CRC - Certified Risk Adjustment Coder Exam — Questions and Answers

Question 1: 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
Work with providers to schedule these members for visits and ensure COPD is documented if clinically supported (Correct answer)
Submit the pharmacy data directly to CMS as a diagnosis

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 2: A risk adjustment coder is reviewing a chart where the provider documents 'morbid obesity' but the patient's recorded BMI is 37.2. Which action is most appropriate?

Code E66.01 for morbid obesity since the provider documented it
Code E66.01 and Z68.37 to capture both the obesity and BMI
Query the provider because morbid obesity typically requires BMI of 40 or higher or 35 with comorbidity (Correct answer)
Code E66.09 for other obesity since the BMI does not support morbid obesity

Correct answer: Query the provider because morbid obesity typically requires BMI of 40 or higher or 35 with comorbidity

While the provider documented morbid obesity, the BMI of 37.2 does not automatically support that diagnosis. A query is needed to verify if comorbidities support the morbid obesity designation.

Question 3: A discharge summary lists 12 diagnosis codes but only 8 have supporting narrative. How should the CRC handle the 4 unsupported codes?

Code all 12 since they appear in the official discharge summary
Code none since the documentation is incomplete
Code all 12 but flag the 4 for a provider query
Code only the 8 supported by narrative documentation (Correct answer)

Correct answer: Code only the 8 supported by narrative documentation

Codes without narrative support may not survive RADV audit scrutiny. Code the 8 supported conditions and consider querying for the remaining 4.

Question 4: A CRC is abstracting from a multi-provider encounter. Which documentation sources can be used for risk adjustment coding?

Documentation from any qualified provider with a face-to-face encounter (Correct answer)
Only the billing provider's documentation
Only the attending physician's documentation
All clinical staff including nurses and medical assistants

Correct answer: Documentation from any qualified provider with a face-to-face encounter

Diagnoses can be coded from any qualified healthcare provider (MD, DO, NP, PA) who had a face-to-face encounter.

Question 5: Which compliance safeguard is most critical when using chart review vendors for retrospective risk adjustment coding?

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

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

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

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

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

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: How often should coding compliance audits be performed?

Never, if coders are trained
Only after violations
Once every five years
Annually or regularly (Correct answer)

Correct answer: Annually or regularly

Coding compliance audits should be performed annually or on a regular, ongoing basis to ensure accuracy and adherence to coding guidelines. Regular audits help identify potential errors, reinforce best practices, and prevent fraud and abuse. Consistent oversight is essential for maintaining coding integrity and adapting to evolving regulatory requirements.

Question 9: Which HEDIS measure most directly depends on accurate mental health coding?

Breast Cancer Screening
Comprehensive Diabetes Care
Follow-Up After Hospitalization for Mental Illness (FUH) (Correct answer)
Medication Reconciliation Post-Discharge

Correct answer: Follow-Up After Hospitalization for Mental Illness (FUH)

FUH requires identifying members hospitalized with a principal mental health diagnosis. Accurate coding determines whether the measure is triggered.

Question 10: A provider documents 'uncontrolled diabetes.' What code should be assigned?

E13.9 for other specified diabetes
E11.9 for Type 2 diabetes without complication
E11.65 for diabetes with hyperglycemia (Correct answer)
A query should be sent since 'uncontrolled' is not an ICD-10-CM descriptor

Correct answer: E11.65 for diabetes with hyperglycemia

The ICD-10-CM Alphabetic Index directs 'uncontrolled' to 'with hyperglycemia,' meaning E11.65 for Type 2.

Question 11: A model identifies 500 members as likely having undocumented CKD. After outreach, only 200 are confirmed. What metric describes this?

40% sensitivity (recall)
40% positive predictive value (precision) (Correct answer)
60% false negative rate
40% accuracy

Correct answer: 40% positive predictive value (precision)

PPV measures the proportion of positive predictions that are true positives: 200/500 = 40%.

Question 12: A CDI team is measuring financial impact of their risk adjustment program. Which metric best demonstrates value?

Total CDI queries generated per quarter
Number of diagnosis code changes from CDI queries
Query response rate percentage
Net RAF score change attributable to CDI-identified improvements (Correct answer)

Correct answer: Net RAF score change attributable to CDI-identified improvements

Net RAF score change directly quantifies financial impact and can be converted to dollar impact.

Question 13: Which documentation practice presents the highest RADV audit risk?

Submitting diagnosis codes from problem lists not addressed in encounter notes (Correct answer)
Templated notes with comprehensive review of systems
Multiple providers documenting the same condition differently
Addendum notes added within 24 hours

Correct answer: Submitting diagnosis codes from problem lists not addressed in encounter notes

Unaddressed problem list entries are the highest risk because RADV auditors look for evidence conditions were actively evaluated during the encounter.

