CRC - Certified Risk Adjustment Coder Exam — Questions and Answers

Question 1: The discharge summary says 'acute kidney injury' while the nephrology consultation documents 'acute on chronic kidney disease stage 3.' Which documentation should drive CDI action?

Both should be coded separately
A CDI query should reconcile the conflicting documentation (Correct answer)
Nephrology consultation takes precedence as specialist
Discharge summary always takes precedence

Correct answer: A CDI query should reconcile the conflicting documentation

Conflicting documentation requires reconciliation by the attending physician.

Question 2: Which system does CMS use to process and validate encounter data submitted by Medicare Advantage plans?

EDS (Encounter Data System) (Correct answer)
PECOS
FISS (Fiscal Intermediary Shared System)
NPPES

Correct answer: EDS (Encounter Data System)

CMS uses the Encounter Data System (EDS) to process, validate, and store encounter data submitted by Medicare Advantage organizations.

Question 3: 12% of submitted codes come from encounters where the provider specialty does not typically diagnose the condition. What does this suggest?

All such codes should be retroactively removed
This is normal since any provider can document any diagnosis
The finding warrants investigation for possible copy-forward artifacts (Correct answer)
These encounters should be excluded from submission

Correct answer: The finding warrants investigation for possible copy-forward artifacts

Provider specialty-diagnosis mismatches warrant investigation but are not automatically invalid. Common causes include copy-forward of problem lists.

Question 4: What is the Rx-HCC model, and how does it relate to CMS-HCC?

Rx-HCC replaced CMS-HCC for all payment
Rx-HCC is CMS-HCC applied to pharmacy claims
Rx-HCC is used for specialty pharmacy prior authorization
Rx-HCC is a separate model for Part D prescription drug payment, with its own HCC categories calibrated for drug costs (Correct answer)

Correct answer: Rx-HCC is a separate model for Part D prescription drug payment, with its own HCC categories calibrated for drug costs

RxHCC uses the same diagnosis codes but maps them to categories predicting prescription drug costs rather than medical costs.

Question 5: A compliance officer for a Medicare Advantage plan is developing a proactive strategy to prepare for annual RADV audits. Which of the following activities is most crucial for minimizing compliance risk?

Sending a monthly newsletter of coding tips to all network providers.
Purchasing the newest edition of the ICD-10-CM codebook for all coders.
Ensuring the plan's member services phone number is easy to find.
Conducting regular internal mock audits on high-risk HCCs. (Correct answer)

Correct answer: Conducting regular internal mock audits on high-risk HCCs.

Conducting regular internal mock RADV audits allows the plan to proactively identify and address documentation and coding vulnerabilities before an official audit occurs. Focusing on high-risk or commonly flagged HCCs (like major depression, vascular disease, and diabetes with complications) is a key part of an effective compliance program.

Question 6: A CDI specialist reviews a chart where the physician documents 'CHF' without further specification. Which query would be most effective for risk adjustment?

Is the heart failure systolic, diastolic, or combined?
What is the heart failure type, acuity, and current severity class? (Correct answer)
Does the patient have acute or chronic heart failure?
Should we code I50.9 for unspecified heart failure?

Correct answer: What is the heart failure type, acuity, and current severity class?

An effective CDI query should address all specificity elements: type, acuity, and severity. This avoids multiple follow-ups.

Question 7: Which regulatory body has primary authority over Medicare Advantage risk adjustment compliance?

State insurance departments
The Department of Justice exclusively
CMS through its Center for Program Integrity (Correct answer)
AHIP as industry self-regulatory body

Correct answer: CMS through its Center for Program Integrity

CMS/CPI administers RADV, sets data submission requirements, and enforces compliance. DOJ may pursue FCA cases, but CMS is primary.

Question 8: An MA plan receives a qui tam complaint alleging risk adjustment fraud. What protections does the whistleblower have?

Protection only if currently employed
Protection from retaliation, 15-30% of government recovery, and right to participate in proceedings (Correct answer)
Automatic immunity from personal liability
No protections

Correct answer: Protection from retaliation, 15-30% of government recovery, and right to participate in proceedings

The FCA provides anti-retaliation protection, a financial share of recovery, and the right to participate in litigation.

Question 9: An addendum is added 45 days after the original encounter. Under what conditions is this acceptable for risk adjustment?

All addenda are automatically acceptable
Acceptable if it clarifies the original note, is signed and dated, and the original supports a face-to-face evaluation (Correct answer)
Addenda older than 24 hours are never acceptable
Acceptable only if added before claim submission

Correct answer: Acceptable if it clarifies the original note, is signed and dated, and the original supports a face-to-face evaluation

Late addenda can be acceptable if they meet documentation integrity standards and the original note supports a qualifying encounter.

Question 10: A CDI program is implementing risk adjustment-focused outpatient reviews. Which approach is most effective for condition capture?

Focus on patients with known chronic conditions whose annual wellness visits are approaching (Correct answer)
Only review encounters for patients with low RAF scores
Review every encounter for every patient
Limit reviews to specialist encounters

Correct answer: Focus on patients with known chronic conditions whose annual wellness visits are approaching

Targeting patients with chronic conditions around annual wellness visits maximizes impact with focused resources.

Question 11: A CDI team finds query response rate dropped from 85% to 60%. Which strategy is most likely to improve physician engagement?

Redesign queries to be more specific with clinical indicators and response checkboxes (Correct answer)
Reduce queries to only target high-value HCC conditions
Implement mandatory query response requirements with consequences
Switch from concurrent to retrospective queries

Correct answer: Redesign queries to be more specific with clinical indicators and response checkboxes

Improving query design with specific clinical indicators and easy response formats is the most effective strategy.

Question 12: A provider documents 'paraplegia secondary to old T12 spinal cord injury' from 8 years ago. How should this be coded?

T91.3XXS Sequela of injury of spinal cord
G82.20 and S34.109S for both current condition and cause (Correct answer)
G82.20 Paraplegia, unspecified
S34.109S Injury of lumbar spinal cord, sequela

Correct answer: G82.20 and S34.109S for both current condition and cause

Both the current functional deficit (G82.20) and the sequela code for the cause should be coded. Paraplegia maps to HCC 70.

Question 13: Which risk adjustment strategy involves reviewing medical records AFTER the date of service to identify and submit diagnoses that support HCC capture?

