Medical Record Coding
70%of exam
Risk Adjustment Models
15%of exam
Compliance Audit
15%of exam
Quick Facts
- Exam
- CRC
- Owner
- AAPC
- Questions
- 100 MCQ
- Time
- 4 hours
- Pass
- 70%
- Book
- ICD-10-CM
- Core model
- CMS-HCC
- Score
- RAF impact
- Focus
- Valid diagnoses
MEAT
Monitor, evaluate, assess, treat.
MonitorEvaluateAssessTreat
MEAT vs Problem List
MEAT
- Current support
- Provider action
Problem list
- Stored history
- Needs validation
Lists alone fail
Code Picker
- Diagnosis documented→ICD index
- Index found→Tabular verify
- Guideline note→Follow sequencing
- Complication stated→Combination code
- Unclear linkage→Provider query
- Unsupported only→Do not code
ICD Conventions
- Code first
- Sequence etiology first
- Use additional
- Add required detail
- Excludes1
- Never code together
- Excludes2
- May code together
- NEC
- Other specified
- NOS
- Unspecified
- Laterality
- Side documented
- 7th character
- Episode detail
ICD Flow
Index, tabular, notes, specificity.
IndexTabularNotesSpecificity
Acute vs Chronic
Acute
- Current episode
- May resolve
Chronic
- Ongoing condition
- Annual recapture
Acuity changes code
Specificity
- Type
- Disease subtype
- Stage
- Severity level
- Acuity
- Acute or chronic
- Complication
- Linked condition
- Manifestation
- Disease effect
- Status
- Ongoing state
- History
- Past condition
- Provider
- Diagnosis source
Active vs History
Active
- Under treatment
- May risk-adjust
History
- No active disease
- Status/history code
Treatment status decides
Chronic Conditions
- Diabetes
- Type plus complication
- CKD
- Stage matters
- CHF
- Type and acuity
- COPD
- Chronic pulmonary disease
- Cancer
- Active versus history
- Stroke
- Acute or sequela
- Amputation
- Status code often
- Morbid obesity
- BMI supports code
MEAT Documentation
- Monitor
- Track condition status
- Evaluate
- Review test results
- Assess
- Clinical judgment
- Treat
- Medication or plan
- Signature
- Provider authentication
- Date
- Current encounter
- Linkage
- Cause-effect documented
- Query
- Clarify incomplete record
Chart Review
- Encounter
- Face-to-face evidence
- Assessment
- Provider diagnosis list
- Plan
- Management evidence
- Labs
- Support not code alone
- Medication
- Support not code alone
- Problem list
- Needs current support
- Copy-forward
- Validate current status
- Addendum
- Must be authenticated
Clinical Anchors
- A1c
- Diabetes control marker
- GFR
- Kidney stage clue
- EF
- Heart failure clue
- BMI
- Obesity support
- Dialysis
- ESRD support
- Metastasis
- Advanced cancer clue
- Hemiplegia
- Stroke sequela clue
- Ostomy
- Status clue
HCC Flow
Diagnosis maps, hierarchy filters, RAF sums.
DiagnosisHierarchyRAF
CMS-HCC vs HHS-HCC
CMS-HCC
- Medicare Advantage
- Older population
HHS-HCC
- ACA marketplace
- Commercial population
Population controls model
Model Picker
- Medicare Advantage→CMS-HCC
- ACA marketplace→HHS-HCC
- Medicaid population→CDPS
- Drug benefit→RxHCC
- Severe category exists→Hierarchy
- New year starts→Recapture
Model Basics
- CMS-HCC
- Medicare Advantage model
- HHS-HCC
- ACA marketplace model
- CDPS
- Medicaid risk model
- RxHCC
- Drug payment model
- RAF
- Relative risk score
- Demographics
- Age/sex factors
- Hierarchy
- Severe condition wins
- Recapture
- Annual chronic capture
RAF HCC
- HCC
- Condition category
- Mapping
- ICD to HCC
- Coefficient
- Model weight
- Baseline
- RAF near 1.0
- Additive
- Factors combine
- Interaction
- Disease pair effect
- Deletion
- Remove unsupported code
- Payment
- Risk-adjusted capitation
Audit Flow
Evidence, code, support, trail.
EvidenceCodeSupportTrail
Upcoding vs Undercoding
Upcoding
- Unsupported severity
- Overpayment risk
Undercoding
- Missed valid risk
- Incomplete picture
Accuracy beats direction
Audit Picker
- Before claim feed→Prospective review
- After submission→Retrospective review
- CMS validation→RADV
- Unsupported HCC→Deletion file
- Ambiguous record→Compliant query
- Pattern error→Education plan
Compliance Basics
- FCA
- False claims risk
- OIG
- Federal oversight
- CMS
- Program authority
- Overpayment
- Return identified funds
- Undercoding
- Missed supported risk
- Upcoding
- Unsupported higher risk
- Balanced coding
- Accurate both ways
- Audit trail
- Evidence of decision
Prospective vs Retrospective
Prospective
- Before submission
- Prevents errors
Retrospective
- After encounter
- Finds gaps
Timing decides name
Audit Types
- RADV
- Risk data validation
- Prospective
- Before submission
- Retrospective
- After encounter
- Chart chase
- Retrieve records
- Deletion file
- Remove bad diagnoses
- Sampling
- Review subset
- Extrapolation
- Project error impact
- Remediation
- Correct process gap
Common Traps
Problem List Trap
Listed diagnosis ≠ Supported diagnosis
History Trap
Active cancer ≠ History of cancer
Lab Trap
Abnormal result ≠ Provider diagnosis
Linkage Trap
Diabetes with CKD ≠ Separate conditions
Hierarchy Trap
Multiple HCCs ≠ Highest HCC counts
Compliance Trap
Higher RAF ≠ Supported RAF
Last Minute
- 1.Start with provider diagnosis
- 2.Verify tabular instructions
- 3.Check Excludes notes
- 4.Capture only current support
- 5.Confirm MEAT evidence
- 6.Query unclear linkage
- 7.Distinguish active from history
- 8.Respect HCC hierarchies
- 9.Document audit rationale
- 10.Code both directions accurately
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