Question 14: What is the primary goal of a compliant physician query in the context of clinical documentation improvement for risk adjustment?

To obtain additional clarification or specificity for a documented condition that is not clearly supported. (Correct answer)
To suggest diagnoses that will lead to a higher RAF score.
To educate the physician on how to code more effectively.
To correct billing errors found on previous claims.

Correct answer: To obtain additional clarification or specificity for a documented condition that is not clearly supported.

A compliant physician query should be non-leading and aim to clarify, specify, or provide a cause-and-effect relationship for conditions already documented in the medical record. Its purpose is to ensure the documentation accurately reflects the patient's condition to support precise coding, not to influence the physician to document for reimbursement purposes.

Question 15: 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
Wait for the next RADV cycle
Extrapolate the error rate and report estimated overpayment to CMS within 60 days (Correct answer)

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

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

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 17: Which law is designed to protect patient health information (PHI)?

FMLA
OSHA
HIPAA (Correct answer)
FERPA

Correct answer: HIPAA

The Health Insurance Portability and Accountability Act (HIPAA) of 1996 is a federal law specifically designed to protect sensitive patient health information (PHI). HIPAA establishes national standards for the privacy and security of PHI, ensuring it is not disclosed without the patient's consent or knowledge. This law is fundamental to maintaining patient confidentiality in healthcare.

Question 18: A patient has Type 2 diabetes with diabetic chronic kidney disease, stage 4. Which code combination is correct?

E11.65 and N18.4
E11.9 and N18.4
E11.22 only
E11.22 and N18.4 (Correct answer)

Correct answer: E11.22 and N18.4

E11.22 establishes the causal relationship. N18.4 must be coded additionally to specify the CKD stage.

Question 19: Which population does the HHS-HCC model serve, and what key structural difference exists from CMS-HCC?

Medicaid populations with 5-year age bands
Federal Employee Health Benefit populations with provider specialty variables
ACA marketplace populations using concurrent rather than prospective risk adjustment (Correct answer)
Medicare Supplement populations with prescription drug data

Correct answer: ACA marketplace populations using concurrent rather than prospective risk adjustment

HHS-HCC serves ACA marketplace populations and uses concurrent risk adjustment (same-year diagnoses predict same-year costs).

Question 20: What is the 'normalization factor' in the CMS-HCC model?

A quality adjustment factor for Star Ratings
A budget-neutrality adjustment preventing total MA payments from growing solely due to coding intensity (Correct answer)
A factor adjusting for regional cost differences
A demographic correction for plan member age

Correct answer: A budget-neutrality adjustment preventing total MA payments from growing solely due to coding intensity

The normalization factor ensures aggregate payments remain budget-neutral as coding practices change.

Question 21: An MA plan contracts with a vendor for retrospective chart reviews. Which OIG compliance concern is most relevant?

Prohibition on upcoding if the vendor is incentivized to find diagnoses regardless of support (Correct answer)
Stark Law referral relationships
Anti-Kickback Statute
HIPAA privacy rules only

Correct answer: Prohibition on upcoding if the vendor is incentivized to find diagnoses regardless of support

Chart review vendors paid to find HCC gaps have an inherent incentive to add diagnoses that may not be fully supported.

Question 22: Under CMS rules, which type of provider is authorized to document diagnoses that qualify for HCC submission in Medicare Advantage?

Any healthcare worker documenting in the medical record
Physicians, nurse practitioners, physician assistants, and other qualified non-physician practitioners (Correct answer)
Only Medicare-certified hospital facilities
Only primary care physicians enrolled in Medicare

Correct answer: Physicians, nurse practitioners, physician assistants, and other qualified non-physician practitioners

CMS accepts diagnoses from physicians and other qualified non-physician practitioners (e.g., NPs, PAs) who are authorized to diagnose under state law and treat within the Medicare program.

Question 23: Which of the following is a characteristic feature of the HHS-HCC model that is NOT present in the CMS-HCC model?

Inclusion of demographic factors like age and gender in risk score calculation.
It is used exclusively for patients in long-term institutional care.
The use of Hierarchical Condition Categories (HCCs).
The inclusion of specific categories for infants and children, and the use of prescription drug categories (RxCs). (Correct answer)

Correct answer: The inclusion of specific categories for infants and children, and the use of prescription drug categories (RxCs).

The HHS-HCC model is designed for the commercial ACA population, which includes all ages. Therefore, it has specific categories for adults, children, and infants. It also incorporates prescription drug data (RxCs) into its calculations, unlike the CMS-HCC model which primarily focuses on medical diagnoses for its payment model.

Question 24: What is the most critical NLP limitation for risk adjustment applications?