Concurrent coding
Predictive modeling
Prospective coding
Retrospective coding (Correct answer)

Correct answer: Retrospective coding

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

Question 14: What is the primary purpose of using predictive analytics in a risk adjustment program?

A To replace the need for certified coders with automated systems.
D To calculate the final risk adjustment payment from CMS for the entire health plan.
B To automatically add diagnosis codes to claims based on lab values.
C To identify and prioritize members with the highest likelihood of having undocumented, risk-adjusting conditions for review. (Correct answer)

Correct answer: C To identify and prioritize members with the highest likelihood of having undocumented, risk-adjusting conditions for review.

The core function of predictive analytics in risk adjustment is to efficiently sift through vast amounts of data to forecast which members are most likely to have active, but uncaptured, HCCs. This allows the organization to prioritize its resources, such as chart reviews and provider queries, on the cases with the highest probability of yielding accurate and complete coding. [4, 6, 12]

Question 15: A provider documents 'acute exacerbation of chronic systolic heart failure.' What is the correct code?

I50.9 Heart failure, unspecified
I50.21 Acute systolic heart failure
I50.23 Acute on chronic systolic heart failure (Correct answer)
I50.22 Chronic systolic heart failure

Correct answer: I50.23 Acute on chronic systolic heart failure

I50.23 captures both the chronic nature and the acute episode in a single combination code.

Question 16: Why must MA plans track and resolve encounter data rejections promptly?

To satisfy state insurance department requirements
To maintain HEDIS scores
To ensure all diagnoses are captured in risk adjustment calculations and payments are accurate (Correct answer)
To avoid provider contract penalties

Correct answer: To ensure all diagnoses are captured in risk adjustment calculations and payments are accurate

Unresolved encounter data rejections mean diagnoses are not counted in risk adjustment, potentially resulting in underpayment to the plan and incomplete member health profiles.

Question 17: In encounter data submission, what does '837P' refer to?

Professional claims format used for physician services (Correct answer)
Dental claims format
Pharmacy claims format
Institutional claims format for hospitals

Correct answer: Professional claims format used for physician services

The 837P is the ANSI X12 electronic transaction format for professional physician services claims and encounter data submissions.

Question 18: An automated coding system assigns HCC codes without provider documentation review. Which OIG compliance element has failed?

Internal monitoring and auditing (Correct answer)
Designated compliance officer oversight
Written policies and procedures
Corrective action procedures

Correct answer: Internal monitoring and auditing

Internal monitoring and auditing failed because the organization did not detect the automated system was assigning codes without documentation verification.

Question 19: When is it appropriate to assign a diagnosis code for a condition that no longer exists?

Only when patient requests
If the condition is documented as current (Correct answer)
Whenever symptoms were once present
Always, regardless of relevance

Correct answer: If the condition is documented as current

Diagnosis codes should only be assigned for conditions that are actively present and documented as current during the patient encounter. If a condition no longer exists or is resolved, it should not be coded unless it has residual effects that are still being managed. Accurate coding relies on the medical record clearly indicating the current status of the condition.

Question 20: Why is accurate medical record documentation essential in risk adjustment coding?

To fill out claim forms
To avoid follow-up care
To speed up coding reviews
To support diagnoses and coding validity (Correct answer)

Correct answer: To support diagnoses and coding validity

Accurate and thorough medical record documentation is the cornerstone of valid risk adjustment coding. It provides the essential clinical evidence needed to justify the reported diagnoses and procedures. Without clear, comprehensive documentation, the validity of coded information cannot be supported, which can lead to compliance issues and inaccurate risk scores.

Question 21: A patient has rheumatoid arthritis affecting both hands with rheumatoid nodules and rheumatoid lung disease. What codes are needed?

M05.441 and M05.442 for RA with nodules of both hands
M05.441, M05.442, and M05.10 for hands with lung involvement (Correct answer)
M06.09 for RA of multiple sites
M05.441, M05.442, and J99

Correct answer: M05.441, M05.442, and M05.10 for hands with lung involvement

RA with nodules needs laterality-specific codes for each hand, plus M05.10 for lung involvement as a separate manifestation.

Question 22: What role do 'payment condition counts' play in newer CMS-HCC versions?

They reduce payment for members with too few conditions
They add incremental payment for members with many HCCs, reflecting disproportionately higher costs of complex patients (Correct answer)
They count total ICD-10-CM codes submitted
They track how many times a condition is submitted

Correct answer: They add incremental payment for members with many HCCs, reflecting disproportionately higher costs of complex patients

Payment condition counts recognize that patients with many concurrent HCCs have costs exceeding the sum of individual weights.

Question 23: A risk adjustment coder identifies that a provider consistently fails to document the severity of malnutrition. This results in the assignment of a lower-weighted HCC and a lower risk score for these patients. What is the most appropriate action for the coder to take?

Communicate the documentation discrepancy to the provider and offer education on the specificity required for accurate risk adjustment coding. (Correct answer)
Report the provider to the Office of Inspector General (OIG) for fraud.
Automatically assign the higher-weighted HCC based on lab values alone.
Ignore the issue as it is the provider's sole responsibility.

Correct answer: Communicate the documentation discrepancy to the provider and offer education on the specificity required for accurate risk adjustment coding.

A key role of a CRC is to identify and address documentation deficiencies. The appropriate step is to engage in provider education to improve the quality and specificity of the clinical documentation, ensuring it accurately reflects the patient's health status for proper coding and risk score calculation.

Question 24: What federal agency enforces healthcare fraud and abuse laws?

IRS
NIH
DEA
OIG (Correct answer)

Correct answer: OIG

The Office of Inspector General (OIG) within the U.S. Department of Health and Human Services (HHS) is the federal agency primarily responsible for enforcing healthcare fraud and abuse laws. The OIG conducts audits, investigations, and evaluations to combat waste, fraud, and abuse in Medicare, Medicaid, and other HHS programs. Its mission is to protect the integrity of these vital healthcare programs.

Question 25: Which of the following statements is TRUE regarding the coding of chronic conditions for risk adjustment purposes?

Chronic conditions should only be coded once when they are first diagnosed.
A chronic condition can be coded from a problem list without being addressed during the encounter.
Only chronic conditions that are the primary reason for the visit should be coded.
All co-existing chronic conditions that affect patient care can be reported annually. (Correct answer)

Correct answer: All co-existing chronic conditions that affect patient care can be reported annually.

