CRC Compliance and RADV Audits 2

Question 1

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?

Accepted Answer

HCC will be confirmed because diabetes with renal manifestations supports E11.22

Answer

Documentation of 'diabetes with renal manifestations' generally supports a diabetic kidney condition and E11.22.

Question 2

An MA plan discovers systematic upcoding of diabetes by a provider group. Under the False Claims Act, what element must be present for liability?

Accepted Answer

Knowledge of false claims or deliberate ignorance of their falsity

Answer

The FCA requires scienter: knowledge, deliberate ignorance, or reckless disregard. Specific intent to defraud is NOT required.

Question 3

Which documentation practice presents the highest RADV audit risk?

Accepted Answer

Submitting diagnosis codes from problem lists not addressed in encounter notes

Answer

Unaddressed problem list entries are the highest risk because RADV auditors look for evidence conditions were actively evaluated during the encounter.

Question 4

What is the primary purpose of the RADV Fee-for-Service Adjuster?

Accepted Answer

To account for coding errors in the FFS benchmark that inflate the comparison baseline

Answer

The FFS Adjuster recognizes that FFS Medicare also contains coding inaccuracies, leveling the playing field.

Question 5

A compliance officer identifies suspiciously high HCC 96 capture rates for a provider group. What is the appropriate first step?

Accepted Answer

Conduct a targeted chart audit of a sample of HCC 96 claims

Answer

A targeted chart audit determines whether the high rate reflects accurate coding or a problem. Investigation must precede corrective action.

(CRC) Certified Risk Adjustment Coder Practice Test

(CRC) Certified Risk Adjustment Coder Practice Test

CRC Compliance and RADV Audits 2