NLP is too slow for large-scale processing
NLP may identify negated conditions as positive findings (Correct answer)
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 25: Which technique is most appropriate for estimating future healthcare costs using historical risk adjustment data?

Simple linear regression using RAF scores
Logistic regression for high-cost vs low-cost prediction
Gradient boosted trees incorporating HCCs, demographics, utilization, and pharmacy data (Correct answer)
K-means clustering by cost similarity

Correct answer: Gradient boosted trees incorporating HCCs, demographics, utilization, and pharmacy data

Gradient boosted trees capture non-linear relationships and interactions that simple models miss.

Question 26: When should a combination code be used versus multiple separate codes?

Use the combination code when it accurately describes all documented conditions (Correct answer)
Always use separate codes for maximum specificity
Combination codes are only for inpatient DRG assignment
Assign both the combination code and individual component codes

Correct answer: Use the combination code when it accurately describes all documented conditions

Section I.B.9: use the combination code when it captures all elements. Only add codes if the combination lacks necessary specificity.

Question 27: 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?

Supplemental data submission
Prospective risk adjustment (Correct answer)
RADV audit preparation
Retrospective chart review

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 28: A 72-year-old male is seen for management of his chronic conditions. The physician's assessment documents 'Stage 4 Chronic Kidney Disease' and 'End-Stage Renal Disease (ESRD) on dialysis.' Both conditions are addressed in the plan of care. How should these diagnoses be coded and considered for CMS-HCC risk adjustment?

Query the provider to clarify which condition is the primary focus of the visit.
Code only Stage 4 CKD (N18.4) because it is a more specific stage diagnosis.
Code only ESRD (N18.6) because its corresponding HCC takes precedence over the HCC for Stage 4 CKD. (Correct answer)
Code both ESRD and Stage 4 CKD, as both are documented and managed.

Correct answer: Code only ESRD (N18.6) because its corresponding HCC takes precedence over the HCC for Stage 4 CKD.

The CMS-HCC model uses disease hierarchies to prevent counting multiple codes for the same disease progression. Only the most severe condition in a hierarchy is used for risk score calculation. End-Stage Renal Disease (ESRD) is in a higher-ranking HCC category than Chronic Kidney Disease, Stage 4. Therefore, while both codes are clinically accurate, only the HCC for ESRD will be applied in the payment model.

Question 29: What exception exists to the rule that only provider documentation can be used for coding?

No exceptions exist
Any healthcare professional's documentation works for any condition
BMI, pressure ulcer staging, and social determinants may be coded from non-physician sources like nursing or dietitian notes (Correct answer)
Only inpatient coders can use non-physician documentation

Correct answer: BMI, pressure ulcer staging, and social determinants may be coded from non-physician sources like nursing or dietitian notes

Certain clinical assessments are within non-physician scope, but the related diagnosis must still be documented by a provider.

Question 30: A plan's RAF scores increase 3% year-over-year for five years while FFS benchmarks remain flat. What analytical framework applies?

Apply coding intensity adjustment analysis to distinguish true health changes from coding pattern changes (Correct answer)
Compare only to other MA plans
Review only the most recent year
Celebrate improved documentation

Correct answer: Apply coding intensity adjustment analysis to distinguish true health changes from coding pattern changes

Persistent RAF growth exceeding FFS benchmarks suggests coding practice changes rather than true population health changes.

Question 31: What is a risk score in the context of risk adjustment?

Predicted cost of care (Correct answer)
Appointment frequency
Medical error rate
Test result

Correct answer: Predicted cost of care

In the context of risk adjustment, a risk score is a numerical value assigned to a patient based on their demographic information and documented diagnoses. This score is used to predict the anticipated healthcare costs for that individual in a future period. Health plans use these scores to receive appropriate reimbursement for managing patients with varying health complexities.

Question 32: How can risk adjustment coding data support a heart failure readmission reduction initiative?

By coding HF at the highest severity level
By identifying all HF members, their complication profiles, and risk stratification for targeted care management (Correct answer)
By increasing RAF scores to generate revenue for programs
Risk adjustment data cannot be used for quality improvement

Correct answer: By identifying all HF members, their complication profiles, and risk stratification for targeted care management

Accurate coding creates a comprehensive dataset enabling risk stratification and targeted interventions.

Question 33: A patient has 'chronic pain syndrome' and 'chronic pain due to left hip osteoarthritis.' How should the coder proceed?

Code G89.4 as it encompasses all chronic pain
Code G89.29 and M16.12
Code G89.4 and M16.12, with the underlying condition first (Correct answer)
Code M16.12 only as the underlying cause

Correct answer: Code G89.4 and M16.12, with the underlying condition first

Per ICD-10-CM guidelines, when chronic pain syndrome coexists with an identified cause, both should be coded with the underlying condition sequenced first.