For risk adjustment, all current co-existing chronic conditions that affect the care and management of a patient should be documented and reported at least once each calendar year. This ensures an accurate representation of the patient's health status and risk score.

Question 26: What is considered an example of upcoding?

Reporting accurate conditions
Omitting a resolved condition
Reporting a more severe diagnosis than supported (Correct answer)
Using unspecified codes

Correct answer: Reporting a more severe diagnosis than supported

Upcoding is a fraudulent practice where a healthcare provider intentionally submits a claim for a more complex or severe diagnosis or procedure than what was actually performed or documented in the medical record. This unethical practice leads to higher reimbursement than what is legitimately deserved, making it a serious violation of healthcare regulations and a target for fraud enforcement.

Question 27: An EHR assessment section contains 20+ conditions on the problem list but the plan section only addresses 5. Which conditions can be coded for risk adjustment?

All 20+ conditions on the problem list
All conditions ever treated
Only the 5 conditions addressed in the plan section (Correct answer)
Only conditions appearing in both sections

Correct answer: Only the 5 conditions addressed in the plan section

Conditions addressed in the plan demonstrate active provider engagement. Problem list conditions not addressed may not meet the standard.

Question 28: Which of the following is a best practice for regulatory compliance in coding?

Code for maximum reimbursement
Rely solely on software tools
Ensure regular audits and documentation (Correct answer)
Use past codes without review

Correct answer: Ensure regular audits and documentation

A best practice for regulatory compliance in coding is to ensure regular audits and thorough documentation. Regular audits help identify and correct coding errors, ensuring adherence to all applicable laws and guidelines. Comprehensive documentation provides the necessary evidence to support coded services and diagnoses, demonstrating compliance and mitigating risks.

Question 29: Which principle should be emphasized as the foundation of all CDI activities?

Prioritizing conditions with highest RAF weights
Maximizing RAF scores through aggressive query strategies
Focusing exclusively on HCC-mapped conditions
Ensuring documentation accurately reflects the patient's true clinical complexity (Correct answer)

Correct answer: Ensuring documentation accurately reflects the patient's true clinical complexity

The foundation of CDI must be clinical accuracy, not revenue optimization. This ensures compliance and quality of care.

Question 30: A patient has atrial fibrillation and sick sinus syndrome with tachycardia-bradycardia. How are these coded?

I48.91 and I49.5 separately (Correct answer)
I48.91 only
I49.5 and I48.20 together
I49.5 only, as it includes the atrial fibrillation

Correct answer: I48.91 and I49.5 separately

These are distinct arrhythmia conditions without an Excludes1 note between them. Both may coexist independently.

Question 31: How often must chronic conditions be coded for CMS-HCC purposes?

Every 3 years
Once they reach HCC status, they carry forward automatically
Once, and they persist permanently
Every calendar year; if not recaptured, the HCC drops from following year's RAF (Correct answer)

Correct answer: Every calendar year; if not recaptured, the HCC drops from following year's RAF

The prospective model requires annual documentation. A condition not recaptured in 2025 is lost from 2026 payment.

Question 32: What is the ESRD model in CMS risk adjustment?

A separate model with unique HCCs, dialysis and transplant status factors, and specific cost calibration (Correct answer)
The standard model with a simple multiplier
ESRD members are excluded from risk adjustment
ESRD adjustment handled entirely by dialysis facilities

Correct answer: A separate model with unique HCCs, dialysis and transplant status factors, and specific cost calibration

CMS maintains a separate model including ESRD-specific HCCs, dialysis modality factors, transplant status, and disease duration.

Question 33: What does CMS use to compare MA plan costs to expected costs under traditional Medicare?

The Medical Loss Ratio
The risk-adjusted benchmark comparison
The Star Rating differential
The bid-to-benchmark ratio (Correct answer)

Correct answer: The bid-to-benchmark ratio

CMS compares each MA plan's bid to the county benchmark to determine whether the plan receives a rebate or charges a premium to enrollees.

Question 34: A compliance officer identifies suspiciously high HCC 96 capture rates for a provider group. What is the appropriate first step?

Apply a correction factor to future submissions
Conduct a targeted chart audit of a sample of HCC 96 claims (Correct answer)
Immediately report to CMS
Terminate the provider contract

Correct answer: Conduct a targeted chart audit of a sample of HCC 96 claims

A targeted chart audit determines whether the high rate reflects accurate coding or a problem. Investigation must precede corrective action.

Question 35: Which compliance safeguard is most critical when using chart review vendors for retrospective risk adjustment coding?

Limiting vendor access to previously uncoded conditions
Ensuring vendors use only CRC-certified coders
Prohibiting vendors from being compensated based on HCCs identified (Correct answer)
Requiring vendor codes to be submitted without plan review

Correct answer: Prohibiting vendors from being compensated based on HCCs identified

Incentive-based compensation tied to HCC identification creates a financial incentive to overcode. CMS and OIG have specifically identified this as a risk.

Question 36: Which of the following best describes a 'gap closure' activity in prospective risk adjustment?

Submitting corrected claims for denied encounters
Scheduling patients with chronic conditions for annual visits to document and code existing diagnoses (Correct answer)
Filing appeals for rejected RADV audit findings
Reprocessing encounter data to fix submission errors

Correct answer: Scheduling patients with chronic conditions for annual visits to document and code existing diagnoses

Gap closure in prospective risk adjustment refers to scheduling members with chronic conditions for visits so that providers can document and code those conditions before the benefit year closes.

Question 37: What is the most critical NLP limitation for risk adjustment applications?

NLP may identify negated conditions as positive findings (Correct answer)
NLP is too slow for large-scale processing
NLP cannot differentiate code specificity levels
NLP cannot process handwritten notes

Correct answer: NLP may identify negated conditions as positive findings

Negation detection is critical. Clinical notes frequently mention conditions in negative context like 'ruled out' or 'no evidence of.'

Question 38: What does an 'acceptable diagnosis cluster' in RAPS submissions require?

Only primary diagnoses
Diagnoses submitted in alphabetical order
At least three related diagnoses submitted together
A from date, through date, provider type, and valid ICD-10-CM code (Correct answer)

Correct answer: A from date, through date, provider type, and valid ICD-10-CM code

A valid RAPS diagnosis cluster requires specific elements including service dates, provider type, and an ICD-10-CM code for the submission to be accepted.

Question 39: What is the relationship between RAPS and EDS for risk adjustment?

