CRC - Certified Risk Adjustment Coder Risk Adjustment Models Overview Questions and Answers

Question 1

What is the primary purpose of risk adjustment models in the context of healthcare insurance?

Accepted Answer

To predict the health costs of individuals and populations to ensure fair payments to health plans for covering their members.

Answer

To penalize providers for inaccurate diagnosis coding.

Answer

To exclusively determine patient eligibility for specific government-sponsored health programs.

Answer

To replace the fee-for-service payment model entirely with a value-based system.

Question 2

A coder is reviewing a chart for a 72-year-old patient enrolled in a Medicare Advantage plan. The documentation supports diagnoses of diabetes and congestive heart failure. Which risk adjustment model would primarily be used to calculate the risk score for this encounter?

Accepted Answer

CMS-HCC (Centers for Medicare & Medicaid Services - Hierarchical Condition Category)

Answer

HHS-HCC (Health and Human Services - Hierarchical Condition Category)

Answer

CDPS (Chronic Illness and Disability Payment System)

Answer

D-SNP (Dual Eligible Special Needs Plan) Model

Question 3

Which of the following best describes a key difference between a prospective and a retrospective risk adjustment review?

Accepted Answer

Retrospective reviews focus on identifying and correcting documentation and coding issues from past encounters, while prospective reviews aim to address them at or before the point of care.

Answer

Prospective reviews occur after claims are submitted, while retrospective reviews happen before the patient encounter.

Answer

Only prospective reviews can be used for RADV audits.

Answer

Retrospective reviews use data from the current year to predict next year's costs, while prospective reviews use data from a base year to predict costs for the same year.

Question 4

The HHS-HCC risk adjustment model is considered a 'concurrent' model. What does this mean?

Accepted Answer

It uses diagnosis and demographic data from the current year to predict costs for the same year.

Answer

It uses diagnosis data from a previous year to predict costs for the current year.

Answer

It can only be used concurrently with the CMS-HCC model.

Answer

It requires concurrent approval from both the health plan and the provider before a risk score is finalized.

Question 5

Which of the following is a characteristic feature of the HHS-HCC model that is NOT present in the CMS-HCC model?

Accepted Answer

The inclusion of specific categories for infants and children, and the use of prescription drug categories (RxCs).

Answer

The use of Hierarchical Condition Categories (HCCs).

Answer

Inclusion of demographic factors like age and gender in risk score calculation.

Answer

It is used exclusively for patients in long-term institutional care.

Question 6

A risk adjustment coder identifies that a provider consistently fails to document the severity of malnutrition. This results in the assignment of a lower-weighted HCC and a lower risk score for these patients. What is the most appropriate action for the coder to take?

Accepted Answer

Communicate the documentation discrepancy to the provider and offer education on the specificity required for accurate risk adjustment coding.

Answer

Automatically assign the higher-weighted HCC based on lab values alone.

Answer

Report the provider to the Office of Inspector General (OIG) for fraud.

Answer

Ignore the issue as it is the provider's sole responsibility.