Question 34: What does HCC stand for in risk adjustment coding?

Hierarchical Condition Category (Correct answer)
Hospital Care Category
Health Compliance Category
Health Care Code

Correct answer: Hierarchical Condition Category

HCC stands for Hierarchical Condition Category, which is a risk adjustment model used by Medicare and other payers to predict future healthcare costs for patients. These categories group diagnoses that have similar cost implications, allowing for more accurate risk assessment and fair reimbursement to healthcare providers. Accurate HCC coding is crucial for appropriate payment based on patient health status.

Question 35: What is the primary goal of a 'chase program' in risk adjustment?

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

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 36: How does risk adjustment data quality affect the HEDIS Controlling High Blood Pressure measure?

No impact on blood pressure measures
Only pharmacy data affects blood pressure measures
Higher codes increase payment but decrease quality scores
Accurate hypertension coding ensures all hypertensive members are in the denominator (Correct answer)

Correct answer: Accurate hypertension coding ensures all hypertensive members are in the denominator

HEDIS CBP requires identifying all members with hypertension. If hypertension is uncoded for some members, the denominator is incomplete.

Question 37: Which of the following conditions would MOST likely increase a patient's risk score significantly?

Seasonal allergies
Mild hypertension controlled by diet
Stage 4 chronic kidney disease with diabetes (Correct answer)
History of a minor sprain

Correct answer: Stage 4 chronic kidney disease with diabetes

Stage 4 CKD with diabetes represents multiple high-cost HCCs that significantly increase a patient's predicted cost and risk score.

Question 38: An MA plan receives a qui tam complaint alleging risk adjustment fraud. What protections does the whistleblower have?

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

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

I50.22 Chronic systolic heart failure
I50.23 Acute on chronic systolic heart failure (Correct answer)
I50.9 Heart failure, unspecified
I50.21 Acute 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 40: How is the causal relationship between diabetes and a complication established under ICD-10-CM guidelines?

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

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 41: An 82-year-old male is seen for an annual wellness visit. The problem list includes 'History of lung cancer.' In the HPI, the physician notes, 'Patient had lung cancer treated with resection 6 years ago, no evidence of recurrence, on surveillance only.' The assessment and plan for the visit do not address the cancer. How should the coder report the lung cancer diagnosis for this encounter?

Code the active lung cancer, as it is part of the patient's permanent medical history.
Assign code Z85.118 (Personal history of malignant neoplasm of bronchus and lung) as the condition is resolved and not currently being treated. (Correct answer)
Query the provider to confirm if the cancer is considered 'cured' or 'in remission'.
Do not code the cancer in any form, as it was not part of the active assessment and plan.

Correct answer: Assign code Z85.118 (Personal history of malignant neoplasm of bronchus and lung) as the condition is resolved and not currently being treated.

For risk adjustment, a diagnosis must be current and meet MEAT (Monitored, Evaluated, Assessed, Treated) criteria for the specific encounter. The documentation clearly indicates the cancer is resolved, not under active treatment, and only subject to surveillance. Therefore, coding it as an active malignancy would be non-compliant. The correct approach is to use a 'personal history of' code (Z85.118), which accurately reflects the patient's condition but does not map to a cancer HCC.

Question 42: A patient with CKD stage 4 develops secondary hyperparathyroidism. What pathophysiological mechanism connects these conditions?

Excess calcium absorption stimulates PTH release
Uremia causes parathyroid hypertrophy independently
Kidney disease directly damages parathyroid glands
Impaired kidneys reduce vitamin D activation, lowering calcium and triggering PTH overproduction (Correct answer)

Correct answer: Impaired kidneys reduce vitamin D activation, lowering calcium and triggering PTH overproduction

Failing kidneys cannot convert vitamin D to its active form, leading to hypocalcemia and compensatory PTH overproduction.

Question 43: What is the relationship between RAPS and EDS for risk adjustment?

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
RAPS and EDS are identical systems

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

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

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 45: What is the key distinction between prospective and retrospective risk adjustment activities from a compliance standpoint?

Prospective activities require CMS pre-approval; retrospective activities do not
Retrospective activities must be supported by face-to-face encounter documentation; prospective activities occur during live patient visits (Correct answer)
Prospective activities are always compliant; retrospective activities are not
There is no compliance difference between the two strategies

Correct answer: Retrospective activities must be supported by face-to-face encounter documentation; prospective activities occur during live patient visits

Retrospective diagnoses must be supported by valid face-to-face encounter documentation; prospective activities capture diagnoses during actual patient encounters, making both compliant when properly documented.

Question 46: In ICD-10-CM, an instructional note states 'Code first underlying condition.' This note is associated with a manifestation code. What does this indicate to the coder?

