CRC (Court Reporting Certifications) flashcards

32 cards. Read the term and the definition here. The deck at the top of this page is optional.

HCC risk score

A risk score is the sum of HCC weights, demographic factors, and interaction weights, normalized so the average enrollee equals 1.0. Higher weights indicate greater expected cost.

Hierarchy in HCC models

Within a disease family, a higher-severity HCC suppresses lower-severity HCCs from payment. For example, a complication category supersedes uncomplicated diabetes.

Interaction weight

An additional weight added when two conditions co-occur, such as diabetes with CHF or diabetes with CKD. Both conditions must be documented to receive it.

RAPS versus EDS

RAPS and EDS are the two Medicare Advantage data sources for diagnoses. CMS blends the resulting risk scores according to published phase-in percentages.

ACA HHS risk adjustment

The ACA model uses EDGE data and its own HCC groupings and coefficients. Its weights are separate from CMS-HCC and cannot be substituted across models.

Demographic factors in risk scores

Age/sex bands and, in institutional models, originally disabled status and Medicaid eligibility adjust the base score independently of any diagnosis codes.

Look-back year

The CMS-HCC model uses diagnoses from a prior year of claims to predict the following payment year. Only accepted encounters in that period count.

Highest specificity coding

ICD-10-CM requires coding to the most specific documented level. Use combination codes when one code fully describes a condition and its manifestation.

MEAT criteria

Monitor, Evaluate, Assess/treat. At least one element tied to the condition must appear in the encounter documentation to support reporting a chronic condition.

Problem list is not evidence

A diagnosis appearing only on a problem list, medication list, or prior-year note is not reportable. The condition must be documented and assessed at the current encounter.

RADV audit

A CMS review comparing submitted diagnoses to the medical record. Unsupported diagnoses are deleted, lowering the risk score and potentially triggering repayment or penalties.

Documentation gap

A condition present in the record but not coded, or coded without required specificity or linkage. Gaps lower risk scores and are common chart-review targets.

Status codes

Codes such as long-term insulin use, dialysis status, or transplant status add risk weight only when documented. They are frequently missed and audited.

Ruled-out diagnosis

A condition considered but not confirmed is not coded as active. Only conditions documented as current, treated, or monitored are reportable.

Compliant physician query

A clarification request that asks for missing detail without leading the provider toward a specific diagnosis or code, preserving documentation integrity.

High-risk code monitoring

Compliance programs track high-weight codes such as major complications, sepsis, and respiratory failure because they carry high audit scrutiny and repayment risk.

Diabetic CKD linkage

E11.22 requires documentation stating a causal link between diabetes and CKD. Without the link, code the conditions separately, which changes HCC assignment.

CKD staging codes

N18.1 through N18.6 specify stage. Stage 5 and ESRD map to the highest renal HCC; stages 1 and 2 generally carry no HCC weight.

Heart failure specificity

I50.2x systolic, I50.3x diastolic, I50.4x combined. Acuity (acute, chronic, acute on chronic) must be specified because weights differ.

COPD coding

J44.0 includes acute lower respiratory infection, J44.1 acute exacerbation, J44.9 unspecified. Documentation should state type and exacerbation status.

History of cancer

Z85.x indicates a personal history of cancer and is not active disease. Active cancer requires a site-specific code supported by current documentation.

Metastatic cancer coding

Code the primary site and, when documented, the metastatic site. Both may carry HCC weight, so complete documentation of spread matters.

Principal diagnosis sequencing

The principal diagnosis is the condition after study chiefly responsible for the encounter. Managed chronic conditions are coded as secondary with explicit linkage.

Diabetes complication coding

Use combination codes such as E11.22 or E11.40 and add the manifestation code after the diabetes code, per the ICD-10-CM tabular instructions.

Peripheral arterial disease

I73.9 codes PAD and carries HCC weight. Documentation should specify site and laterality where the code set requires it.

Risk score capture

The score reflects submitted HCCs, demographics, and interactions. Missing HCCs lower payment; unsupported HCCs raise it and are recoverable on audit.

Chart review classification

Each reviewed diagnosis is classified as supported, unsupported, or needing clarification. Findings are aggregated into error rates and dollar impact.

Inter-rater reliability

A second reviewer re-audits a sample. Low agreement signals a need for coder retraining or clearer query templates.

HEDIS and Star Ratings

Quality measures such as HbA1c control and medication adherence are separate from risk adjustment but depend on the same encounter documentation.

Value-based benchmark adjustment

Shared savings programs such as MSSP use risk adjustment to set benchmarks. Accurate coding affects both the benchmark and measured performance.

Encounter completeness

All documented diagnoses, not just the primary, must be submitted. Verify the encounter date falls within the collection period and the correct system received it.

Audit dollar impact

Quantify deleted HCCs and their payment effect by provider or code family. This prioritizes education and tracks improvement over time.