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CRC (Court Reporting Certifications) practice questions

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Question 1Core risk adjustment knowledge (ICD-10-CM application, HCCs and other risk adjustment models, risk adjustment payment systems such as Medicare Advantage and ACA)

Under the CMS-HCC risk adjustment model used for Medicare Advantage, what does an HCC represent?

  1. A beneficiary cost-sharing tier in Part D
  2. A fee schedule code used to price physician services
  3. A hierarchy of diagnoses grouped by clinical similarity and expected cost Correct answer.
  4. A quality measure reported on the Star Rating system

Explanation

HCC stands for Hierarchical Condition Category. Diagnoses are mapped into clinically coherent groups that predict future cost, and the hierarchy suppresses lower-ranked related diagnoses when a more severe one is present.

Question 2Core risk adjustment knowledge (ICD-10-CM application, HCCs and other risk adjustment models, risk adjustment payment systems such as Medicare Advantage and ACA)

Which data source is the primary basis for calculating a Medicare Advantage enrollee's risk score under the CMS-HCC model?

  1. Self-reported health status collected at enrollment
  2. Pharmacy claims only
  3. Provider credentialing records
  4. Encounter data and diagnoses submitted by the plan for prior years Correct answer.

Explanation

CMS calculates risk scores from diagnoses captured on encounter and claims data submitted by the plan, using a prior-year model run. The diagnoses must be documented and coded according to official guidelines.

Question 3Core risk adjustment knowledge (ICD-10-CM application, HCCs and other risk adjustment models, risk adjustment payment systems such as Medicare Advantage and ACA)

A coder reviews a chart where the physician documents "diabetes with diabetic chronic kidney disease" and lists CKD stage 3a. Which coding action best supports accurate risk adjustment?

  1. Assign only the CKD stage code without diabetes linkage
  2. Assign the combination code for diabetes with diabetic CKD and the stage 3a code Correct answer.
  3. Assign a diabetes code plus a symptom code for kidney dysfunction
  4. Assign only the diabetes code and omit the kidney stage

Explanation

ICD-10-CM provides combination codes for diabetes with diabetic chronic kidney disease, and the CKD stage should also be reported when documented. Capturing both the combination code and the stage reflects the full documented severity.

Question 4Core risk adjustment knowledge (ICD-10-CM application, HCCs and other risk adjustment models, risk adjustment payment systems such as Medicare Advantage and ACA)

In the CMS-HCC hierarchy, if a beneficiary has diagnoses in both HCC 85 (Congestive Heart Failure) and HCC 86 (Acute Myocardial Infarction), how is the hierarchy typically applied?

  1. Both categories are always added together in full
  2. Only the higher-ranked category in the hierarchy counts for payment Correct answer.
  3. The lower-ranked category is doubled
  4. Neither category counts until the following year

Explanation

HCC hierarchies are designed so that when a beneficiary has multiple related conditions, only the most severe (highest-ranked) category in that hierarchy contributes to the risk score. This prevents double counting of clinically overlapping conditions.

Question 5Core risk adjustment knowledge (ICD-10-CM application, HCCs and other risk adjustment models, risk adjustment payment systems such as Medicare Advantage and ACA)

Which statement accurately describes the role of the risk adjustment factor (RAF) score in Medicare Advantage payment?

  1. It sets the plan's administrative expense ratio
  2. It establishes the member's monthly premium directly
  3. It determines the plan's network adequacy rating
  4. It adjusts the plan's capitation payment to reflect the expected cost of its enrolled population Correct answer.

Explanation

The RAF score modifies the base payment rate so that plans enrolling sicker beneficiaries receive higher capitated payments. It is a relative measure of expected cost, not a premium or expense ratio.

Question 6Core risk adjustment knowledge (ICD-10-CM application, HCCs and other risk adjustment models, risk adjustment payment systems such as Medicare Advantage and ACA)

Under the ACA individual market risk adjustment program, which statement best describes how payments flow?

  1. Only insurers with more than 100,000 members participate in the pool
  2. Enrollees with chronic conditions pay a surcharge into the pool
  3. The federal government funds all risk adjustment payments from general revenue
  4. Insurers with lower-risk enrollees pay into a pool that funds insurers with higher-risk enrollees Correct answer.

