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CRC Risk Adjustment Coding study materials
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CRC Risk Adjustment Coding practice questions

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Question 1Core risk adjustment knowledge

In the CMS-HCC risk adjustment model, what does an HCC represent?

  1. A carrier code assigned to each Medicare Advantage plan
  2. A claims editing rule applied to outpatient encounters
  3. A hospital cost center used for inpatient rate setting
  4. A hierarchical condition category grouping clinically related diagnoses Correct answer.

Explanation

The CMS-HCC model assigns each ICD-10-CM diagnosis to a hierarchical condition category that groups clinically similar conditions with similar expected cost. Categories are organized by body system and disease type, and some categories are hierarchical, meaning a more severe category supersedes a less severe one in the same hierarchy.

Question 2Core risk adjustment knowledge

Which body maintains the HCC risk adjustment models and publishes the annual coefficients used for Medicare Advantage payment?

  1. The American Health Information Management Association
  2. The Office of Inspector General
  3. The Centers for Medicare & Medicaid Services Correct answer.
  4. The National Committee for Quality Assurance

Explanation

CMS develops and publishes the HCC risk adjustment models, including the coefficients, hierarchies, and model software used to calculate risk scores for Medicare Advantage payment. Other organizations may comment on or audit the program, but CMS owns the model itself.

Question 3Core risk adjustment knowledge

A coder reports a diagnosis documented as "history of myocardial infarction" with no active treatment on an outpatient encounter. How should this be captured for risk adjustment?

  1. Report it as an active acute myocardial infarction
  2. Report it with the appropriate history code, which does not map to an HCC Correct answer.
  3. Report it as an old MI with a current HCC assignment
  4. Omit it entirely and code only the reason for visit

Explanation

A history code describes a resolved condition that no longer requires treatment and does not map to a payment HCC. Active myocardial infarction codes map to the acute MI category, so documentation must clearly support active disease before that category is captured.

Question 4Core risk adjustment knowledge

What is the purpose of a hierarchy in the CMS-HCC model?

  1. To rank providers by their coding accuracy
  2. To prevent payment when a diagnosis lacks laboratory confirmation
  3. To limit payment to the single most severe category within a related disease group Correct answer.
  4. To require a specialist to confirm every diagnosis before submission

Explanation

Hierarchies ensure that when several related conditions from the same disease group are documented, only the most severe category generates a payment weight. This avoids paying multiple times for conditions that are clinically part of the same disease process.

Question 5Core risk adjustment knowledge

Which submission is required for a Medicare Advantage organization to receive risk-adjustment credit for a diagnosis?

  1. A pharmacy claim for a related medication
  2. A paper attestation signed by the member
  3. An encounter data record containing the coded diagnosis Correct answer.
  4. A referral authorization for a specialist visit

Explanation

Risk adjustment credit flows from encounter data (and, historically, from risk adjustment processing system submissions) that contain valid ICD-10-CM diagnoses from acceptable provider types and settings. The diagnosis must appear on a qualifying encounter record, not merely on an authorization or pharmacy claim.

Question 6Core risk adjustment knowledge

A patient's chart lists diabetes with diabetic chronic kidney disease and also documents stage 3a CKD separately. What coding principle applies?

  1. Use the combination code for diabetes with CKD and do not report the CKD separately Correct answer.
  2. Code only the CKD because it is more severe
  3. Code only the diabetes because it is the principal condition
  4. Code both conditions independently with no combination code

Explanation

ICD-10-CM provides combination codes for diabetes with chronic kidney disease, and coding guidelines direct the coder to use the combination code rather than reporting the diabetes and CKD as separate codes. The stage of CKD is included in the combination code, so a separate CKD code is not added.

Question 7Core risk adjustment knowledge

What does a risk adjustment factor (RAF) score of 1.0 generally indicate for a Medicare Advantage member?

  1. The member is enrolled in a special needs plan
  2. The member's diagnoses were all submitted by a specialist
  3. The member's expected cost equals the average for the payment model population Correct answer.
  4. The member has no chronic conditions

Explanation

A RAF score of 1.0 represents average expected cost relative to the model population, so scores above 1.0 predict higher-than-average cost and scores below 1.0 predict lower cost. The score is built from demographic factors plus diagnosis category weights.

Question 8Core risk adjustment knowledge

Which documentation element is essential for a coder to assign a diabetes code with the correct complication and control status?

