CRC Prospective and Retrospective Risk Adjustment Strategies 3

Question 1

Under CMS rules, which type of provider is authorized to document diagnoses that qualify for HCC submission in Medicare Advantage?

Accepted Answer

Physicians, nurse practitioners, physician assistants, and other qualified non-physician practitioners

Answer

Any healthcare worker documenting in the medical record

Answer

Only Medicare-certified hospital facilities

Answer

Only primary care physicians enrolled in Medicare

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:

Accepted Answer

Code only the presenting signs and symptoms, not the 'possible' diagnosis

Answer

Code CHF as confirmed since the physician wrote it in the assessment

Answer

Query the physician to confirm or rule out the diagnosis before coding

Answer

Code CHF with an uncertain diagnosis modifier

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:

Accepted Answer

Add a query to the physician and await documentation before submitting

Answer

Code the calculated CKD stage since the clinical evidence supports it

Answer

Not code CKD — coders cannot determine stage from lab values alone without physician documentation

Answer

Submit CKD unspecified and note the lab values in the submission

Question 4

Which of the following correctly describes a 'sweep' in the context of Medicare Advantage risk adjustment data submission?

Accepted Answer

A scheduled CMS processing run that incorporates newly submitted encounter data into risk score calculations

Answer

A CMS audit of plan-submitted encounter data for compliance purposes

Answer

A health plan's internal review of all submitted diagnoses for accuracy

Answer

A CMS process to remove outdated diagnoses from the risk score model

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?

Accepted Answer

Chronic conditions present in the member population are not being adequately documented and submitted

Answer

Members are healthier than the national average

Answer

The plan is overcoding diagnoses relative to CMS benchmarks

Answer

The plan's premium payments are higher than expected

Question 6

Which of the following is the MOST important compliance principle for health plans using third-party vendors to conduct retrospective chart reviews?

Accepted Answer

The health plan remains responsible for the accuracy and compliance of all submitted diagnoses, regardless of vendor actions

Answer

Vendors must be paid on a per-diagnosis-found basis to ensure thoroughness

Answer

Vendors are solely responsible for any coding errors or fraud found in their submissions

Answer

CMS requires all chart reviews to be conducted by the health plan's internal staff

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:

Accepted 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

Answer

Automatically add all listed HCC diagnoses to the encounter without clinical assessment

Answer

Return the report to the health plan without review since it is not part of the medical record

Answer

Bill for each listed HCC diagnosis to capture the risk score revenue