The underlying condition is optional and coded only if known.
The manifestation code can never be the principal diagnosis. (Correct answer)
The manifestation code should be sequenced before the underlying condition.
This note only applies to inpatient coding scenarios.

Correct answer: The manifestation code can never be the principal diagnosis.

The 'Code first' note is a sequencing instruction indicating that the underlying etiology must be coded first, before the manifestation code. Therefore, the manifestation code, which has this instructional note, can never be sequenced as the principal or first-listed diagnosis.

Question 47: 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)
HRA findings cannot be used under any circumstances
All HRA checklist conditions are automatically codable
Only if the PCP subsequently confirms

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 48: How did CMS-HCC V28 change substance use disorder categorization?

Substance use disorders were removed entirely
V28 created more granular categories differentiating by substance type and severity (Correct answer)
V28 combined all into a single HCC
The change only affected payment timing

Correct answer: V28 created more granular categories differentiating by substance type and severity

V28 recognizes that different substances and severity levels predict different cost patterns, requiring more specific coding.

Question 49: When should Z-codes be used as the principal or first-listed diagnosis?

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

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

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

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 51: 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 with an uncertain diagnosis modifier
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 as confirmed since the physician wrote it in the assessment

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 52: During a RADV audit, an auditor reviews HCC 18 based on code E11.22. The chart shows 'diabetes with renal manifestations' but no mention of CKD. What is the likely outcome?

HCC will be deleted due to insufficient specificity
The audit will defer to the submitting organization
HCC will be downgraded to HCC 19
HCC will be confirmed because diabetes with renal manifestations supports E11.22 (Correct answer)

Correct answer: HCC will be confirmed because diabetes with renal manifestations supports E11.22

Documentation of 'diabetes with renal manifestations' generally supports a diabetic kidney condition and E11.22.

Question 53: What is the minimum coding intensity adjustment CMS applies to MA risk adjustment payments?

A variable adjustment based on individual audit results
A mandatory 5.91% reduction to all MA risk scores to account for MA-FFS coding differences (Correct answer)
10% reduction for plans below 3.0 Stars
An increase for dual-eligible populations

Correct answer: A mandatory 5.91% reduction to all MA risk scores to account for MA-FFS coding differences

The 5.91% reduction accounts for the documented fact that MA plans capture more diagnoses than FFS Medicare.

Question 54: When abstracting data, which type of documentation should be avoided?

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

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 55: 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 56: What is the MEAT criteria used for?

To justify diagnosis coding (Correct answer)
To define disease stages
To calculate a patient’s BMI
To identify billing errors

Correct answer: To justify diagnosis coding

The MEAT criteria (Monitored, Evaluated, Assessed, Treated) are essential guidelines used to justify the reporting of a diagnosis, particularly for risk adjustment. These criteria ensure that the medical record documentation demonstrates that a chronic condition was actively managed by the provider during the encounter. This validation confirms the ongoing impact of the condition on the patient's health and the resources required for their care.

Question 57: What is the purpose of a compliance program in medical coding?

Increase revenue automatically
Reduce patient volume
Avoid chart reviews
Promote accurate coding and prevent fraud (Correct answer)

Correct answer: Promote accurate coding and prevent fraud

A compliance program in medical coding is a structured set of policies and procedures designed to ensure adherence to all relevant laws, regulations, and ethical standards. Its primary purpose is to promote accurate and ethical coding practices, thereby preventing errors, waste, abuse, and fraudulent activities. This proactive approach helps protect the organization from legal and financial penalties.

Question 58: What is the recommended minimum sample size for validating a suspected documentation gap pattern?

10 charts
50 charts regardless of population size
A statistically significant sample with 95% confidence and 5% margin of error (Correct answer)
All matching charts must be reviewed

Correct answer: A statistically significant sample with 95% confidence and 5% margin of error

Statistical rigor requires a sample calculated based on population size, confidence level, and margin of error.

Question 59: When a provider documents 'suspected' or 'probable' condition in an outpatient encounter, how should the coder handle this for risk adjustment?

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

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 60: What is the significance of the 'one-best-code' methodology in RADV audits?

Plans must identify the best code before submission
Auditors assign the single most accurate code, which may differ from what was submitted (Correct answer)
Only one code per HCC category is validated per year
Auditors select only one code per encounter

Correct answer: Auditors assign the single most accurate code, which may differ from what was submitted

RADV coders independently assign what they determine to be the most accurate code. If it differs from the submitted code and maps differently, the submitted HCC may be deleted.

Question 61: 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?

Ignore the issue as it is the provider's sole responsibility.
Automatically assign the higher-weighted HCC based on lab values alone.
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.

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 62: 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?

