CRC Prospective and Retrospective Risk Adjustment Strategies 3 — Questions and Answers
Question 1: Under CMS rules, which type of provider is authorized to document diagnoses that qualify for HCC submission in Medicare Advantage?
- Any healthcare worker documenting in the medical record
- Only Medicare-certified hospital facilities
- Physicians, nurse practitioners, physician assistants, and other qualified non-physician practitioners (Correct answer)
- Only primary care physicians enrolled in Medicare
Correct answer: Physicians, nurse practitioners, physician assistants, and other qualified non-physician practitioners
CMS accepts diagnoses from physicians and other qualified non-physician practitioners (e.g., NPs, PAs) who are authorized to diagnose under state law and treat within the Medicare program.
Question 2: When conducting a retrospective chart review, a coder finds a diagnosis of 'possible CHF' in the physician's assessment. Under ICD-10-CM guidelines for outpatient coding, this coder should:
- Code CHF as confirmed since the physician wrote it in the assessment
- Code only the presenting signs and symptoms, not the 'possible' diagnosis (Correct answer)
- Query the physician to confirm or rule out the diagnosis before coding
- Code CHF with an uncertain diagnosis modifier
Correct answer: Code only the presenting signs and symptoms, not the 'possible' diagnosis
For outpatient/physician encounters, ICD-10-CM guidelines prohibit coding diagnoses qualified as 'possible,' 'probable,' or 'suspected'; only signs and symptoms should be coded.
Question 3: A retrospective coding program identifies that a patient's chronic kidney disease (CKD) stage was not documented by the provider in any encounter. The coder calculates the stage from lab values in the chart. The coder should:
- Code the calculated CKD stage since the clinical evidence supports it
- Not code CKD — coders cannot determine stage from lab values alone without physician documentation
- Add a query to the physician and await documentation before submitting (Correct answer)
- Submit CKD unspecified and note the lab values in the submission
Correct answer: Add a query to the physician and await documentation before submitting
Coders cannot assign specificity beyond what the physician has documented; a query should be sent to the provider to confirm and document the CKD stage before it is coded and submitted.
Question 4: Which of the following correctly describes a 'sweep' in the context of Medicare Advantage risk adjustment data submission?
- A CMS audit of plan-submitted encounter data for compliance purposes
- A scheduled CMS processing run that incorporates newly submitted encounter data into risk score calculations (Correct answer)
- A health plan's internal review of all submitted diagnoses for accuracy
- A CMS process to remove outdated diagnoses from the risk score model
Correct answer: A scheduled CMS processing run that incorporates newly submitted encounter data into risk score calculations
A 'sweep' refers to a scheduled CMS processing run in which recently submitted encounter data is incorporated into the risk score calculation, with multiple sweeps occurring throughout the payment year.
Question 5: A health plan calculates its 'HCC capture rate' as part of its risk adjustment program. What does a low HCC capture rate indicate?
- Members are healthier than the national average
- The plan is overcoding diagnoses relative to CMS benchmarks
- Chronic conditions present in the member population are not being adequately documented and submitted (Correct answer)
- The plan's premium payments are higher than expected
Correct answer: Chronic conditions present in the member population are not being adequately documented and submitted
A low HCC capture rate indicates that chronic conditions expected based on member demographics and clinical indicators are not being documented and submitted, suggesting gaps in the prospective or retrospective coding process.
Question 6: Which of the following is the MOST important compliance principle for health plans using third-party vendors to conduct retrospective chart reviews?
- Vendors must be paid on a per-diagnosis-found basis to ensure thoroughness
- The health plan remains responsible for the accuracy and compliance of all submitted diagnoses, regardless of vendor actions (Correct answer)
- Vendors are solely responsible for any coding errors or fraud found in their submissions
- CMS requires all chart reviews to be conducted by the health plan's internal staff
Correct answer: The health plan remains responsible for the accuracy and compliance of all submitted diagnoses, regardless of vendor actions
Health plans are ultimately responsible for the accuracy and compliance of all risk adjustment data submitted to CMS, even when third-party vendors conduct chart reviews on their behalf.
Question 7: In a prospective risk adjustment program, a provider receives a 'HCC gap report' prior to a patient's annual wellness visit. The provider's APPROPRIATE use of this report is to:
- Automatically add all listed HCC diagnoses to the encounter without clinical assessment
- Use the report as a clinical prompt to review and assess each listed condition during the visit, documenting only those confirmed as current and active (Correct answer)
- Return the report to the health plan without review since it is not part of the medical record
- Bill for each listed HCC diagnosis to capture the risk score revenue
Correct answer: Use the report as a clinical prompt to review and assess each listed condition during the visit, documenting only those confirmed as current and active
HCC gap reports are clinical prompts to help providers remember to assess and document chronic conditions; providers must clinically evaluate each condition and document only those that are current, active, and confirmed.
CRC Prospective and Retrospective Risk Adjustment Strategies 3
Under CMS rules, which type of provider is authorized to document diagnoses that qualify for HCC submission in Medicare Advantage?