RAPS and EDS are identical systems
RAPS submits diagnosis codes only; EDS submits complete encounter data for both risk adjustment and quality measurement (Correct answer)
EDS replaced RAPS entirely
RAPS is for quality; EDS is for risk adjustment only

Correct answer: RAPS submits diagnosis codes only; EDS submits complete encounter data for both risk adjustment and quality measurement

RAPS is diagnosis-only for risk adjustment. EDS submits complete encounter records supporting both risk adjustment and quality measurement.

Question 40: What is the primary goal of a 'chase program' in risk adjustment?

To follow up on denied claims with payers
To pursue outstanding premium payments from members
To chase down RADV audit results from CMS
To identify members with suspected undocumented conditions and prompt provider outreach (Correct answer)

Correct answer: To identify members with suspected undocumented conditions and prompt provider outreach

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 41: When should Z-codes be used as the principal or first-listed diagnosis?

Only Z-codes for BMI and blood type can be first
Z-codes can never be principal
Z-codes are always secondary
When the encounter is specifically for the purpose described by the Z-code, such as screening or aftercare (Correct answer)

Correct answer: When the encounter is specifically for the purpose described by the Z-code, such as screening or aftercare

Certain Z-codes can be principal when the encounter is specifically for that purpose: immunization, screening, aftercare, etc.

Question 42: What is the primary purpose of the RADV Fee-for-Service Adjuster?

To increase payment recovery amounts
To account for coding errors in the FFS benchmark that inflate the comparison baseline (Correct answer)
To penalize plans with high error rates
To adjust for regional coding variation

Correct answer: To account for coding errors in the FFS benchmark that inflate the comparison baseline

The FFS Adjuster recognizes that FFS Medicare also contains coding inaccuracies, leveling the playing field.

Question 43: A patient undergoes a routine screening colonoscopy, and a benign polyp is found and removed. What is the appropriate first-listed diagnosis?

D12.6, Benign neoplasm of colon, unspecified
K63.5, Polyp of colon
Z86.010, Personal history of colonic polyps
Z12.11, Encounter for screening for malignant neoplasm of colon (Correct answer)

Correct answer: Z12.11, Encounter for screening for malignant neoplasm of colon

When the reason for the encounter is a screening, the appropriate screening Z code is the first-listed diagnosis, regardless of the findings. In this case, Z12.11 is used for the screening colonoscopy. The finding of a polyp (K63.5 or a more specific benign neoplasm code like D12.6) would be coded as a secondary diagnosis.

Question 44: When a provider documents 'suspected' or 'probable' condition in an outpatient encounter, how should the coder handle this for risk adjustment?

Code the suspected condition as confirmed
Code only signs, symptoms, or findings — never code suspected conditions in outpatient settings (Correct answer)
Code both the suspected condition and symptoms
Query the provider before coding anything

Correct answer: Code only signs, symptoms, or findings — never code suspected conditions in outpatient settings

Section IV.H states uncertain diagnoses should NOT be coded in outpatient settings. Code to the highest degree of certainty.

Question 45: A health plan's risk adjustment strategy includes both prospective outreach AND retrospective chart review. The PRIMARY advantage of this combined approach is:

It allows the plan to bypass standard encounter data submission requirements
It eliminates the need for RADV audit readiness
It maximizes HCC capture by addressing gaps both during and after the service year (Correct answer)
It reduces the plan's premium payments to CMS

Correct answer: It maximizes HCC capture by addressing gaps both during and after the service year

A combined prospective and retrospective strategy is most effective because it captures diagnoses during care delivery while also ensuring that any gaps missed prospectively are identified through post-service chart review.

Question 46: A provider documents 'patient has controlled HIV on antiretroviral therapy with undetectable viral load.' What code is assigned?

Z21 since controlled status means the disease is not active
B20 Human immunodeficiency virus disease (Correct answer)
Z86.19 Personal history of other infectious diseases
Z21 Asymptomatic HIV infection status

Correct answer: B20 Human immunodeficiency virus disease

B20 is correct. Once diagnosed with HIV disease, B20 is assigned for all subsequent encounters regardless of viral load status.

Question 47: A provider documents 'bilateral knee osteoarthritis.' What is the correct coding approach?

Code M17.0 for bilateral primary osteoarthritis (Correct answer)
Code M17.11 and M17.12 separately
Code M17.9 for unspecified knee
Query the provider for the primary side

Correct answer: Code M17.0 for bilateral primary osteoarthritis

ICD-10-CM provides a specific bilateral code (M17.0) for knee osteoarthritis. When available, use the bilateral code.

Question 48: 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
CMS requires all chart reviews to be conducted by the health plan's internal staff
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

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 49: What compliance challenge is unique to multi-state MA operations?

CMS applies different risk adjustment models by state
Each state has different ICD-10-CM codes
Multi-state plans are exempt from RADV
Varying state documentation standards, provider licensure requirements, and record retention laws create inconsistent practices (Correct answer)

Correct answer: Varying state documentation standards, provider licensure requirements, and record retention laws create inconsistent practices

Multi-state operations face challenges from varying state-level requirements that affect documentation quality.

Question 50: What is the specific time relationship between diagnosis capture and payment in the CMS-HCC prospective model?

Diagnoses affect payment immediately upon submission
Diagnoses in the current calendar year affect next year's capitation payments (Correct answer)
Past 3 years of diagnoses are averaged
Diagnoses coded today affect current month payment

Correct answer: Diagnoses in the current calendar year affect next year's capitation payments

Diagnoses documented in the data collection year determine the following year's payment, creating a one-year lag.

Question 51: In applying HCCs for a dual-eligible patient (Medicare and Medicaid), what additional factor must the coder consider?

Medicaid diagnoses cannot be used for Medicare risk adjustment
Dual-eligible patients require separate HCC submissions to each program
The CMS-HCC model applies a dual-eligible interaction factor that modifies certain HCC weights (Correct answer)
Dual-eligible status has no impact on HCC assignment or RAF calculation

Correct answer: The CMS-HCC model applies a dual-eligible interaction factor that modifies certain HCC weights

The CMS-HCC model includes demographic and enrollment factors, including dual-eligible status, that modify the RAF calculation.

Question 52: An in-home Health Risk Assessment identifies conditions not in PCP records. Can these be coded for risk adjustment?