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

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 63: 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)
Limit reviews to specialist encounters
Only review encounters for patients with low RAF scores
Review every encounter for every patient

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 64: A physician documents 'patient is malnourished.' The dietitian's assessment documents 'severe protein-calorie malnutrition with BMI 15.2.' For CDI purposes, which source can be used?

The dietitian's assessment directly
Both sources are equally valid
Only the physician's documentation
A CDI query should be generated for the physician to confirm the severity (Correct answer)

Correct answer: A CDI query should be generated for the physician to confirm the severity

Best practice for risk adjustment is to have the physician document or confirm the severity, creating the strongest documentation for RADV audit defense.

Question 65: What coding principle is critical when submitting an HCC diagnosis?

Rely on patient recall
Always use unspecified codes
Document MEAT criteria (Monitored, Evaluated, Assessed, Treated) (Correct answer)
Use of highest-paying code

Correct answer: Document MEAT criteria (Monitored, Evaluated, Assessed, Treated)

When submitting an HCC diagnosis, it is critical that the medical record documentation supports the active management of the condition. The MEAT criteria (Monitored, Evaluated, Assessed, Treated) ensure that the provider's notes clearly demonstrate the ongoing nature and impact of the chronic condition. This documentation validates the diagnosis for risk adjustment purposes, proving it was addressed during the encounter.

Question 66: What is the 'frailty adjuster' in Medicare Advantage risk adjustment?

A penalty for incomplete documentation
An additional payment for enrollees in institutional settings (Correct answer)
A bonus for preventive screenings
A reduction in payment for healthy enrollees

Correct answer: An additional payment for enrollees in institutional settings

The frailty adjuster provides additional payment for institutionalized enrollees who have higher care needs not fully captured by HCCs.

Question 67: An addendum is added 45 days after the original encounter. Under what conditions is this acceptable for risk adjustment?

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

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 68: Which of the following is used when no prior-year diagnosis data exists for a newly enrolled MA member?

Disease hierarchy model
Standard demographic factor only
New enrollee model using only demographic factors (Correct answer)
ESRD adjustment

Correct answer: New enrollee model using only demographic factors

The new enrollee model uses only demographic factors such as age, sex, and Medicaid status since no prior-year diagnosis data exists for newly enrolled members.

Question 69: In which scenario is retrospective CDI review more appropriate than concurrent review?

When the provider is available for real-time queries
When capturing HCCs for the current payment year
When the patient is still hospitalized
When analyzing prior year encounter data to identify systematic documentation gaps (Correct answer)

Correct answer: When analyzing prior year encounter data to identify systematic documentation gaps

Retrospective CDI is most appropriate for analyzing historical data to identify systematic patterns and inform future documentation improvement.

Question 70: A coder encounters 'history of breast cancer, currently on tamoxifen for chemoprevention' after mastectomy 3 years ago with no recurrence. Which code applies?

C50.911 and Z85.3 together
Z85.3 Personal history of malignant neoplasm of breast (Correct answer)
C50.911 Malignant neoplasm of breast
Z86.000 Personal history of in-situ neoplasm

Correct answer: Z85.3 Personal history of malignant neoplasm of breast

Z85.3 is appropriate when cancer has been excised with no recurrence. Tamoxifen for chemoprevention does not indicate active cancer.

Question 71: What happens when a diagnosis code does not map to any HCC?

The diagnosis is stored but does not affect RAF — only HCC-mapped conditions contribute to payment (Correct answer)
The diagnosis is rejected
CMS assigns the nearest matching HCC
The plan receives a default minimum payment

Correct answer: The diagnosis is stored but does not affect RAF — only HCC-mapped conditions contribute to payment

Approximately 9,500 of 70,000+ ICD-10-CM codes map to HCCs. Non-HCC codes are still submitted for completeness and quality measurement.

Question 72: What is the 'face-to-face' requirement in risk adjustment documentation?

A CMS audit procedure
In-person meetings between plan and CMS officials
The requirement that diagnoses be documented during an in-person or qualifying telehealth encounter with a provider (Correct answer)
A requirement for provider network meetings

Correct answer: The requirement that diagnoses be documented during an in-person or qualifying telehealth encounter with a provider

Risk adjustment regulations require diagnoses to be documented during face-to-face or qualifying telehealth encounters with eligible providers — administrative-only documentation is insufficient.

Question 73: Which data visualization is most effective for presenting risk adjustment patterns to non-technical stakeholders?

Heat maps showing capture rates compared to benchmarks by provider (Correct answer)
Pie charts of HCC distribution
Raw data tables of code frequencies
Regression output with coefficients

Correct answer: Heat maps showing capture rates compared to benchmarks by provider

Heat maps provide intuitive visual comparison that non-technical stakeholders can immediately understand.