Explanation

The ACA risk adjustment program is budget neutral: issuers whose enrollees have lower-than-average risk pay contributions, and those with higher-risk enrollees receive payments. No general revenue subsidizes the transfers.

Question 7Core risk adjustment knowledge (ICD-10-CM application, HCCs and other risk adjustment models, risk adjustment payment systems such as Medicare Advantage and ACA)

A Medicare Advantage plan's chart review identifies a documented diagnosis that was never submitted on encounter data. What is the compliant way to address this?

  1. Submit the diagnosis only if the member requests it
  2. Leave it out because only claims data can be used
  3. Submit a corrected encounter record supported by the medical record documentation Correct answer.
  4. Add the diagnosis without documentation because the chart review found it

Explanation

Plans may submit corrected or supplemental encounter data when the diagnosis is supported by the medical record and meets coding requirements. Every submitted diagnosis must be documented and validated.

Question 8Core risk adjustment knowledge (ICD-10-CM application, HCCs and other risk adjustment models, risk adjustment payment systems such as Medicare Advantage and ACA)

Which element is required for a diagnosis to be valid for risk adjustment submission?

  1. It is mentioned as a rule-out on the problem list
  2. It appears in the member's family history section
  3. It is inferred from an abnormal lab value alone
  4. It is documented by an acceptable provider during a face-to-face encounter and coded per guidelines Correct answer.

Explanation

Only conditions that are documented as confirmed by a qualified provider during a valid encounter and coded accurately can be submitted. Rule-out, history-only, or inferred conditions do not meet the standard.

Question 9Core risk adjustment knowledge (ICD-10-CM application, HCCs and other risk adjustment models, risk adjustment payment systems such as Medicare Advantage and ACA)

In ICD-10-CM, a code for a chronic condition that is documented and managed during an office visit should generally be reported when:

  1. The provider only mentions it in the past medical history without evaluation
  2. The condition is addressed or affects the management of the patient during that encounter Correct answer.
  3. The condition was resolved more than five years ago
  4. The patient asks about it but the provider does not address it

Explanation

Chronic conditions that are evaluated, managed, or otherwise affect care during the encounter are reportable. Merely listing a historical condition without assessment does not support reporting.

Question 10Core risk adjustment knowledge (ICD-10-CM application, HCCs and other risk adjustment models, risk adjustment payment systems such as Medicare Advantage and ACA)

Which of the following best characterizes the purpose of a risk adjustment model's diagnosis-to-category mapping?

  1. To assign each diagnosis a fixed fee for reimbursement
  2. To group clinically related diagnoses that predict similar future healthcare cost Correct answer.
  3. To rank providers by their coding productivity
  4. To determine which drugs are covered under the formulary

Explanation

Risk adjustment models map diagnoses into categories that share clinical meaning and cost-prediction power. The mapping supports payment accuracy rather than fee setting or formulary decisions.

Question 11Core risk adjustment knowledge (ICD-10-CM application, HCCs and other risk adjustment models, risk adjustment payment systems such as Medicare Advantage and ACA)

A beneficiary is documented with both "Type 2 diabetes with retinopathy" and "Type 2 diabetes without complications" in the same encounter. Which coding principle applies?

  1. Report neither until a specialist confirms the retinopathy
  2. Report both codes as separate primary diagnoses
  3. Report only the code without complications because it is broader
  4. Report the code that reflects the most specific documented complication Correct answer.

Explanation

When documentation supports a more specific complication, the specific combination code is reported rather than a less specific unspecified code. Reporting both would be redundant and inconsistent.

Question 12Core risk adjustment knowledge (ICD-10-CM application, HCCs and other risk adjustment models, risk adjustment payment systems such as Medicare Advantage and ACA)

Which statement about the source of diagnoses for ACA market risk adjustment is accurate?

  1. Diagnoses are self-reported by enrollees on the application
  2. Diagnoses are estimated from prescription drug utilization
  3. Diagnoses are taken from hospital discharge data only
  4. Diagnoses come from claims submitted by issuers for enrollees in the individual and small group markets Correct answer.

Explanation

ACA risk adjustment relies on claims-based diagnosis data submitted by issuers for enrollees in the applicable markets. The diagnoses are then mapped to the HHS risk adjustment model categories.