HRA findings from a qualifying face-to-face encounter can be coded if supported by clinical evaluation (Correct answer)
All HRA checklist conditions are automatically codable
Only if the PCP subsequently confirms
HRA findings cannot be used under any circumstances

Correct answer: HRA findings from a qualifying face-to-face encounter can be coded if supported by clinical evaluation

Documentation must include clinical assessment supporting each diagnosis, not just checkboxes or patient self-reports.

Question 53: The benchmark in Medicare Advantage is based on:

State Medicaid rates
County-level fee-for-service Medicare spending rates (Correct answer)
National average Medicare costs
The plan's historical costs

Correct answer: County-level fee-for-service Medicare spending rates

MA benchmarks are set at the county level based on projected fee-for-service Medicare spending in that county.

Question 54: Which of the following is a risk associated with relying solely on retrospective chart reviews for risk adjustment?

Diagnoses found may lack face-to-face encounter documentation required by CMS (Correct answer)
Retrospective coding eliminates the need for provider education
Risk scores are always higher than with prospective methods
CMS prohibits retrospective submissions entirely

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

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 55: When a patient is admitted with localized infection and develops sepsis during the stay, how should codes be sequenced?

Localized infection is principal since it was present on admission
Both listed with equal priority
Sepsis code is sequenced first per sepsis guidelines, with localized infection additionally (Correct answer)
Sepsis becomes principal as the more severe condition

Correct answer: Sepsis code is sequenced first per sepsis guidelines, with localized infection additionally

Per Section I.C.1.d, when sepsis develops during an encounter, the sepsis code is sequenced first as principal.

Question 56: A specialist defers final diagnosis to the referring physician but documents extensive evaluation findings. Can the specialist's findings be used?

No, the specialist deferred the diagnosis
Only procedure codes can be submitted
Only if the PCP subsequently confirms
Yes, conditions the specialist assessed and documented can be coded (Correct answer)

Correct answer: Yes, conditions the specialist assessed and documented can be coded

A specialist who performs a face-to-face evaluation has generated codable documentation, even if they defer ongoing management.

Question 57: What is the primary purpose of risk adjustment in Medicare Advantage?

To increase Medicare premiums
To reduce provider payments
To ensure plans are paid appropriately based on enrollee health status (Correct answer)
To eliminate duplicate claims

Correct answer: To ensure plans are paid appropriately based on enrollee health status

Risk adjustment ensures MA plans receive payments that reflect the actual health risk of their enrolled population.

Question 58: What is the primary purpose of ICD-10-CM coding guidelines?

Increase patient visits
Train new physicians
Ensure consistent and accurate coding (Correct answer)
Create new diagnoses

Correct answer: Ensure consistent and accurate coding

ICD-10-CM coding guidelines provide a standardized set of rules and instructions for assigning diagnosis codes. Their primary purpose is to ensure consistent and accurate coding across all healthcare settings. This consistency is vital for proper reimbursement, public health reporting, and the reliable statistical analysis of disease patterns.

Question 59: Why do patients with advanced heart failure develop hepatic congestion?

Reduced cardiac output causes hepatic ischemia
Right-sided heart failure increases central venous pressure, causing blood to back up into the liver (Correct answer)
Heart failure medications are hepatotoxic
Left-sided heart failure compresses the hepatic artery

Correct answer: Right-sided heart failure increases central venous pressure, causing blood to back up into the liver

Right-sided heart failure increases CVP, transmitting backward through IVC and hepatic veins into liver sinusoids.

Question 60: Which of the following correctly describes a 'sweep' in the context of Medicare Advantage risk adjustment data submission?

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 audit of plan-submitted encounter data for compliance purposes
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 61: What analytical approach correctly models the V24 to V28 transition impact?

Multiply current revenue by V28/V24 ratio
Only analyze members with changed HCC mappings
Apply V28 weights to all members and calculate the difference
Calculate RAF under both models, apply CMS blending percentages, and account for normalization changes (Correct answer)

Correct answer: Calculate RAF under both models, apply CMS blending percentages, and account for normalization changes

Accurate analysis requires dual-model calculation, CMS blending percentages, and normalization factor changes.

Question 62: Which of the following best describes a key difference between a prospective and a retrospective risk adjustment review?

Prospective reviews occur after claims are submitted, while retrospective reviews happen before the patient encounter.
Retrospective reviews focus on identifying and correcting documentation and coding issues from past encounters, while prospective reviews aim to address them at or before the point of care. (Correct answer)
Retrospective reviews use data from the current year to predict next year's costs, while prospective reviews use data from a base year to predict costs for the same year.
Only prospective reviews can be used for RADV audits.

Correct answer: Retrospective reviews focus on identifying and correcting documentation and coding issues from past encounters, while prospective reviews aim to address them at or before the point of care.

Retrospective reviews analyze documentation after care has been delivered and claims have often been submitted, looking back to find and correct errors. Prospective reviews are proactive, often involving pre-visit planning or point-of-care interventions to ensure accurate documentation and coding during the encounter itself.

Question 63: Under Medicare Advantage risk adjustment, what is the diagnosis submission deadline for the prior benefit year under the retrospective data submission timeline?

January 31 of the current year
September 30 of the prior year
February 14 of the current year
March 31 of the current year (Correct answer)

Correct answer: March 31 of the current year

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.

Question 64: How is the causal relationship between diabetes and a complication established under ICD-10-CM guidelines?

ICD-10-CM assumes a causal relationship for certain conditions unless provider documents otherwise (Correct answer)
Each complication needs a separate linkage code
Only complications developing after the diabetes diagnosis qualify
Provider must explicitly state 'due to diabetes' for every complication

Correct answer: ICD-10-CM assumes a causal relationship for certain conditions unless provider documents otherwise

Section I.C.4.a.6 presumes a causal link between diabetes and certain listed conditions unless the provider documents a different cause.

Question 65: A patient presents with sepsis due to MRSA. Which coding sequence is correct?

A41.02 only
B95.62 first, then A41.02
A41.02 first, then B95.62 (Correct answer)
R65.20 first for severe sepsis, then A41.02

Correct answer: A41.02 first, then B95.62

A41.02 is sequenced first as the systemic infection. B95.62 identifies the infectious agent additionally.

Question 66: What is abstraction in the context of medical coding?

