Certified Medical Coding Specialist Risk Assessment & Management 5 — Questions and Answers
Question 1: A coder reviews a record where the physician documents 'diabetic neuropathy' but does not specify the type of diabetes. What is the correct coding approach?
- Default to Type 1 diabetes with neuropathy
- Default to Type 2 diabetes with diabetic neuropathy, as Type 2 is the default when type is not specified (Correct answer)
- Query the physician before assigning any code
- Assign only the neuropathy code without a diabetes code
Correct answer: Default to Type 2 diabetes with diabetic neuropathy, as Type 2 is the default when type is not specified
Per ICD-10-CM guidelines, when the type of diabetes is not documented, the default is Type 2 diabetes mellitus.
Question 2: Which of the following best describes the role of a 'suspect condition' in Medicare Advantage risk adjustment?
- Suspect conditions can be coded and submitted for risk adjustment based on clinical indicators
- Suspect conditions cannot be submitted for risk adjustment; only confirmed diagnoses are valid (Correct answer)
- Suspect conditions are automatically approved if flagged by a health plan algorithm
- Suspect conditions require only a nurse practitioner sign-off to be coded
Correct answer: Suspect conditions cannot be submitted for risk adjustment; only confirmed diagnoses are valid
CMS requires confirmed diagnoses documented by a qualified provider; suspect or probable conditions cannot be submitted for Medicare Advantage risk adjustment.
Question 3: What is the primary compliance risk associated with 'chart-chasing' in risk adjustment?
- It may lead to duplicate billing for the same service
- It may result in coding diagnoses not supported by the current year's medical record documentation (Correct answer)
- It causes delays in claims processing timelines
- It violates HIPAA minimum necessary standards
Correct answer: It may result in coding diagnoses not supported by the current year's medical record documentation
Chart-chasing involves retrospectively reviewing records to find additional diagnoses, which can lead to coding conditions not validly documented in qualifying encounters.
Question 4: Which of the following is a key difference between HCC risk adjustment and traditional fee-for-service payment?
- HCC risk adjustment pays per procedure performed, while FFS pays capitation
- HCC risk adjustment pays a capitated rate adjusted by patient health status, while FFS pays per service rendered (Correct answer)
- HCC risk adjustment applies only to Medicaid patients
- HCC risk adjustment does not involve diagnosis codes
Correct answer: HCC risk adjustment pays a capitated rate adjusted by patient health status, while FFS pays per service rendered
HCC-based risk adjustment modifies per-member-per-month capitation payments based on predicted health costs from diagnosis data, unlike FFS per-procedure payment.
Question 5: A health plan conducts an internal audit and finds that 15% of submitted HCC diagnoses lack adequate medical record support. What is the most appropriate next step?
- Submit the data as-is and await external audit findings
- Delete all unsupported HCCs and resubmit corrected data to CMS (Correct answer)
- Ignore findings if the percentage is under 20%
- Only correct records from providers who are still contracted
Correct answer: Delete all unsupported HCCs and resubmit corrected data to CMS
Compliance requires proactive correction and deletion of unsupported diagnoses with resubmission of accurate data to CMS to avoid False Claims Act liability.
Question 6: Which ICD-10-CM code category is used to report body mass index (BMI) as an additional code in risk-relevant obesity documentation?
- Z68 (Body mass index) (Correct answer)
- E11 (Type 2 diabetes mellitus)
- Z87 (Personal history of diseases)
- M79 (Other and unspecified soft tissue disorders)
Correct answer: Z68 (Body mass index)
Category Z68 contains BMI codes that are reported as additional codes to support obesity diagnoses documented by the provider.
Question 7: Under the CMS-HCC model, atherosclerotic coronary artery disease maps to an HCC. Which documentation element is essential for a coder to capture this condition for risk adjustment?
- A stress test result indicating ischemia
- Physician documentation of coronary artery disease (CAD) or atherosclerosis of coronary artery in a qualifying encounter (Correct answer)
- A cardiology referral letter
- Patient-reported chest pain history
Correct answer: Physician documentation of coronary artery disease (CAD) or atherosclerosis of coronary artery in a qualifying encounter
Physician documentation of the confirmed diagnosis in a valid clinical encounter is required; ancillary test results or referrals alone do not suffice.
Certified Medical Coding Specialist Risk Assessment & Management 5
A coder reviews a record where the physician documents 'diabetic neuropathy' but does not specify the type of diabetes.
What is the correct coding approach?