CRC Encounter Data Submission and Processing 2 — Questions and Answers
Question 1: When submitting encounter data, MA plans must include which key element for risk adjustment purposes?
- Patient's insurance premium amount
- ICD-10-CM diagnosis codes with date of service (Correct answer)
- Provider's home address
- Patient's credit score
Correct answer: ICD-10-CM diagnosis codes with date of service
ICD-10-CM diagnosis codes paired with dates of service are the critical elements that drive risk score calculations in encounter data submissions.
Question 2: What is 'chart review' in the context of risk adjustment data validation?
- A provider reviewing patient charts for medical accuracy only
- A retrospective review of medical records to identify diagnoses that support or should be added to encounter data (Correct answer)
- An audit of billing records for fraud detection only
- A quality measure assessment
Correct answer: A retrospective review of medical records to identify diagnoses that support or should be added to encounter data
Chart reviews involve retrospectively reviewing medical records to identify all documented diagnoses that should be reflected in encounter data submissions for accurate risk scoring.
Question 3: What does an 'acceptable diagnosis cluster' in RAPS submissions require?
- At least three related diagnoses submitted together
- A from date, through date, provider type, and valid ICD-10-CM code (Correct answer)
- Diagnoses submitted in alphabetical order
- Only primary diagnoses
Correct answer: A from date, through date, provider type, and valid ICD-10-CM code
A valid RAPS diagnosis cluster requires specific elements including service dates, provider type, and an ICD-10-CM code for the submission to be accepted.
Question 4: Which type of provider encounter is MOST critical to capture for risk adjustment purposes?
- Emergency visits for acute minor conditions
- Outpatient visits where chronic conditions are assessed, monitored, and treated (Correct answer)
- Preventive screenings with no diagnoses
- Administrative visits
Correct answer: Outpatient visits where chronic conditions are assessed, monitored, and treated
Outpatient visits where chronic conditions are documented, assessed, and managed are the highest-value encounters for risk adjustment because they capture ongoing HCC-qualifying diagnoses.
Question 5: What is the significance of the 'date of service' in encounter data for risk adjustment?
- It determines the provider's payment rate
- It establishes that the diagnosis was treated in the applicable data collection year (Correct answer)
- It affects the patient's deductible
- It determines the formulary tier for drugs
Correct answer: It establishes that the diagnosis was treated in the applicable data collection year
The date of service in encounter data confirms that a diagnosis was treated within the applicable data collection year, making it eligible for that year's risk score calculation.
Question 6: What is the 'face-to-face' requirement in risk adjustment documentation?
- In-person meetings between plan and CMS officials
- The requirement that diagnoses be documented during an in-person or qualifying telehealth encounter with a provider (Correct answer)
- A requirement for provider network meetings
- A CMS audit procedure
Correct answer: The requirement that diagnoses be documented during an in-person or qualifying telehealth encounter with a provider
Risk adjustment regulations require diagnoses to be documented during face-to-face or qualifying telehealth encounters with eligible providers — administrative-only documentation is insufficient.
CRC Encounter Data Submission and Processing 2
When submitting encounter data, MA plans must include which key element for risk adjustment purposes?