Summarizing patient preferences
Extracting relevant data from records (Correct answer)
Drawing lab samples
Filing insurance claims

Correct answer: Extracting relevant data from records

Abstraction in medical coding is the crucial process of carefully reviewing a patient's medical record to identify and extract all pertinent clinical information. This includes diagnoses, procedures, and services rendered, which are then translated into standardized codes. This meticulous extraction ensures that all relevant data is captured accurately for billing, data analysis, and risk adjustment.

Question 67: An MA plan uses predictive modeling to identify patients with suspected undocumented conditions. Which data source combination is most effective?

Claims data only
Claims combined with pharmacy data to identify conditions suggested by medication patterns (Correct answer)
EHR data only
Survey data combined with demographics

Correct answer: Claims combined with pharmacy data to identify conditions suggested by medication patterns

Pharmacy data reveals conditions not captured in diagnosis codes, such as a patient on metformin without a diabetes diagnosis.

Question 68: What is 'trumping' in the CMS-HCC hierarchy?

Within a hierarchy, higher-severity HCCs supersede lower ones, with only the highest counted (Correct answer)
Most recently documented condition trumps earlier ones
Inpatient diagnoses trump outpatient
Provider's diagnosis trumps the coder's code

Correct answer: Within a hierarchy, higher-severity HCCs supersede lower ones, with only the highest counted

Trumping prevents double-counting of related conditions at different severity levels within the same hierarchy.

Question 69: A provider documents 'hepatic encephalopathy secondary to cirrhosis.' What causes the neurological symptoms?

Coagulopathy leads to brain micro-hemorrhages
The cirrhotic liver cannot metabolize ammonia, allowing toxic levels to reach the brain (Correct answer)
Direct liver toxin production damages neurons
Portal hypertension causes cerebral edema

Correct answer: The cirrhotic liver cannot metabolize ammonia, allowing toxic levels to reach the brain

Elevated blood ammonia from impaired hepatic metabolism crosses the blood-brain barrier, causing astrocyte swelling and neurotransmitter dysfunction.

Question 70: Which data source does CMS primarily use to calculate risk scores for MA plans?

Both FFS claims and encounter data submitted by MA plans (Correct answer)
Hospital discharge data only
Fee-for-service Medicare claims only
Encounter data submitted by MA plans only

Correct answer: Both FFS claims and encounter data submitted by MA plans

CMS uses both fee-for-service Medicare claims and encounter data submitted by MA plans to calculate risk scores.

Question 71: Which of the following documents is generally considered the MOST reliable and acceptable source to validate an HCC during a RADV audit?

A list of diagnoses from a prior year's discharge summary.
A patient-completed Health Risk Assessment (HRA) form.
A diagnostic lab report without a physician's interpretation and assessment.
A signed, face-to-face outpatient progress note from the year of service. (Correct answer)

Correct answer: A signed, face-to-face outpatient progress note from the year of service.

RADV audits require that diagnoses be supported by documentation from a face-to-face encounter with an acceptable provider type within the specified data collection period. A signed progress note from the relevant year provides the necessary direct evidence of the provider's assessment and management of the condition.

Question 72: A patient record from an annual wellness visit includes documented and managed diagnoses of Type 2 Diabetes without complications (E11.9), Congestive Heart Failure (I50.9), and Chronic Obstructive Pulmonary Disease (J44.9). Assuming all conditions meet MEAT criteria, how are these diagnoses treated in the CMS-HCC model?

Each of these diagnoses maps to a separate HCC, and all three can contribute to the final risk score. (Correct answer)
A disease hierarchy applies, and only the Diabetes and CHF are counted.
Diabetes and COPD are combined into a single cardiorespiratory HCC.
Only the single highest-risk diagnosis (Congestive Heart Failure) will be counted toward the risk score.

Correct answer: Each of these diagnoses maps to a separate HCC, and all three can contribute to the final risk score.

The CMS-HCC model is additive, meaning that multiple chronic conditions in different disease categories can each contribute to the patient's overall risk score. Diabetes, Congestive Heart Failure, and COPD belong to separate HCC categories and do not have hierarchies with each other. Therefore, if all are properly documented and managed during an encounter, each would contribute its respective HCC to the risk score calculation, providing a more complete picture of the patient's health complexity.

Question 73: What is the difference between a 'payment HCC' and a 'non-payment HCC'?

All HCCs result in payment
The distinction only applies to the ESRD model
Non-payment HCCs are not real diseases
Some HCCs have zero payment weight but serve structural purposes in hierarchy, participating in trumping without contributing directly to RAF (Correct answer)

Correct answer: Some HCCs have zero payment weight but serve structural purposes in hierarchy, participating in trumping without contributing directly to RAF

Non-payment HCCs can participate in trumping and disease interactions but have zero direct coefficient.

Question 74: What does CMS set to ensure MA plans submit a sufficient volume of encounter data?

Minimum encounter data submission rate floors (Correct answer)
Maximum coding density limits
Prior authorization requirements
Provider network adequacy standards

Correct answer: Minimum encounter data submission rate floors

CMS sets minimum encounter data submission rate floors that MA plans must meet to ensure complete and accurate risk adjustment data is available.

Question 75: How does accurate risk adjustment coding impact a Medicare Advantage plan's Star Rating?

Accurate coding ensures quality measure denominator populations are correctly identified (Correct answer)
Higher RAF scores automatically increase Star Ratings
Star Ratings are based solely on patient satisfaction
Risk adjustment has no connection to quality measurement

Correct answer: Accurate coding ensures quality measure denominator populations are correctly identified

Accurate coding ensures patients are correctly identified for quality measure populations. Without it, quality performance appears artificially inflated.

Question 76: A physician uses extensive non-standard abbreviations. What abstraction risk does this create?

Acceptable as long as the coder can interpret them
Only a problem in handwritten notes
The CRC should translate without verification
Abbreviations may be ambiguous, misinterpreted, or not clearly support a specific diagnosis for HCC coding (Correct answer)

Correct answer: Abbreviations may be ambiguous, misinterpreted, or not clearly support a specific diagnosis for HCC coding

Non-standard abbreviations create risk because RADV auditors may interpret them differently than the abstractor.

Question 77: A provider documents 'morbid obesity with BMI of 42' and obesity hypoventilation syndrome. What is the complete code set?

E66.2, Z68.42, E66.01
E66.01, Z68.42
E66.01, Z68.42, E66.2 (Correct answer)
E66.01 and E66.2 only

Correct answer: E66.01, Z68.42, E66.2

E66.01 for morbid obesity, Z68.42 for specific BMI, and E66.2 for obesity hypoventilation syndrome. Each captures distinct clinical information.

