CRC - Certified Risk Adjustment Coder Compliance and RADV Audits Questions and Answers 1 — Questions and Answers
Question 1: A Medicare Advantage organization knowingly encourages its network providers to add diagnoses to patient encounters that are not clinically supported, with the primary goal of increasing risk scores. This practice could expose the organization to significant penalties under which federal law?
- Health Insurance Portability and Accountability Act (HIPAA)
- The False Claims Act (FCA) (Correct answer)
- Emergency Medical Treatment and Labor Act (EMTALA)
- The Stark Law
Correct answer: The False Claims Act (FCA)
The False Claims Act (FCA) imposes liability on persons and companies who defraud governmental programs. Knowingly submitting unsupported diagnoses to obtain higher risk-adjusted payments from Medicare is a violation of the FCA, as it constitutes submitting a false claim for payment.
Question 2: During a CMS-RADV audit, the error rate identified in the sample of 200 members is used to calculate a total recovery amount for the entire health plan contract. What is this statistical process called?
- Prospective Review
- Retrospective Stratification
- Discrepancy Reporting
- Extrapolation (Correct answer)
Correct answer: Extrapolation
Extrapolation is the statistical method used in RADV audits to project the payment error found in a small sample of members across the entire contract. This allows CMS to recover improper payments for the whole contract, not just for the members whose records were reviewed.
Question 3: A coder is preparing records for a RADV audit. For an audited HCC of Major Depressive Disorder, the coder finds a signed outpatient progress note from the correct date of service. The note lists 'Major Depressive Disorder' in the assessment, and the plan section states 'Continue Sertraline 50mg daily. Follow up in 3 months.' Which of the following best describes why this documentation is likely sufficient?
- It is from an outpatient setting.
- The diagnosis is listed on the problem list.
- It meets the MEAT (Monitor, Evaluate, Assess, Treat) criteria. (Correct answer)
- The provider signed the note electronically.
Correct answer: It meets the MEAT (Monitor, Evaluate, Assess, Treat) criteria.
This documentation supports the diagnosis by meeting the MEAT criteria. The Assessment ('Major Depressive Disorder') and Treatment ('Continue Sertraline 50mg') are clearly documented, showing the condition was actively managed during the encounter, which is a requirement for RADV validation.
Question 4: Which of the following documents is generally considered the MOST reliable and acceptable source to validate an HCC during a RADV audit?
- A patient-completed Health Risk Assessment (HRA) form.
- A list of diagnoses from a prior year's discharge summary.
- A signed, face-to-face outpatient progress note from the year of service. (Correct answer)
- A diagnostic lab report without a physician's interpretation and assessment.
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 5: A health plan receives a RADV audit notification for a specific enrollee and HCC. Upon internal review, the coder cannot find any documentation to support the submitted HCC for the specified date of service. However, the coder does find a well-documented, risk-adjusting diagnosis from that same encounter that was never submitted. What is the most appropriate next step?
- Submit the record as is and hope the auditor misses the error.
- Submit the record and use the newly found diagnosis to offset the deletion. (Correct answer)
- Query the provider to add the missing diagnosis to the original note.
- Do not submit any record for this enrollee to avoid a confirmed error.
Correct answer: Submit the record and use the newly found diagnosis to offset the deletion.
In both CMS and HHS-RADV audits, health plans can submit documentation that supports other valid HCCs from the audited encounter. While the original HCC will be found in error, the newly identified and validated HCC can offset the financial impact of the deletion.
Question 6: 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.
- Conducting regular internal mock audits on high-risk HCCs. (Correct answer)
- Ensuring the plan's member services phone number is easy to find.
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.
CRC - Certified Risk Adjustment Coder Compliance and RADV Audits Questions and Answers 1
A Medicare Advantage organization knowingly encourages its network providers to add diagnoses to patient encounters that are not clinically supported, with the primary goal of increasing risk scores.
This practice could expose the organization to significant penalties under which federal law?