CRC Prospective and Retrospective Risk Adjustment Strategies 2

Question 1

What is the key distinction between prospective and retrospective risk adjustment activities from a compliance standpoint?

Accepted Answer

Retrospective activities must be supported by face-to-face encounter documentation; prospective activities occur during live patient visits

Answer

Retrospective diagnoses must be supported by valid face-to-face encounter documentation; prospective activities capture diagnoses during actual patient encounters, making both compliant when properly documented.

Question 2

Which of the following is a risk associated with relying solely on retrospective chart reviews for risk adjustment?

Accepted Answer

Diagnoses found may lack face-to-face encounter documentation required by CMS

Answer

A key risk of retrospective reviews is discovering diagnoses in records that were never linked to a valid face-to-face encounter, which CMS requires for HCC capture under Medicare Advantage.

Question 3

Provider education is a critical component of prospective risk adjustment because it:

Accepted Answer

Ensures providers document the specificity and acuity of chronic conditions during patient encounters

Answer

Provider education in prospective risk adjustment focuses on teaching clinicians to document chronic conditions with appropriate specificity and acuity so that diagnoses are captured accurately during encounters.

Question 4

A health plan identifies that many of its members with COPD do not have a COPD diagnosis in their encounter data despite having inhalers on their pharmacy records. The BEST first step in a prospective strategy is to:

Accepted Answer

Work with providers to schedule these members for visits and ensure COPD is documented if clinically supported

Answer

The prospective approach is to engage providers to schedule affected members, confirm the diagnosis clinically, and ensure it is properly documented during a face-to-face encounter.

Question 5

In retrospective risk adjustment, what does 'medical record abstraction' involve?

Accepted Answer

Reviewing clinical records to identify diagnoses that support HCC capture and were not submitted via encounter data

Answer

Medical record abstraction in retrospective risk adjustment involves trained coders reviewing clinical documentation to identify HCC-relevant diagnoses that may not have been captured in the original encounter submission.

(CRC) Certified Risk Adjustment Coder Practice Test

(CRC) Certified Risk Adjustment Coder Practice Test

CRC Prospective and Retrospective Risk Adjustment Strategies 2