AAPC CRC Certified Risk Adjustment Coder

What is the primary purpose of the CMS-HCC risk adjustment model?

• ATo determine eligibility for Medicare Part A benefits
• BTo calculate copay amounts for Medicare beneficiaries
• CTo establish fee-for-service reimbursement rates for hospitals
• DTo predict healthcare costs and adjust payments to Medicare Advantage plans based on pati…

In the CMS-HCC model, what does the Risk Adjustment Factor (RAF) score represent?

• AThe number of chronic conditions a patient has been diagnosed with
• BA numerical value that predicts a beneficiary's expected healthcare costs relative to the…
• CThe total number of ICD-10-CM codes submitted for a patient in a calendar year
• DThe quality rating assigned to a Medicare Advantage plan

Which of the following is a key difference between the CMS-HCC model and the HHS-HCC model?

• AThe CMS-HCC model is used for Medicare Advantage, while the HHS-HCC model is used for the…
• BThe CMS-HCC model is used for the ACA marketplace, while HHS-HCC is used for Medicare Adv…
• CThe HHS-HCC model only uses demographic factors, not diagnosis codes
• DThe CMS-HCC model does not use hierarchies to organize condition categories

What does the term 'hierarchy' refer to in the CMS-HCC model?

• AThe order in which diagnosis codes must be submitted to CMS
• BThe organizational structure of a Medicare Advantage plan
• CThe ranking of related conditions so that only the most severe condition in a category is…
• DThe sequence of provider credentials required for documentation

How often must chronic conditions be documented and reported for risk adjustment purposes in the CMS-HCC model?

• AOnce when first diagnosed, then never again
• BEvery six months
• CAt least once every calendar year
• DOnly when the patient is hospitalized

A patient has documented diagnoses of Type 2 diabetes with diabetic chronic kidney disease (CKD) stage 3, and also Type 2 diabetes without complications. In the CMS-HCC model, how are these conditions treated?

• ABoth conditions are counted and their RAF values are added together
• BOnly the Type 2 diabetes without complications is counted since it was documented first
• CThe hierarchy applies, and only the more severe condition (diabetes with CKD) is counted
• DNeither condition is counted because they conflict with each other

What are disease interaction terms in the CMS-HCC model?

• ACodes that indicate a patient has been referred to a specialist
• BAdditional RAF value added when certain combinations of HCC conditions coexist in the sam…
• CDiagnosis codes that are automatically excluded from risk adjustment
• DTerms used to describe the progression of a single disease

Which demographic factors are included in the CMS-HCC RAF score calculation?

• AAge, sex, income level, and education
• BAge, sex, Medicaid dual-eligibility status, and institutional/community setting
• CAge, race, geographic region, and marital status
• DSex, employment status, number of dependents, and zip code

In the context of risk adjustment, what is 'suspect logic'?

• AA method used by the OIG to identify fraudulent coding patterns
• BAn analytical approach that uses claims data and clinical indicators to identify conditio…
• CA process where coders suspect a diagnosis based on symptoms alone without provider docum…
• DA CMS algorithm that automatically removes unverified diagnoses from risk adjustment data

What is the Medicaid Chronic Illness and Disability Payment System (CDPS)?

• AA Medicare fee-for-service payment model
• BA federal disability determination system for Social Security benefits
• CA quality improvement program for hospitals treating chronically ill patients
• DA risk adjustment model used to adjust capitation payments for Medicaid managed care plans

Under CMS-HCC Model V28, which of the following is a significant change from the previous V24 model?

• AAll ICD-10-CM codes now map to an HCC
• BThe number of HCCs was reduced from 86 to 50
• COver 2,000 ICD-10-CM codes that previously mapped to a payment HCC no longer map to one i…
• DDemographic factors were removed from the RAF score calculation

What role do CMS Star Ratings play in Medicare Advantage risk adjustment?

• AThey directly determine each patient's RAF score
• BThey replace the HCC model for plans with a 5-star rating
• CThey measure plan quality and performance, which can affect plan bonuses and rebates but…
• DThey are used exclusively for Medicaid managed care quality measurement

Which of the following encounter types is NOT acceptable for risk adjustment data submission to CMS?

• AFace-to-face office visit with a physician
• BTelehealth visit with a qualified provider
• CHospital inpatient admission
• DLab result without a face-to-face or telehealth provider encounter

What does the acronym MEAT stand for in the context of risk adjustment documentation?

• AMedical Evaluation and Assessment Tool
• BMedicare Enrollment and Assignment Terminology
• CMandatory Encounter Audit Tracking
• DMonitor, Evaluate, Assess/Address, Treat

A provider documents 'history of breast cancer' for a patient who completed treatment 5 years ago with no evidence of current disease. How should this be coded for risk adjustment?

• ACode Z85.3 — Personal history of malignant neoplasm of breast
• BCode the active malignant neoplasm of the breast
• CCode the breast cancer as a current chronic condition
• DDo not code it because the condition is resolved