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

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

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: A health plan implements a new program to reduce 30-day hospital readmissions. They successfully lower the readmission rate (an outcome measure) but notice a significant drop in patient satisfaction scores because patients feel they are being discharged too quickly. This drop in satisfaction would be considered what type of measure?

A process measure
A structural measure
A concurrent measure
A balancing measure (Correct answer)

Correct answer: A balancing measure

A balancing measure is used to track unintended consequences, which can be positive or negative, that arise from a quality improvement initiative. In this scenario, while the intended outcome (lower readmissions) was achieved, it had a negative impact on another aspect of care (patient satisfaction), which is what a balancing measure is designed to capture.

Question 76: A health plan's risk adjustment strategy includes both prospective outreach AND retrospective chart review. The PRIMARY advantage of this combined approach is:

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

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 77: When coding alcoholic cirrhosis and hepatitis C together, which convention applies?

Code hepatitis C first as underlying cause
Use a combination code
Code both K70.30 and B18.2 as independent conditions (Correct answer)
Code only alcoholic cirrhosis as the more severe condition

Correct answer: Code both K70.30 and B18.2 as independent conditions

These are independent conditions with separate etiologies. K70.30 maps to HCC 28 and B18.2 maps to HCC 29.

Question 78: A patient undergoes a routine screening colonoscopy, and a benign polyp is found and removed. What is the appropriate first-listed diagnosis?

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

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

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

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

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.
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)
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 81: What federal agency enforces healthcare fraud and abuse laws?

DEA
OIG (Correct answer)
NIH
IRS

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 82: 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 83: What pathophysiological process causes kidney involvement in SLE?

Autoantibodies and immune complexes deposit in glomeruli, triggering inflammation (Correct answer)
T-cell infiltration destroys renal tubules
SLE causes renal artery vasculitis
Lupus medications are nephrotoxic

Correct answer: Autoantibodies and immune complexes deposit in glomeruli, triggering inflammation

Autoantibodies form immune complexes that deposit in the glomerular basement membrane, activating complement and triggering inflammation.

Question 84: A provider documents 'COPD with acute exacerbation' and 'cor pulmonale.' What connects these?

Left heart failure from COPD strains the right heart
COPD medications cause right ventricular hypertrophy
Chronic coughing compresses the right ventricle
Chronic hypoxia causes pulmonary vasoconstriction leading to right heart strain (Correct answer)

Correct answer: Chronic hypoxia causes pulmonary vasoconstriction leading to right heart strain

COPD causes chronic hypoxia, triggering pulmonary vasoconstriction and eventually pulmonary hypertension and right heart failure.

Question 85: 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
M80.051A (Correct answer)
Z87.81, M80.051A
M81.0, S72.001A

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

A health plan's internal review of all submitted diagnoses for accuracy
A scheduled CMS processing run that incorporates newly submitted encounter data into risk score calculations (Correct answer)
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 87: Why is accurate medical record documentation essential in risk adjustment coding?

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

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 88: A CDI specialist notices lab values showing eGFR of 22 mL/min but the physician only documents 'renal insufficiency.' What is the appropriate CDI action?

Code N18.4 for CKD stage 4 based on lab values alone
Query the provider to document CKD stage consistent with the eGFR findings (Correct answer)
Document the CKD stage in a CDI note for the coder
Wait for the discharge summary for additional specificity

Correct answer: Query the provider to document CKD stage consistent with the eGFR findings

CDI specialists cannot diagnose based on lab values alone. The appropriate action is to query the provider to document the CKD stage.

Question 89: A CDI specialist notices that a physician consistently documents 'CKD' for patients with chronic kidney disease without specifying the stage. Why is this a significant issue for risk adjustment?

It prevents the assignment of a more specific HCC that reflects a higher disease burden and risk score. (Correct answer)
It only matters for inpatient coding, not ambulatory encounters.
It violates HIPAA regulations regarding patient privacy.
It is not an issue, as 'CKD' maps to a valid HCC.

Correct answer: It prevents the assignment of a more specific HCC that reflects a higher disease burden and risk score.

Different stages of Chronic Kidney Disease (CKD) map to different HCCs, with later stages representing a higher severity and, therefore, a higher risk adjustment factor (RAF) score. Failing to document the specific stage (e.g., Stage 3, Stage 4, ESRD) prevents accurate capture of the patient's disease burden and results in an under-representation of their health risk.

Question 90: What is a common reason encounter data records are rejected by CMS?

Submitting records electronically
Invalid or missing NPI numbers (Correct answer)
Including the enrollee's date of birth
Using ICD-10-CM codes correctly

Correct answer: Invalid or missing NPI numbers

Missing or invalid National Provider Identifier (NPI) numbers are a common cause of encounter data rejection by CMS.

Question 91: What does the CMS-HCC model use to predict?