Question 13Core risk adjustment knowledge (ICD-10-CM application, HCCs and other risk adjustment models, risk adjustment payment systems such as Medicare Advantage and ACA)

What is the effect of a coding error that adds an unsupported diagnosis to a Medicare Advantage encounter record?

  1. It automatically corrects itself in the next model year
  2. It has no effect because CMS audits only inpatient claims
  3. It lowers the plan's risk score
  4. It can inflate the risk score and create compliance and payment recovery risk Correct answer.

Explanation

Unsupported diagnoses increase the RAF score and can lead to overpayment, which CMS may recover through audits such as RADV. Accurate documentation protects both payment integrity and compliance.

Question 14Core risk adjustment knowledge (ICD-10-CM application, HCCs and other risk adjustment models, risk adjustment payment systems such as Medicare Advantage and ACA)

A provider documents "possible pneumonia" and orders a chest x-ray. How should this be coded for risk adjustment purposes?

  1. Code pneumonia only if the x-ray is abnormal
  2. Code pneumonia as confirmed because testing was ordered
  3. Code pneumonia with an unspecified code to be safe
  4. Do not code pneumonia because it is not confirmed; code any documented signs or symptoms Correct answer.

Explanation

Diagnoses documented as possible, probable, or suspected are not coded as confirmed conditions. Signs and symptoms that are documented may be coded instead.

Question 15Core risk adjustment knowledge (ICD-10-CM application, HCCs and other risk adjustment models, risk adjustment payment systems such as Medicare Advantage and ACA)

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

  1. CMS-HCC applies only to prescription drug costs
  2. HHS-HCC does not use diagnosis codes
  3. CMS-HCC is used only for Medicaid populations
  4. HHS-HCC incorporates age and metal level factors specific to the individual market Correct answer.

Explanation

The HHS-HCC model was calibrated for the ACA individual and small group markets and includes age and plan-level factors. CMS-HCC is used for Medicare Advantage and differs in structure and population.

Question 16Core risk adjustment knowledge (ICD-10-CM application, HCCs and other risk adjustment models, risk adjustment payment systems such as Medicare Advantage and ACA)

Under the CMS-HCC model, which beneficiary characteristic is incorporated directly as a demographic factor in the risk score?

  1. Marital status
  2. Occupation
  3. Age and sex Correct answer.
  4. Zip code of residence

Explanation

CMS-HCC demographic factors include age and sex, along with institutional status and originally disabled status in some segments. These demographic adjusters are combined with diagnosis-based factors.

Question 17Core risk adjustment knowledge (ICD-10-CM application, HCCs and other risk adjustment models, risk adjustment payment systems such as Medicare Advantage and ACA)

A chart review reveals that a diagnosis was documented by a nurse practitioner who is a credentialed provider in the group. What is the risk adjustment implication?

  1. The diagnosis may be submitted if the encounter and documentation meet program requirements Correct answer.
  2. The diagnosis cannot be used because only physicians may document
  3. The diagnosis must be re-documented by a physician in a later year
  4. The diagnosis is valid only for inpatient settings

Explanation

Acceptable provider types for risk adjustment include qualified non-physician practitioners when permitted by program rules and state scope. Documentation and encounter standards must still be met.

Question 18Core risk adjustment knowledge (ICD-10-CM application, HCCs and other risk adjustment models, risk adjustment payment systems such as Medicare Advantage and ACA)

Which term describes the process of reviewing medical records to confirm that submitted diagnoses are supported and complete?

  1. Network credentialing
  2. Capitation reconciliation
  3. Chart review and validation Correct answer.
  4. Formulary tiering

Explanation

Chart review and validation confirm that diagnoses submitted for risk adjustment are documented and accurate. This supports both completeness and compliance with data integrity standards.

Question 19Core risk adjustment knowledge (ICD-10-CM application, HCCs and other risk adjustment models, risk adjustment payment systems such as Medicare Advantage and ACA)

In risk adjustment, what does the term "suspect" condition refer to in analytics?

  1. A condition that must be submitted immediately without review
  2. A condition suggested by data patterns but not yet confirmed in the record Correct answer.
  3. A code used only for inpatient claims
  4. A diagnosis that has been fully validated by a coder

Explanation

Suspect conditions are identified through analytics as possible gaps, but they require documentation review before submission. They cannot be submitted based on suspicion alone.