Question 78: What was the most significant change in the CMS-HCC V24 to V28 transition?

V28 reclassified condition categories, added new HCCs, and revised hierarchies for current medical practice (Correct answer)
V28 added prescription drug data
V28 eliminated disease interaction terms
V28 changed from prospective to concurrent approach

Correct answer: V28 reclassified condition categories, added new HCCs, and revised hierarchies for current medical practice

V28 involved significant reclassification: new HCCs, splits, merges, hierarchy revisions, and recalibrated weights.

Question 79: What is a 'quality bonus payment' in Medicare Advantage?

Extra payment for high-risk patients
Payment for preventive care services
Reimbursement for quality improvement initiatives
Additional payment for plans with 4 or more stars on the CMS Star Rating (Correct answer)

Correct answer: Additional payment for plans with 4 or more stars on the CMS Star Rating

MA plans with 4 or more stars on the CMS Star Rating system receive quality bonus payments as a percentage increase to their benchmark.

Question 80: A chart documents 'history of DVT, currently on anticoagulation.' How do guidelines distinguish history from active conditions?

History codes are never used with medication
The coder independently determines based on medication review
If on medication, always code as active
The provider's documentation determines status; 'history of' uses Z-codes unless the condition is documented as active (Correct answer)

Correct answer: The provider's documentation determines status; 'history of' uses Z-codes unless the condition is documented as active

The provider's documentation drives the decision. History codes generally do not map to HCCs, while active condition codes often do.

Question 81: 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
Query the physician to confirm or rule out the diagnosis before coding
Code only the presenting signs and symptoms, not the 'possible' diagnosis (Correct answer)
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 82: What is 'chart review' in the context of risk adjustment data validation?

A provider reviewing patient charts for medical accuracy only
A retrospective review of medical records to identify diagnoses that support or should be added to encounter data (Correct answer)
A quality measure assessment
An audit of billing records for fraud detection only

Correct answer: A retrospective review of medical records to identify diagnoses that support or should be added to encounter data

Chart reviews involve retrospectively reviewing medical records to identify all documented diagnoses that should be reflected in encounter data submissions for accurate risk scoring.

Question 83: What is the primary mechanism of diabetic peripheral neuropathy?

Chronic hyperglycemia causes polyol pathway activation, AGE formation, and microvascular damage (Correct answer)
Diabetic ketoacidosis causes nerve inflammation
Insulin directly damages nerve myelin sheaths
Oral diabetes medications have neurotoxic effects

Correct answer: Chronic hyperglycemia causes polyol pathway activation, AGE formation, and microvascular damage

Multiple interconnected pathways converge: polyol pathway (osmotic damage), AGEs (structural damage), and microvascular disease of the vasa nervorum.

Question 84: How do guidelines handle conditions that are 'integral' to a disease process versus 'not integral'?

Only the primary disease code is ever needed
Integral signs and symptoms should not be coded separately, but non-routine findings should be coded additionally (Correct answer)
All associated conditions should be coded separately
The coder decides subjectively

Correct answer: Integral signs and symptoms should not be coded separately, but non-routine findings should be coded additionally

Section I.B.5: integral symptoms (e.g., chest pain with MI) are not coded separately, but non-routine findings should be coded.

Question 85: A coder reviews the chart of an 80-year-old patient with a BMI of 17.0, documented 12% unintentional weight loss in the past 6 months, and loss of subcutaneous fat. The physician documents "malnutrition." Based on these clinical indicators, which pathophysiological state should the coder query the provider to specify for accurate risk adjustment?

Mild protein-calorie malnutrition
Morbid Obesity
Cachexia
Severe protein-calorie malnutrition (Correct answer)

Correct answer: Severe protein-calorie malnutrition

The clinical indicators provided (very low BMI, significant involuntary weight loss, muscle/fat wasting) are classic signs of a severe protein-calorie malnutrition state. Specifying this is crucial for risk adjustment because 'Severe protein-calorie malnutrition' (e.g., E43) maps to a high-weighted HCC, while an unspecified 'malnutrition' diagnosis (E46) often does not risk adjust or carries a much lower weight.

Question 86: A 75-year-old female with known osteoporosis (M81.0) trips and falls at home, sustaining a pathologic fracture of the right hip. This is the initial encounter for the fracture. What is the correct primary diagnosis code?

S72.001A, M81.0
M81.0, S72.001A
M80.051A (Correct answer)
Z87.81, M80.051A

Correct answer: M80.051A

ICD-10-CM directs coders to use a code from category M80 for pathological fractures in patients with osteoporosis. M80.051A (Age-related osteoporosis with current pathological fracture, right femur, initial encounter for fracture) is the specific combination code that captures both the fracture and the underlying osteoporosis, and it should be sequenced first.

Question 87: How should chronic conditions be coded when documented in the medical record?

Code each time they are addressed (Correct answer)
Code only if medication is prescribed
Do not code unless resolved
Code only once per year

Correct answer: Code each time they are addressed

Chronic conditions are long-term illnesses that often require ongoing management. According to coding guidelines, if a chronic condition is documented and addressed during a patient encounter, it should be coded for that encounter. This practice accurately reflects the patient's health status and the services provided, even if the condition is stable.

Question 88: A patient with chronic atrial fibrillation develops a stroke. What mechanism links these conditions?

Rapid heart rates cause cerebral hypoperfusion
AF medications increase hemorrhagic stroke risk
AF causes irregular blood pressure damaging cerebral arteries
Irregular rhythm causes blood stasis in the left atrial appendage, promoting thrombus formation that can embolize to the brain (Correct answer)

Correct answer: Irregular rhythm causes blood stasis in the left atrial appendage, promoting thrombus formation that can embolize to the brain

In AF, ineffective atrial contraction causes blood stasis, promoting clot formation that can travel to cerebral arteries.

Question 89: An MA plan achieves a 4.5 Star Rating with 5% quality bonus. How does coding accuracy contribute to maintaining this rating?

The bonus is based solely on patient satisfaction surveys
Coding accuracy has no relationship to Star Rating maintenance
Accurate coding maintains reliable denominators, prevents audit penalties, and ensures risk-adjusted measures are calibrated (Correct answer)
Higher coding intensity directly increases Star Ratings

Correct answer: Accurate coding maintains reliable denominators, prevents audit penalties, and ensures risk-adjusted measures are calibrated

Maintaining ratings requires consistent performance, which depends on reliable measurement infrastructure supported by accurate coding.

