CRC Encounter Data Submission and Processing 2

Question 1

When submitting encounter data, MA plans must include which key element for risk adjustment purposes?

Accepted Answer

ICD-10-CM diagnosis codes with date of service

Answer

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?

Accepted Answer

A retrospective review of medical records to identify diagnoses that support or should be added to encounter data

Answer

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?

Accepted Answer

A from date, through date, provider type, and valid ICD-10-CM code

Answer

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?

Accepted Answer

Outpatient visits where chronic conditions are assessed, monitored, and treated

Answer

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?

Accepted Answer

It establishes that the diagnosis was treated in the applicable data collection year

Answer

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.

(CRC) Certified Risk Adjustment Coder Practice Test

(CRC) Certified Risk Adjustment Coder Practice Test

CRC Encounter Data Submission and Processing 2