CRC Prospective and Retrospective Risk Adjustment Strategies 1 — Questions and Answers
Question 1: Which risk adjustment strategy involves reviewing medical records AFTER the date of service to identify and submit diagnoses that support HCC capture?
- Prospective coding
- Retrospective coding (Correct answer)
- Concurrent coding
- Predictive modeling
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 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?
- Retrospective chart review
- RADV audit preparation
- Prospective risk adjustment (Correct answer)
- Supplemental data submission
Correct answer: Prospective risk adjustment
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?
- To pursue outstanding premium payments from members
- To identify members with suspected undocumented conditions and prompt provider outreach (Correct answer)
- To chase down RADV audit results from CMS
- To follow up on denied claims with payers
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 4: Supplemental data sources used in retrospective risk adjustment most commonly include which of the following?
- Lab results and pharmacy data only
- Member satisfaction surveys
- Medical records, lab data, and pharmacy data reviewed outside the normal claims flow (Correct answer)
- HEDIS reports and quality metrics
Correct answer: Medical records, lab data, and pharmacy data reviewed outside the normal claims flow
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?
- March 31 of the current year (Correct answer)
- January 31 of the current year
- September 30 of the prior year
- February 14 of the current year
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 6: 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 7: A health plan uses pharmacy claims showing prescriptions for insulin and metformin to identify members who may have undocumented diabetes. This is an example of using supplemental data for which purpose?
- RADV audit defense
- Prospective member targeting for outreach (Correct answer)
- Encounter data error correction
- ICD-10-CM code validation
Correct answer: Prospective member targeting for outreach
Using pharmacy data to identify members with probable chronic conditions not documented in encounters is a common prospective targeting method to prioritize outreach and close coding gaps.
CRC Prospective and Retrospective Risk Adjustment Strategies 1
Which risk adjustment strategy involves reviewing medical records AFTER the date of service to identify and submit diagnoses that support HCC capture?