Compliance and RADV Audits Flashcards
6 cards from real CRC practice questions. Tap to flip, then mark Knew It or Still Learning — missed cards come back until you master them.
Read the first 6 Compliance and RADV Audits flashcards as text
During a RADV audit, an auditor reviews HCC 18 based on code E11.22. The chart shows 'diabetes with renal manifestations' but no mention of CKD. What is the likely outcome?
Answer: HCC will be confirmed because diabetes with renal manifestations supports E11.22
Documentation of 'diabetes with renal manifestations' generally supports a diabetic kidney condition and E11.22.
An MA plan discovers systematic upcoding of diabetes by a provider group. Under the False Claims Act, what element must be present for liability?
Answer: Knowledge of false claims or deliberate ignorance of their falsity
The FCA requires scienter: knowledge, deliberate ignorance, or reckless disregard. Specific intent to defraud is NOT required.
Which documentation practice presents the highest RADV audit risk?
Answer: Submitting diagnosis codes from problem lists not addressed in encounter notes
Unaddressed problem list entries are the highest risk because RADV auditors look for evidence conditions were actively evaluated during the encounter.
What is the primary purpose of the RADV Fee-for-Service Adjuster?
Answer: To account for coding errors in the FFS benchmark that inflate the comparison baseline
The FFS Adjuster recognizes that FFS Medicare also contains coding inaccuracies, leveling the playing field.
A compliance officer identifies suspiciously high HCC 96 capture rates for a provider group. What is the appropriate first step?
Answer: Conduct a targeted chart audit of a sample of HCC 96 claims
A targeted chart audit determines whether the high rate reflects accurate coding or a problem. Investigation must precede corrective action.
Which encounter type is NOT acceptable for risk adjustment diagnosis submission?
Answer: Lab-only encounter with no face-to-face provider interaction
Lab-only encounters without face-to-face provider interaction do not qualify. CMS requires diagnoses from encounters where a provider directly evaluates the patient.