Free CRC Exam Flashcards

The CRC tests whether you can abstract supported diagnoses, assign accurate ICD-10-CM codes, understand HCC risk models, and recognize compliance risk.

Local metadata lists 70%, or 70 of 100 questions, as the passing score for the AAPC CRC exam.

CRC candidates must navigate ICD-10-CM quickly. Tabular instructions, chapter guidelines, Excludes notes, and code specificity drive correct answers.

Risk adjustment predicts expected healthcare cost or resource use based on demographics and documented health status, so plans are paid more fairly for sicker populations.

The CMS-HCC model maps selected ICD-10-CM diagnoses to hierarchical condition categories for Medicare Advantage payment adjustment.

A Risk Adjustment Factor score estimates expected cost relative to an average beneficiary. A RAF above 1.0 predicts above-average cost.

Capitation pays a fixed amount per member for a period. Risk adjustment modifies that payment based on the member's documented risk.

A hierarchy ranks related conditions so only the most severe category in that disease group counts for payment, preventing double counting.

Chronic HCC conditions generally must be documented and reported each calendar year. A condition captured last year does not automatically count this year.

CMS-HCC is used for Medicare Advantage populations. HHS-HCC is used for Affordable Care Act commercial marketplace risk adjustment.

CDPS is a risk adjustment model often associated with Medicaid populations. CRC candidates should recognize that different payers use different models.

Risk models may include age, sex, Medicaid status, disability status, institutional status, and other demographic variables in addition to diagnosis codes.

MEAT stands for Monitor, Evaluate, Assess or Address, and Treat. At least one supported element can help validate a diagnosis for risk adjustment.

Monitor documentation shows the provider tracked a condition, such as reviewing labs, symptoms, disease status, or treatment response.

Evaluate documentation shows the provider assessed test results, disease progression, exam findings, or clinical significance of a condition.

Assess or address documentation shows the provider considered the condition in the assessment, impression, status, or decision-making.

Treat documentation shows medication, referral, procedure, counseling, monitoring plan, or other management for the condition.

A query asks the provider to clarify incomplete, inconsistent, vague, or conflicting documentation. It must be nonleading and clinically supported.

Prospective review happens before or at the visit to identify suspected chronic conditions and gaps that the provider may need to evaluate and document.

Concurrent review occurs during the encounter or care episode, allowing documentation clarification while the provider can still address the patient record promptly.

Retrospective review examines completed records after the encounter to find supported diagnoses, missed HCCs, or unsupported submitted codes.

Suspect logic uses clues such as medications, labs, claims, or history to flag possible conditions. The coder still needs provider documentation before coding.

Risk adjustment coding requires the most specific ICD-10-CM code supported by documentation. Unspecified codes may fail to map or may understate severity.

Do not code probable, suspected, questionable, rule-out, or differential diagnoses as confirmed in outpatient risk adjustment. Code known signs, symptoms, or confirmed conditions.

Use active cancer codes when disease is present or under active treatment. Use personal history codes when treatment is complete and there is no evidence of current disease.

If Type 2 diabetes is documented without complications, code uncomplicated diabetes. Do not infer complications from medication alone; query when clinical indicators support more specificity.

ICD-10-CM presumes a causal relationship between diabetes and CKD unless documentation says otherwise. Use a diabetes-with-CKD code plus the CKD stage code.

When hypertension and CKD are documented, ICD-10-CM presumes a relationship unless another cause is stated. Use the hypertensive CKD combination code and CKD stage.

Documented type and acuity matter: systolic, diastolic, acute, chronic, and acute on chronic codes can map differently than unspecified heart failure.

COPD with acute exacerbation is more specific than unspecified COPD. Code only what the provider documents and supports.

Code the documented CKD stage. A dialysis-dependent patient is commonly coded as ESRD with dialysis status when documentation supports it.

Residual deficits from an old stroke are coded with sequelae codes, not acute stroke codes. Current hemiplegia or other deficits may risk-adjust.

When supported, code the primary malignancy, metastatic site, and related conditions such as cachexia. Complete capture reflects disease burden.

A completed amputation is coded with an acquired absence status code when relevant. Status codes can carry risk adjustment value and need annual recapture when current.

A current tracheostomy can be reported with a status code when it is relevant to the encounter and supported by documentation.

Excludes1 means the two conditions generally cannot be coded together because they are mutually exclusive for the same encounter.

Excludes2 means the condition is not included under that code, but both conditions may be coded together if the patient has both.

A Code First note tells the coder to sequence the underlying condition before the manifestation or associated condition.

A Use Additional Code note tells the coder to add another code for a fuller clinical picture, such as a manifestation, exposure, or status.

Laterality identifies right, left, or bilateral involvement. Use laterality when the code set and documentation support it.

Some ICD-10-CM categories require a seventh character for encounter type or healing status. Missing required characters make codes invalid.

A coder may not choose a more severe code just because it has higher risk value. Severity must be explicitly documented and clinically supported.

Upcoding reports a diagnosis or severity level not supported by the record. In risk adjustment, it creates payment and audit risk.

Undercoding omits supported conditions or uses nonspecific codes when specificity is documented. It understates patient risk and can distort quality data.

The False Claims Act prohibits knowingly submitting false claims to federal programs. Unsupported HCC submissions can create FCA exposure.

Risk Adjustment Data Validation audits verify that submitted diagnoses are supported in medical records. Unsupported HCCs can be deleted and payments recouped.

Risk adjustment diagnoses must come from an acceptable provider type and a valid encounter. Coders cannot use unsupported problem-list or nonprovider clues alone.

Copied-forward diagnoses can create unsupported coding if the condition was not addressed during the current encounter. MEAT helps identify current support.

When unsupported risk adjustment payments are identified, organizations must investigate, correct, and return overpayments according to applicable rules.

A strong CRC captures all supported conditions without adding unsupported ones. Accuracy, specificity, and compliance matter more than maximizing RAF.