CRC Prospective and Retrospective Risk Adjustment Strategies

Question 1

Which risk adjustment strategy involves reviewing medical records AFTER the date of service to identify and submit diagnoses that support HCC capture?

Accepted Answer

Retrospective coding

Answer

Retrospective coding involves reviewing medical records after services have been rendered to identify diagnoses and submit them to improve risk score accuracy.

Question 2

A health plan conducts annual wellness visits with structured questionnaires to ensure chronic conditions are captured before the coding year ends. This is an example of which strategy?

Accepted Answer

Prospective risk adjustment

Answer

Prospective risk adjustment involves activities conducted during or before the date of service to ensure conditions are documented and coded in the current benefit year.

Question 3

What is the primary goal of a 'chase program' in risk adjustment?

Accepted Answer

To identify members with suspected undocumented conditions and prompt provider outreach

Answer

A chase program identifies members who likely have chronic conditions based on claims or pharmacy data but lack supporting face-to-face documentation, then prompts provider outreach to close those gaps.

Question 4

Supplemental data sources used in retrospective risk adjustment most commonly include which of the following?

Accepted Answer

Medical records, lab data, and pharmacy data reviewed outside the normal claims flow

Answer

Supplemental data sources include medical records, lab results, and pharmacy data that are reviewed outside the traditional encounter data submission flow to capture additional diagnoses.

Question 5

Under Medicare Advantage risk adjustment, what is the diagnosis submission deadline for the prior benefit year under the retrospective data submission timeline?

Accepted Answer

March 31 of the current year

Answer

CMS requires that diagnoses from the prior benefit year be submitted via encounter data by March 31 of the current payment year for inclusion in the final risk score reconciliation.

(CRC) Certified Risk Adjustment Coder Practice Test

(CRC) Certified Risk Adjustment Coder Practice Test

CRC Prospective and Retrospective Risk Adjustment Strategies