Patient satisfaction scores
Future healthcare expenditures (Correct answer)
Hospital readmission rates
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 92: Supplemental data sources used in retrospective risk adjustment most commonly include which of the following?

Medical records, lab data, and pharmacy data reviewed outside the normal claims flow (Correct answer)
Member satisfaction surveys
Lab results and pharmacy data only
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 93: A Medicare Advantage plan analyzes its claims and pharmacy data to identify members with a diagnosis of diabetes who are also prescribed medications for chronic kidney disease (CKD), but have no corresponding diagnosis of CKD in their claims history. What is this data analysis process an example of?

D A CMS-mandated RADV audit.
C Predictive modeling for diagnostic suspecting. (Correct answer)
B HEDIS measure reporting for quality of care.
A Fraud, Waste, and Abuse (FWA) investigation.

Correct answer: C Predictive modeling for diagnostic suspecting.

This scenario describes predictive modeling, or suspecting, where data is mined to find patterns (e.g., specific prescriptions) that suggest the presence of an undocumented or uncoded chronic condition. The goal is to identify potential gaps in clinical documentation to be reviewed for accuracy, not to assume fraud or conduct a formal audit. [10, 6]

Question 94: A 65-year-old patient with a long history of Type 2 diabetes presents with declining kidney function. Lab work confirms Stage 4 Chronic Kidney Disease (CKD). The physician documents "diabetic nephropathy" and "Stage 4 CKD." From a pathophysiological standpoint, why is it critical for a coder to ensure these two conditions are linked in the claim?

It allows the provider to bill for additional, unrelated lab services.
Linking them is an internal tracking metric that does not change the risk score.
It is only necessary to code the Stage 4 CKD, as it is the more severe condition.
Linking the conditions establishes a causal relationship that accurately reflects the disease process and triggers a higher-weighted HCC for diabetes with chronic complications. (Correct answer)

Correct answer: Linking the conditions establishes a causal relationship that accurately reflects the disease process and triggers a higher-weighted HCC for diabetes with chronic complications.

The pathophysiology of diabetic nephropathy involves damage to the glomeruli from chronic hyperglycemia. ICD-10-CM provides combination codes (e.g., E11.22) to capture this specific causal link. Accurately coding this relationship reflects the patient's true disease burden and maps to a higher-weighted HCC (e.g., HCC 37) than coding diabetes and CKD as separate, unrelated conditions.

Question 95: Which of the following is a best practice for regulatory compliance in coding?

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

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 96: A patient with Hb-SS sickle cell disease presents with acute chest syndrome and pain crisis. What is the correct coding?

D57.00 for sickle cell with crisis, unspecified
D57.01 for acute chest syndrome, which encompasses the crisis state (Correct answer)
D57.01 and D57.02 coded separately
D57.01 and D57.00 separately

Correct answer: D57.01 for acute chest syndrome, which encompasses the crisis state

D57.01 specifically identifies acute chest syndrome in Hb-SS disease, which inherently indicates a crisis state.

Question 97: A 68-year-old male presents for a follow-up visit for his Type 2 diabetes and hypertension. The physician documents the patient's diabetes is complicated by peripheral vascular disease (PVD). How should this be coded in ICD-10-CM?

E11.9, I73.9
I73.9, E11.9
E11.51 (Correct answer)
E11.69, I70.90

Correct answer: E11.51

ICD-10-CM provides a combination code, E11.51, for Type 2 diabetes mellitus with diabetic peripheral angiopathy without gangrene. This single code accurately captures both the diabetes and the specified complication of PVD, reflecting the causal relationship. Using separate codes for the conditions is incorrect when a specific combination code is available.

Question 98: In applying HCCs for a dual-eligible patient (Medicare and Medicaid), what additional factor must the coder consider?

Dual-eligible patients require separate HCC submissions to each program
Medicaid diagnoses cannot be used for Medicare risk adjustment
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 99: Which risk adjustment strategy involves reviewing medical records AFTER the date of service to identify and submit diagnoses that support HCC capture?

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

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 100: In a prospective risk adjustment program, a provider receives a 'HCC gap report' prior to a patient's annual wellness visit. The provider's APPROPRIATE use of this report is to:

Bill for each listed HCC diagnosis to capture the risk score revenue
Automatically add all listed HCC diagnoses to the encounter without clinical assessment
Use the report as a clinical prompt to review and assess each listed condition during the visit, documenting only those confirmed as current and active (Correct answer)
Return the report to the health plan without review since it is not part of the medical record

Correct answer: Use the report as a clinical prompt to review and assess each listed condition during the visit, documenting only those confirmed as current and active

HCC gap reports are clinical prompts to help providers remember to assess and document chronic conditions; providers must clinically evaluate each condition and document only those that are current, active, and confirmed.

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%

To Pass

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