Question 90: A patient with peripheral arterial disease (PAD) is evaluated, and the physician notes the patient has pain in their right foot even when resting. Pathophysiologically, this indicates critical limb ischemia. How does documenting PAD with rest pain differ in HCC coding compared to documenting PAD with claudication only?

Only PAD that has resulted in an ulcer or amputation will risk adjust.
PAD with rest pain maps to a more heavily weighted HCC, reflecting a higher disease severity and risk of limb loss. (Correct answer)
There is no difference in HCC value between PAD with claudication and PAD with rest pain.
The presence of rest pain is for clinical information only and does not influence the ICD-10-CM code selection.

Correct answer: PAD with rest pain maps to a more heavily weighted HCC, reflecting a higher disease severity and risk of limb loss.

The pathophysiology of PAD is progressive, moving from claudication (pain with exertion) to rest pain, and finally to ulceration/gangrene. PAD with rest pain (e.g., I70.22-) represents a much more advanced and severe stage of the disease, known as critical limb ischemia. This increased severity and risk is reflected in risk adjustment models by mapping it to a higher-weighted HCC category compared to PAD with intermittent claudication (e.g., I70.21-).

Question 91: An internal audit reveals a 15% HCC error rate in 200 charts. What is the most compliant course of action?

Commission a larger audit to narrow the confidence interval first
Report only the sampled charts' overpayments
Extrapolate the error rate and report estimated overpayment to CMS within 60 days (Correct answer)
Wait for the next RADV cycle

Correct answer: Extrapolate the error rate and report estimated overpayment to CMS within 60 days

Under the 60-Day Rule, the plan should extrapolate to the full population and report. Delaying violates the reporting obligation.

Question 92: When abstracting data, which type of documentation should be avoided?

Specialist consultation notes
Hospital discharge summaries
Problem list without documentation (Correct answer)
Physician progress notes

Correct answer: Problem list without documentation

While a problem list provides a summary of a patient's conditions, coding directly from it without supporting documentation in the current encounter is generally avoided. For a diagnosis to be coded and submitted, especially for risk adjustment, the medical record must clearly show that the condition was addressed, assessed, or managed during that specific visit. A problem list alone does not provide this necessary validation.

Question 93: Which OIG concern has been most consistently cited regarding MA risk adjustment?

Provider credentialing inadequacies
Undercoding of chronic conditions
Diagnoses submitted that are not supported by medical record documentation (Correct answer)
Plans failing to submit data on time

Correct answer: Diagnoses submitted that are not supported by medical record documentation

OIG has consistently focused on unsupported diagnoses — conditions submitted where documentation does not adequately support the code.

Question 94: Which of the following phrases in a physician's documentation best supports a reportable diagnosis for risk adjustment purposes by satisfying the 'MEAT' criteria?

Patient has a history of myocardial infarction.
Continue lisinopril for management of hypertension. (Correct answer)
Hypertension is listed on the problem list.
Discussed patient's ongoing struggle with morbid obesity.

Correct answer: Continue lisinopril for management of hypertension.

The phrase 'Continue lisinopril for management of hypertension' clearly documents the 'Treatment' component of the MEAT (Monitor, Evaluate, Assess, Treat) criteria. This indicates active management of the condition during the encounter, making it a valid and reportable diagnosis for risk adjustment.

Question 95: 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:

Add the COPD ICD-10-CM code to the encounters retroactively
Report the gap to the OIG for investigation
Submit the pharmacy data directly to CMS as a diagnosis
Work with providers to schedule these members for visits and ensure COPD is documented if clinically supported (Correct answer)

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

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 96: What documentation requirements must a telehealth encounter meet for risk adjustment?

Must document real-time audio-visual interaction, use qualifying modifiers, and meet same standards as in-person visits (Correct answer)
Only audio-only encounters qualify
Telehealth encounters cannot be used
Only if the patient is in a rural area

Correct answer: Must document real-time audio-visual interaction, use qualifying modifiers, and meet same standards as in-person visits

Qualifying telehealth encounters must include real-time audio-visual communication and meet the same documentation standards.

Question 97: A coder is abstracting diagnoses from a specialist consultation note containing code F33.1 for major depressive disorder, recurrent, moderate. The PCP's note lists 'depression' without specificity. Which code should be submitted?

Neither code since the conflicting documentation requires a query
F33.1 as the most specific code supported by documentation (Correct answer)
F32.9 as the PCP documentation takes precedence
Both F32.9 and F33.1 to capture all documented information

Correct answer: F33.1 as the most specific code supported by documentation

F33.1 is the most specific code supported by the specialist's documentation. For risk adjustment, the most specific code from any qualified provider should be used.

Question 98: A plan's diabetic retinopathy screening rate is 72% vs 58% national average, but only 60% of diabetic members are properly coded. What is the true rate?

58% matching the national average
72% because that is the measured rate
Approximately 43% because the denominator should be larger
Cannot be determined without data on uncoded members' screening status (Correct answer)

Correct answer: Cannot be determined without data on uncoded members' screening status

The true rate depends on how many uncoded members received screening, which is unknown.

Question 99: What does the CMS-HCC model use to predict?

Patient satisfaction scores
Hospital readmission rates
Future healthcare expenditures (Correct answer)
Prescription drug usage only

Correct answer: Future healthcare expenditures

The CMS-HCC model predicts future healthcare expenditures based on demographic factors and documented chronic conditions.

Question 100: A RADV auditor finds a provider note signed 90 days after the date of service. What is the impact?

Diagnoses are valid regardless of signature timing
Late signature creates a rebuttable presumption of invalidity (Correct answer)
The note is automatically invalidated
CMS requires signatures within 30 days or the encounter is excluded

Correct answer: Late signature creates a rebuttable presumption of invalidity

A significantly late signature raises credibility concerns. The burden shifts to the plan to demonstrate documentation reliability.

CRC - Certified Risk Adjustment Coder Exam

The AAPC CRC exam validates proficiency in risk adjustment coding, including ICD-10-CM diagnosis coding, HCC mapping, medical record documentation, and compliance within Medicare Advantage and other risk adjustment models.

100

Questions

240 min

Time Limit

70%

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