  1. The patient's insurance product type
  2. The specific type of diabetes, any complications, and whether it is controlled or uncontrolled Correct answer.
  3. The name of the prescribing clinician
  4. The date of the patient's last eye exam

Explanation

Diabetes coding requires the type of diabetes, any associated complications, and the documented control status when stated. Without these details the coder cannot select the most specific combination code, which affects HCC capture.

Question 9Core risk adjustment knowledge

An inpatient record documents "CHF exacerbation" and "acute on chronic systolic heart failure" in the discharge summary. Which action best supports accurate risk adjustment?

  1. Code acute diastolic heart failure by default
  2. Code only CHF, since it is the term used first
  3. Report both CHF and acute on chronic systolic heart failure as separate HCCs
  4. Query the provider to clarify the specific heart failure type and acuity for code assignment Correct answer.

Explanation

When documentation contains conflicting or nonspecific heart failure terminology, a compliant query resolves the specific type and acuity so the correct code and HCC are assigned. Coders cannot assume systolic or diastolic status without clarification.

Question 10Core risk adjustment knowledge

Which statement correctly describes the role of the suspecting of diagnosis in risk adjustment coding?

  1. A coder may assign a diagnosis based on clinical indicators even when the provider does not document it
  2. A coder may assign a diagnosis when a prior-year claim contains the same code
  3. A coder may assign a diagnosis only when the provider documents it as a confirmed condition Correct answer.
  4. A coder may assign a diagnosis whenever a medication for that condition appears in the record

Explanation

Coders may not report a condition based solely on their own suspicion, test results, or medication lists; the provider must document the diagnosis as confirmed. If the evidence suggests an undocumented condition, the correct action is a provider query, not unilateral code assignment.

Question 11Core risk adjustment knowledge

A chart note from a specialist states "rule out lung cancer" with no confirmed diagnosis. How should the coder handle this for risk adjustment?

  1. Code an abnormal finding code and map it to the cancer HCC
  2. Do not code lung cancer; the condition is not confirmed Correct answer.
  3. Code a personal history of lung cancer
  4. Code lung cancer because the specialist suspected it

Explanation

Conditions documented as "rule out," "suspected," or "probable" in the outpatient setting are not coded as confirmed diagnoses. The coder should not assign the cancer code or its HCC until the provider documents confirmation.

Question 12Core risk adjustment knowledge

Which encounter setting typically allows diagnosis codes from a face-to-face visit to be captured for risk adjustment?

  1. A telehealth visit documented by an acceptable provider type Correct answer.
  2. A member self-reported health survey
  3. A pharmacy refill authorization
  4. A laboratory result interface with no provider evaluation

Explanation

Risk adjustment accepts diagnoses from qualifying face-to-face encounters, including telehealth when the model and plan rules permit it, provided an acceptable provider type documents the condition. Data sources without a provider evaluation do not generate diagnosis capture.

Question 13Core risk adjustment knowledge

A member's record shows a documented diagnosis of major depressive disorder, and the coder also sees a screening PHQ-9 score in the chart. What is the correct coding approach?

  1. Code both the score and the diagnosis as separate HCCs
  2. Code major depressive disorder based on the provider's documented diagnosis Correct answer.
  3. Code the PHQ-9 score as the diagnosis
  4. Code only the screening encounter

Explanation

The provider's documented diagnosis of major depressive disorder supports the code and its HCC assignment. Screening tool scores are clinical data that may support documentation but are not themselves coded as diagnoses.

Question 14Core risk adjustment knowledge

Which of the following best describes the annual requirement that plans recapture diagnoses?

  1. Diagnoses must be supported by documentation in the current payment year to count Correct answer.
  2. Diagnoses are recaptured only when the member changes plans
  3. Diagnoses persist indefinitely once submitted
  4. Diagnoses are recaptured automatically from prior-year claims

Explanation

Risk adjustment is prospective and year-specific, so a diagnosis counts only when it is documented and submitted for the current payment year. Prior-year diagnoses cannot be carried forward without current documentation.

Question 15Core risk adjustment knowledge

A provider documents "status post below-knee amputation" with no current complications. How does this affect risk adjustment?