Question 20Core risk adjustment knowledge (ICD-10-CM application, HCCs and other risk adjustment models, risk adjustment payment systems such as Medicare Advantage and ACA)

Which scenario best illustrates appropriate capture of a hierarchical condition category for a diabetic beneficiary?

  1. Coding diabetes as a history code after the first year
  2. Documenting diabetes once at age 50 and never reassessing
  3. Documenting diabetes with a specific complication such as neuropathy and coding the combination code Correct answer.
  4. Coding diabetes only when the patient is hospitalized

Explanation

Risk adjustment depends on annual documentation of the beneficiary's current conditions. Specific complications should be documented and coded with the appropriate combination code each year.

Question 21Core risk adjustment knowledge (ICD-10-CM application, HCCs and other risk adjustment models, risk adjustment payment systems such as Medicare Advantage and ACA)

What is the primary purpose of risk adjustment in health insurance payment systems?

  1. To reduce the number of diagnosis codes submitted
  2. To penalize providers who order too many tests
  3. To set uniform premiums for all enrollees regardless of plan
  4. To compensate plans or issuers for enrolling populations with higher expected healthcare costs Correct answer.

Explanation

Risk adjustment transfers funds toward plans or issuers whose enrollees are expected to cost more, reducing incentives to avoid sicker members. It supports fair payment across heterogeneous populations.

Question 22Core risk adjustment knowledge (ICD-10-CM application, HCCs and other risk adjustment models, risk adjustment payment systems such as Medicare Advantage and ACA)

A Medicare Advantage member's record lists "history of myocardial infarction" from 2019 with no current cardiac evaluation. How should this be handled for the current model year?

  1. Submit it only if the member reports chest pain
  2. Do not submit an acute MI diagnosis unless the condition is currently documented and relevant Correct answer.
  3. Submit the acute MI code because it happened once
  4. Submit the code with an unspecified status

Explanation

Historical conditions that are not currently evaluated or managed generally do not support a current diagnosis submission. Documentation must reflect the patient's status in the relevant period.

Question 23Core risk adjustment knowledge (ICD-10-CM application, HCCs and other risk adjustment models, risk adjustment payment systems such as Medicare Advantage and ACA)

Which of the following best explains why the CMS-HCC model uses a prior-year diagnosis period rather than the current payment year?

  1. It allows payment rates to be set before the payment year begins using observed morbidity Correct answer.
  2. It eliminates the need for documentation review
  3. It requires real-time claims adjudication
  4. It prevents plans from submitting any diagnoses

Explanation

Using a prior-year period lets CMS calculate and apply risk scores prospectively before the payment year. The approach relies on observed diagnoses to predict future cost.

Question 24Core risk adjustment knowledge (ICD-10-CM application, HCCs and other risk adjustment models, risk adjustment payment systems such as Medicare Advantage and ACA)

Which data integrity practice is most consistent with CMS expectations for Medicare Advantage risk adjustment submissions?

  1. Submitting diagnoses based on pharmacy fill history
  2. Submitting only diagnoses that are documented and supported in the medical record Correct answer.
  3. Submitting every code on the problem list regardless of documentation
  4. Submitting diagnoses from prior years without review

Explanation

CMS expects submissions to reflect documented, validated diagnoses. Problem lists and historical entries may be inaccurate and must be verified against the record.

Question 25Core risk adjustment knowledge (ICD-10-CM application, HCCs and other risk adjustment models, risk adjustment payment systems such as Medicare Advantage and ACA)

In the HHS risk adjustment model, what role do enrollee age and plan level play in the calculation?

  1. They replace diagnosis codes entirely
  2. They are ignored because only diagnoses matter
  3. They are incorporated as rating factors that adjust the expected cost alongside diagnoses Correct answer.
  4. They apply only to catastrophic plans

Explanation

The HHS-HCC model combines diagnosis-based factors with demographic and plan-level factors such as age and metal level. These adjust expected cost for the enrolled population.

Question 26Core risk adjustment knowledge (ICD-10-CM application, HCCs and other risk adjustment models, risk adjustment payment systems such as Medicare Advantage and ACA)

In the CMS-HCC risk adjustment model, what does a Hierarchical Condition Category (HCC) represent?

