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

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:

Accepted Answer

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

Answer

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:

Accepted Answer

Add a query to the physician and await documentation before submitting

Answer

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?

Accepted Answer

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

Answer

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?

Accepted Answer

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

Answer

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.

(CRC) Certified Risk Adjustment Coder Practice Test

(CRC) Certified Risk Adjustment Coder Practice Test

CRC Prospective and Retrospective Risk Adjustment Strategies 3