  1. It maps to an amputation HCC and increases the score
  2. It is a status code that does not map to a payment HCC Correct answer.
  3. It requires coding the original cause of amputation
  4. It must be coded as an acute injury

Explanation

Status codes describe a patient's current state after a procedure or resolved condition and generally do not map to payment HCCs. Only when an active complication or condition is documented would a mapped category apply.

Question 16Core risk adjustment knowledge

Which action is most consistent with compliant documentation improvement in risk adjustment?

  1. Adding diagnoses to the problem list based on medication review
  2. Submitting codes from prior years to maintain continuity
  3. Educating providers to document conditions with specificity, linkage, and status Correct answer.
  4. Coding from the superbill without reviewing the note

Explanation

Compliant programs improve documentation through provider education about specificity, linkage between conditions and complications, and current status. Diagnosis capture must reflect the provider's own documentation rather than coder inference.

Question 17Core risk adjustment knowledge

In the CMS-HCC model, which factor is combined with diagnosis category weights to produce a member's risk score?

  1. The member's ZIP code and income level
  2. The number of claims submitted that year
  3. The number of providers seen during the year
  4. Demographic factors such as age, sex, and institutional status Correct answer.

Explanation

The risk score combines demographic factors, such as age, sex, and whether the member is community or institutional, with the weights of the HCCs captured. Claim volume, geography, and provider counts are not direct inputs to the calculation.

Question 18Core risk adjustment knowledge

A record documents "diabetic foot ulcer" in the assessment and lists diabetes without complications in the problem list. What should the coder do?

  1. Code diabetes without complications only
  2. Code the ulcer as traumatic in origin
  3. Code the ulcer as a separate condition and ignore the diabetes link
  4. Query or code diabetes with foot ulcer based on the provider's documented linkage Correct answer.

Explanation

When the provider documents a link between diabetes and a foot ulcer, the combination code for diabetes with foot ulcer is appropriate and more specific than diabetes without complications. Conflicting problem list entries should be resolved through documentation review or a query.

Question 19Core risk adjustment knowledge

Which scenario best illustrates a hierarchical interaction that affects payment?

  1. A patient whose claims were processed by two different carriers
  2. A patient whose diagnosis was documented by a nurse practitioner
  3. A patient with both moderate and severe persistent asthma where only the most severe category pays Correct answer.
  4. A patient with two unrelated conditions each in different body systems

Explanation

Within a hierarchy, related conditions such as moderate and severe persistent asthma do not both generate payment; the most severe category supersedes the lesser one. Unrelated conditions in different hierarchies each contribute their own weight.

Question 20Core risk adjustment knowledge

A coder reviews a record where the provider documents "AKI on CKD stage 4." Which coding approach is most accurate?

  1. Code end-stage renal disease
  2. Code CKD stage 4 only
  3. Code acute kidney failure only
  4. Code acute kidney failure with the appropriate CKD stage, following documentation Correct answer.

Explanation

When both acute kidney failure and chronic kidney disease are documented, both conditions are reported because ICD-10-CM provides distinct codes for acute failure and the CKD stage. The coder must not drop either condition or assume ESRD without documentation.

Question 21Core risk adjustment knowledge

Which of the following is a valid reason a submitted diagnosis might be rejected during risk adjustment data validation?

  1. The diagnosis was supported only by a medication list in the chart Correct answer.
  2. The diagnosis appeared in the discharge summary of an inpatient stay
  3. The diagnosis was documented by a physician during an office visit
  4. The diagnosis was linked to a complication in the assessment

Explanation

A diagnosis supported only by a medication list lacks provider documentation and would not survive validation. Diagnoses documented by a physician in a face-to-face encounter or in a discharge summary are acceptable sources when properly coded.

Question 22Core risk adjustment knowledge

A provider documents "COPD" without further detail, and the coder considers adding emphysema. What is the correct action?

  1. Code both COPD and emphysema
  2. Code emphysema because COPD often includes it
  3. Query the provider to confirm emphysema
  4. Code COPD only, since emphysema is not documented Correct answer.

Explanation

Coders may not assign a more specific diagnosis such as emphysema without provider documentation. COPD itself is coded as documented, and additional specificity requires a query rather than assumption.

Question 23Core risk adjustment knowledge

How does the coding of a major complication such as a transplanted organ status differ from coding an active malignancy for risk adjustment?