  1. A provider specialty code used for network adequacy
  2. A billing code used only for inpatient hospital claims
  3. A geographic rating area used to set premiums
  4. A group of related diagnoses that map to a single risk weight in the payment model Correct answer.

Explanation

The CMS-HCC model groups clinically related ICD-10-CM diagnoses into condition categories, and each category carries a coefficient that contributes to the beneficiary's risk score. The hierarchy means that when a more severe condition in a related group is present, the less severe one is generally not separately counted.

Question 27Core risk adjustment knowledge (ICD-10-CM application, HCCs and other risk adjustment models, risk adjustment payment systems such as Medicare Advantage and ACA)

A Medicare Advantage member has both an HCC for diabetes with chronic complications and a code for diabetes without complications in the same year. How does the hierarchy generally treat these?

  1. The less severe diabetes HCC is typically suppressed in favor of the more severe one Correct answer.
  2. Both HCCs are added together at full weight
  3. Neither HCC is counted until the following year
  4. Only the less severe HCC is counted

Explanation

Hierarchies within the CMS-HCC model are designed so that a beneficiary is counted once within a disease group, generally at the most severe level documented. The lower-severity diabetes category is therefore not separately added when the complication category is present.

Question 28Core risk adjustment knowledge (ICD-10-CM application, HCCs and other risk adjustment models, risk adjustment payment systems such as Medicare Advantage and ACA)

Which statement best describes how the risk score in the CMS-HCC model is constructed?

  1. It is the sum of demographic coefficients and diagnosis coefficients, normalized so the average is 1.0 Correct answer.
  2. It is a fixed value assigned by the plan based on member satisfaction
  3. It is the member's total annual claims cost divided by the plan's average premium
  4. It equals the number of chronic conditions divided by member age

Explanation

The risk score combines age/sex and other demographic factors with the coefficients of the HCCs documented for the beneficiary. The raw sum is divided by a normalization factor so that the model's average score is 1.0, allowing relative payment comparison.

Question 29Core risk adjustment knowledge (ICD-10-CM application, HCCs and other risk adjustment models, risk adjustment payment systems such as Medicare Advantage and ACA)

In risk adjustment terminology, what is a "suspect" condition?

  1. A diagnosis that has been formally deleted from the encounter data
  2. A code assigned only by the health plan's legal department
  3. A condition that is excluded from all risk adjustment models
  4. A diagnosis identified by analytics as likely present but not yet confirmed in the medical record Correct answer.

Explanation

Suspect conditions come from predictive analytics or chart review that flags a probable diagnosis based on medications, labs, or prior history. The condition must still be confirmed and documented by a provider in the record before it can be submitted.

Question 30Core risk adjustment knowledge (ICD-10-CM application, HCCs and other risk adjustment models, risk adjustment payment systems such as Medicare Advantage and ACA)

A coder sees the provider's note read "history of stroke in 2020, no residual deficits, doing well." How should this be handled for risk adjustment?

  1. Do not submit it as an active condition because it is documented as history without current management Correct answer.
  2. Code the history of stroke as an active condition with an HCC
  3. Submit it only if the patient requests it
  4. Code it as an acute stroke for the current year

Explanation

A condition documented as history with no current treatment or residual effect is not an active problem and generally does not support an HCC. Risk adjustment capture requires documentation that the condition is present and relevant in the payment period.

Question 31Core risk adjustment knowledge (ICD-10-CM application, HCCs and other risk adjustment models, risk adjustment payment systems such as Medicare Advantage and ACA)

Which data source is the primary basis for diagnosis capture in the Medicare Advantage risk adjustment program?

  1. Pharmacy rebate invoices
  2. Member self-reported surveys mailed at enrollment
  3. Provider directory listings
  4. Encounter data submitted from claims and encounters for services provided to the member Correct answer.

Explanation

Diagnoses must come from acceptable encounter and claims data reflecting services rendered to the beneficiary. Survey responses and administrative files are not valid substitutes for documented clinical encounters.

Question 32Core risk adjustment knowledge (ICD-10-CM application, HCCs and other risk adjustment models, risk adjustment payment systems such as Medicare Advantage and ACA)

What is the purpose of the normalization factor applied to CMS-HCC risk scores?

