuropathy, as Type 2 is the default when type is not specified

Answer

Per ICD-10-CM guidelines, when the type of diabetes is not documented, the default is Type 2 diabetes mellitus.

Question 2

Which of the following best describes the role of a 'suspect condition' in Medicare Advantage risk adjustment?

Accepted Answer

Suspect conditions cannot be submitted for risk adjustment; only confirmed diagnoses are valid

Answer

CMS requires confirmed diagnoses documented by a qualified provider; suspect or probable conditions cannot be submitted for Medicare Advantage risk adjustment.

Question 3

What is the primary compliance risk associated with 'chart-chasing' in risk adjustment?

Accepted Answer

It may result in coding diagnoses not supported by the current year's medical record documentation

Answer

Chart-chasing involves retrospectively reviewing records to find additional diagnoses, which can lead to coding conditions not validly documented in qualifying encounters.

Question 4

Which of the following is a key difference between HCC risk adjustment and traditional fee-for-service payment?

Accepted Answer

HCC risk adjustment pays a capitated rate adjusted by patient health status, while FFS pays per service rendered

Answer

HCC-based risk adjustment modifies per-member-per-month capitation payments based on predicted health costs from diagnosis data, unlike FFS per-procedure payment.

Question 5

A health plan conducts an internal audit and finds that 15% of submitted HCC diagnoses lack adequate medical record support. What is the most appropriate next step?

Accepted Answer

Delete all unsupported HCCs and resubmit corrected data to CMS

Answer

Compliance requires proactive correction and deletion of unsupported diagnoses with resubmission of accurate data to CMS to avoid False Claims Act liability.

Certified Medical Coding Specialist Practice Test

Certified Medical Coding Specialist Practice Test

Certified Medical Coding Specialist Risk Assessment & Management 5