CRC - Certified Risk Adjustment Coder Compliance and RADV Audits Questions and Answers

Question 1

A Medicare Advantage organization knowingly encourages its network providers to add diagnoses to patient encounters that are not clinically supported, with the primary goal of increasing risk scores. This practice could expose the organization to significant penalties under which federal law?

Accepted Answer

The False Claims Act (FCA)

Answer

The False Claims Act (FCA) imposes liability on persons and companies who defraud governmental programs. Knowingly submitting unsupported diagnoses to obtain higher risk-adjusted payments from Medicare is a violation of the FCA, as it constitutes submitting a false claim for payment.

Question 2

During a CMS-RADV audit, the error rate identified in the sample of 200 members is used to calculate a total recovery amount for the entire health plan contract. What is this statistical process called?

Accepted Answer

Extrapolation

Answer

Extrapolation is the statistical method used in RADV audits to project the payment error found in a small sample of members across the entire contract. This allows CMS to recover improper payments for the whole contract, not just for the members whose records were reviewed.

Question 3

A coder is preparing records for a RADV audit. For an audited HCC of Major Depressive Disorder, the coder finds a signed outpatient progress note from the correct date of service. The note lists 'Major Depressive Disorder' in the assessment, and the plan section states 'Continue Sertraline 50mg daily. Follow up in 3 months.' Which of the following best describes why this documentation is likely sufficient?

Accepted Answer

It meets the MEAT (Monitor, Evaluate, Assess, Treat) criteria.

Answer

This documentation supports the diagnosis by meeting the MEAT criteria. The Assessment ('Major Depressive Disorder') and Treatment ('Continue Sertraline 50mg') are clearly documented, showing the condition was actively managed during the encounter, which is a requirement for RADV validation.

Question 4

Which of the following documents is generally considered the MOST reliable and acceptable source to validate an HCC during a RADV audit?

Accepted Answer

A signed, face-to-face outpatient progress note from the year of service.

Answer

RADV audits require that diagnoses be supported by documentation from a face-to-face encounter with an acceptable provider type within the specified data collection period. A signed progress note from the relevant year provides the necessary direct evidence of the provider's assessment and management of the condition.

Question 5

A health plan receives a RADV audit notification for a specific enrollee and HCC. Upon internal review, the coder cannot find any documentation to support the submitted HCC for the specified date of service. However, the coder does find a well-documented, risk-adjusting diagnosis from that same encounter that was never submitted. What is the most appropriate next step?

Accepted Answer

Submit the record and use the newly found diagnosis to offset the deletion.

Answer

In both CMS and HHS-RADV audits, health plans can submit documentation that supports other valid HCCs from the audited encounter. While the original HCC will be found in error, the newly identified and validated HCC can offset the financial impact of the deletion.

(CRC) Certified Risk Adjustment Coder Practice Test

(CRC) Certified Risk Adjustment Coder Practice Test

CRC - Certified Risk Adjustment Coder Compliance and RADV Audits Questions and Answers