  1. To ensure the average risk score in the model population equals 1.0 so scores are relative Correct answer.
  2. To remove all members with chronic conditions from the model
  3. To convert risk scores into diagnosis codes
  4. To set the plan's marketing budget

Explanation

Normalization rescales the raw coefficient sums so that the average score across the modeled population is 1.0. This makes each member's score a relative measure, with scores above 1.0 indicating expected cost above average.

Question 33Core risk adjustment knowledge (ICD-10-CM application, HCCs and other risk adjustment models, risk adjustment payment systems such as Medicare Advantage and ACA)

A Medicare Advantage plan submits a diagnosis that is later found unsupported by the medical record. What is the most likely consequence under CMS risk adjustment data validation?

  1. The plan may face recovery of overpayments and must correct its submission processes Correct answer.
  2. The member loses Medicare eligibility
  3. The diagnosis is converted to a different HCC at full weight
  4. The provider's license is automatically revoked

Explanation

CMS RADV audits compare submitted diagnoses to medical records and can result in payment adjustments when documentation does not support the codes. Plans are expected to maintain robust documentation and coding compliance programs to prevent such errors.

Question 34Core risk adjustment knowledge (ICD-10-CM application, HCCs and other risk adjustment models, risk adjustment payment systems such as Medicare Advantage and ACA)

Which of the following best describes the role of the HHS-operated risk adjustment program in the individual and small group markets?

  1. It transfers funds from plans with lower-risk enrollees to plans with higher-risk enrollees within a state market Correct answer.
  2. It sets the monthly premium for every plan in the state
  3. It replaces the need for diagnosis coding entirely
  4. It determines which providers may join a network

Explanation

The HHS risk adjustment program is a state-level transfer mechanism that moves money from plans whose enrollees are predicted to be lower risk toward plans with higher-risk enrollees. It equalizes incentives so plans do not profit by avoiding sicker members.

Question 35Core risk adjustment knowledge (ICD-10-CM application, HCCs and other risk adjustment models, risk adjustment payment systems such as Medicare Advantage and ACA)

Which factor is used in the HHS risk adjustment model but is notably absent as a direct demographic input in the basic CMS-HCC model?

  1. Enrollee sex
  2. Enrollee tobacco use status Correct answer.
  3. Enrollee age
  4. Enrollee institutional status

Explanation

The HHS model for the individual market incorporates tobacco use as a rating and risk factor, reflecting its cost impact in that market. The CMS-HCC model uses age, sex, and institutional status but does not use tobacco status as a model input.

Question 36Core risk adjustment knowledge (ICD-10-CM application, HCCs and other risk adjustment models, risk adjustment payment systems such as Medicare Advantage and ACA)

A provider documents "probable diabetic neuropathy" and orders confirmatory testing. How should this be coded for risk adjustment?

  1. Code the neuropathy as confirmed because testing was ordered
  2. Code it only if the patient has been diabetic for over ten years
  3. Do not code the neuropathy as confirmed until the diagnosis is established Correct answer.
  4. Code it as an adverse effect of medication

Explanation

Uncertain diagnoses such as "probable" or "suspected" are not coded as confirmed conditions in outpatient settings. The condition should be captured only once the provider documents it as established.

Question 37Core risk adjustment knowledge (ICD-10-CM application, HCCs and other risk adjustment models, risk adjustment payment systems such as Medicare Advantage and ACA)

What does the term "recapture" mean in the context of Medicare Advantage risk adjustment?

  1. Reversing a previously paid claim to recover funds
  2. Documenting and submitting an ongoing chronic condition in a subsequent payment year so it continues to count Correct answer.
  3. Re-enrolling a member who disenrolled from the plan
  4. Recalculating premiums after a rate filing

Explanation

Because CMS-HCC scores are based on diagnoses from the relevant diagnosis period each year, chronic conditions must be documented and submitted again in later years to remain in the risk score. This annual reaffirmation is commonly called recapture.

Question 38Core risk adjustment knowledge (ICD-10-CM application, HCCs and other risk adjustment models, risk adjustment payment systems such as Medicare Advantage and ACA)

A chart review finds a diagnosis documented by a physician assistant whose notes are co-signed by the supervising physician. What is the key consideration for submitting the diagnosis?

  1. The diagnosis can be submitted only if the patient is hospitalized
  2. Only diagnoses from physicians may ever be submitted
  3. The diagnosis may be submitted if documentation meets plan and CMS requirements for acceptable provider documentation Correct answer.
  4. The diagnosis must be discarded because a PA wrote the note

Explanation

Acceptable documentation depends on whether the record supports the diagnosis and whether the provider type is recognized under the plan's and CMS's rules. Many non-physician practitioners can document diagnoses when their records meet those standards, especially with appropriate supervision and co-signature.

Question 39Core risk adjustment knowledge (ICD-10-CM application, HCCs and other risk adjustment models, risk adjustment payment systems such as Medicare Advantage and ACA)

Which statement best explains why accurate diagnosis capture matters financially to a Medicare Advantage plan?

  1. Risk scores directly affect the capitation payment the plan receives for each member Correct answer.
  2. Diagnosis codes determine the member's Part B premium
  3. Diagnoses set the plan's star rating for customer service
  4. Diagnoses determine the plan's tax-exempt status

Explanation

CMS uses risk scores derived from diagnoses and demographics to adjust the monthly capitation payment a plan receives for each beneficiary. Complete and accurate capture ensures payment reflects the expected cost of caring for that population.

Question 40Core risk adjustment knowledge (ICD-10-CM application, HCCs and other risk adjustment models, risk adjustment payment systems such as Medicare Advantage and ACA)

A member's record includes an HCC for major depression documented and treated with medication during the year. Which action best supports compliant risk adjustment?

  1. Submit the diagnosis based on the documented and managed condition Correct answer.
  2. Submit it as a history code to avoid overpayment
  3. Suppress it because mental health conditions are excluded
  4. Submit it only if the member is hospitalized

Explanation

A condition that is documented and actively managed during the payment year is generally eligible for submission. Mental health diagnoses are not categorically excluded, and hospitalization is not required.

Question 41Core risk adjustment knowledge (ICD-10-CM application, HCCs and other risk adjustment models, risk adjustment payment systems such as Medicare Advantage and ACA)

Which of the following distinguishes the concept of a "payment year" from a "diagnosis period" in the CMS-HCC model?

  1. The payment year applies only to inpatient claims
  2. The diagnosis period is always two years after the payment year
  3. They are identical and always refer to the same twelve months
  4. The payment year is the year being paid for, while the diagnosis period is the prior period whose diagnoses inform the score Correct answer.

Explanation

The model uses diagnoses from a defined prior period to predict costs for the payment year that follows. This separation reflects the lag between documentation, submission, and payment calculation.

Question 42Core risk adjustment knowledge (ICD-10-CM application, HCCs and other risk adjustment models, risk adjustment payment systems such as Medicare Advantage and ACA)

A plan's analytics flag that many members with chronic kidney disease have no submitted diagnosis despite lab evidence. What is the most appropriate first step?

  1. Submit the diagnosis immediately based on the lab results alone
  2. Ignore the signal because labs are not clinical data
  3. Change the members' plan type to reduce risk
  4. Initiate provider review and documentation of the condition before submission Correct answer.

Explanation

Lab evidence can support a suspect condition, but a diagnosis must be documented by a provider in the record before it is submitted. The appropriate step is to prompt evaluation and documentation, not to code from lab values alone.

Question 43Core risk adjustment knowledge (ICD-10-CM application, HCCs and other risk adjustment models, risk adjustment payment systems such as Medicare Advantage and ACA)

Which statement accurately describes how the CMS-HCC model handles a beneficiary who is a long-term nursing home resident?

  1. Institutional status is recognized through a separate model segment with its own coefficients Correct answer.
  2. Institutional status is ignored and the community model is always used
  3. Nursing home residents are excluded from Medicare Advantage payment
  4. Their risk score is fixed at 1.0 regardless of diagnoses

Explanation

CMS-HCC models use distinct segments, including institutional and community populations, because cost patterns differ substantially. The institutional segment applies its own coefficients reflecting the higher expected cost of that population.

Question 44Core risk adjustment knowledge (ICD-10-CM application, HCCs and other risk adjustment models, risk adjustment payment systems such as Medicare Advantage and ACA)

What is the primary reason risk adjustment is applied to health insurance payment systems?

  1. To compensate plans fairly for enrolling members with differing expected health costs Correct answer.
  2. To standardize provider salaries across regions
  3. To eliminate the need for medical records
  4. To guarantee every plan an identical profit margin

Explanation

Risk adjustment adjusts payments so plans are not advantaged by enrolling healthier members or disadvantaged by enrolling sicker ones. This supports access and discourages risk selection.

Question 45Core risk adjustment knowledge (ICD-10-CM application, HCCs and other risk adjustment models, risk adjustment payment systems such as Medicare Advantage and ACA)

A coder is unsure whether a documented condition maps to an HCC in the current model year. What is the most reliable approach?

  1. Ask the member which category applies
  2. Use last year's mapping without checking for updates
  3. Assume any chronic condition automatically maps to an HCC
  4. Consult the current CMS-HCC mapping files and model documentation for that year Correct answer.

Explanation

HCC mappings and model coefficients are updated periodically, so coders should verify against the current year's official mapping files. Assuming automatic mapping or relying on outdated files can produce submission errors.

Question 46Core risk adjustment knowledge (ICD-10-CM application, HCCs and other risk adjustment models, risk adjustment payment systems such as Medicare Advantage and ACA)

Which of the following best characterizes the relationship between documentation specificity and risk adjustment accuracy?

  1. Less specific documentation always produces higher payment
  2. Specificity matters only for surgical claims
  3. More specific documentation improves the likelihood that the correct HCC and weight are assigned Correct answer.
  4. Specificity has no effect because all codes carry equal weight

Explanation

Risk adjustment depends on precise diagnosis coding because different codes can map to different HCCs and weights. Specific documentation, such as type and complication status for diabetes, supports accurate categorization.

Question 47Core risk adjustment knowledge (ICD-10-CM application, HCCs and other risk adjustment models, risk adjustment payment systems such as Medicare Advantage and ACA)

A member's chart shows an active cancer diagnosis under treatment, but the encounter submitted lists only the chemotherapy administration code without the cancer diagnosis. What is the risk adjustment impact?

  1. The member's risk score increases because administration codes carry high weight
  2. The cancer HCC may be missed, potentially understating the member's risk score Correct answer.
  3. There is no impact because treatment codes are excluded from models
  4. The chemotherapy code automatically triggers the cancer HCC

Explanation

Risk scores depend on submitted diagnosis codes, so an active cancer that is documented but not submitted may not be captured. Complete submission of supported diagnoses is necessary for accurate payment.

Question 48Core risk adjustment knowledge (ICD-10-CM application, HCCs and other risk adjustment models, risk adjustment payment systems such as Medicare Advantage and ACA)

Which of the following is an example of a demographic factor in the CMS-HCC risk score?

  1. The member's age and sex Correct answer.
  2. The member's preferred pharmacy
  3. The member's chosen primary care physician
  4. The member's ZIP code within a rating area

Explanation

Age and sex are demographic variables included directly in the CMS-HCC score calculation alongside diagnosis categories. Other listed items are administrative or network attributes, not model inputs.

Question 49Core risk adjustment knowledge (ICD-10-CM application, HCCs and other risk adjustment models, risk adjustment payment systems such as Medicare Advantage and ACA)

A plan wants to improve its risk adjustment data integrity. Which practice aligns best with CMS expectations?

  1. Conduct internal audits and provider education to ensure submitted diagnoses are supported by records Correct answer.
  2. Rely solely on member surveys to identify conditions
  3. Submit every possible diagnosis code regardless of documentation
  4. Discourage providers from documenting chronic conditions

Explanation

CMS expects plans to maintain compliance programs that verify documentation supports submitted diagnoses. Auditing and education help ensure accuracy and reduce the risk of payment recovery.

Question 50Core risk adjustment knowledge (ICD-10-CM application, HCCs and other risk adjustment models, risk adjustment payment systems such as Medicare Advantage and ACA)

In the HHS risk adjustment model, which combination best reflects the inputs used to calculate an enrollee's risk score?

  1. Only the enrollee's provider network tier
  2. Only the enrollee's county of residence
  3. Only the enrollee's premium amount
  4. Age, plan level, and diagnosis-based condition categories Correct answer.

Explanation

The HHS model combines demographic factors such as age with plan-level factors and diagnosis-based categories to predict relative cost. These inputs together produce the enrollee risk score used in transfers.