  1. Neither maps to any HCC
  2. Transplant status maps to an HCC while malignancy does not
  3. Transplant status is a status code outside HCC mapping, while active malignancy maps to an HCC Correct answer.
  4. Both map to payment HCCs with identical weights

Explanation

Transplant status is a status code that generally falls outside payment HCC mapping, whereas an actively treated malignancy maps to an HCC category. Coders must distinguish status codes from active disease when assessing risk-adjustment impact.

Question 24Core risk adjustment knowledge

A member has documented severe malnutrition and also a documented BMI of 17.0. Which coding consideration is most relevant for risk adjustment?

  1. The BMI code alone drives the risk score
  2. The provider's documented malnutrition diagnosis supports the HCC, while BMI may be reported as an additional code Correct answer.
  3. Neither condition is codable without a dietitian note
  4. The BMI code replaces the malnutrition diagnosis

Explanation

The provider's documented malnutrition diagnosis supports the HCC assignment, and the BMI code may be reported as an additional code when documented. A BMI value alone does not establish malnutrition, and a dietitian note is not required for coding.

Question 25Core risk adjustment knowledge

A coder finds a diagnosis of "unspecified psychosis" in the assessment and a more specific diagnosis of schizophrenia in a prior note from the same year. What is the best approach?

  1. Code neither because documentation conflicts
  2. Code unspecified psychosis from the current assessment and query if specificity affects payment Correct answer.
  3. Code schizophrenia from the prior note without further review
  4. Code both diagnoses as separate HCCs

Explanation

The current encounter's documentation governs code assignment, so the coder reports what the provider documented at that visit. If greater specificity would change the HCC, a query is appropriate rather than importing a diagnosis from an earlier note.

Question 26Core risk adjustment knowledge

Which type of diagnosis code set is used to report member conditions for risk adjustment purposes in the United States?

  1. Healthcare Common Procedure Coding System Level II codes
  2. ICD-10-PCS procedure codes
  3. ICD-10-CM diagnosis codes Correct answer.
  4. Current Procedural Terminology codes

Explanation

Risk adjustment captures diagnoses, and diagnoses are reported with ICD-10-CM codes, which map to the condition categories in the payment model. Procedure code sets describe services rendered rather than the member's conditions. Only ICD-10-CM carries the diagnostic detail the model requires.

Question 27Core risk adjustment knowledge

A member's documented risk score is 1.35. How is this value best interpreted relative to the average member?

  1. The member is expected to cost exactly the same as the average member
  2. The member is expected to cost about 35 percent more than the average member Correct answer.
  3. The member is expected to cost about 135 percent less than the average member
  4. The member is expected to cost about 35 percent less than the average member

Explanation

A risk score of 1.0 represents average expected cost, so a score of 1.35 indicates expected cost about 35 percent above that average. Scores above 1.0 signal higher predicted resource use. The value is a relative measure, not a dollar amount.

Question 28Core risk adjustment knowledge

Which date determines the payment year in which a documented diagnosis is counted for risk adjustment?

  1. The date the claim was adjudicated
  2. The date the diagnosis was first ever recorded
  3. The date the service was rendered Correct answer.
  4. The date the chart was audited

Explanation

Diagnoses are assigned to a payment year based on the date of service on which the condition was documented and reported. Adjudication and audit dates do not control the payment year. A condition recorded years earlier does not carry forward automatically without current documentation.

Question 29Core risk adjustment knowledge

What is the primary purpose of risk adjustment in a Medicare Advantage program?

  1. To adjust payments so plans are compensated for the expected cost of their enrolled members' conditions Correct answer.
  2. To reward plans that submit the largest volume of claims
  3. To standardize premiums across all geographic regions
  4. To replace quality reporting with cost-based incentives

Explanation

Risk adjustment adjusts capitated payments to reflect differences in expected cost driven by members' health conditions, so plans caring for sicker populations are not disadvantaged. It is not a volume-based reward and does not set premiums by region. Quality reporting remains a separate program.

Question 30Core risk adjustment knowledge

Which document type is generally an acceptable source for a diagnosis submitted for risk adjustment when it reflects a face-to-face encounter?

  1. A member-completed health risk assessment questionnaire
  2. A laboratory result flagged as abnormal
  3. A prescription refill authorization
  4. A signed progress note from an office visit Correct answer.

Explanation

A diagnosis must be documented by an acceptable provider during a face-to-face encounter, and a signed office progress note reflects that. Laboratory results and prescription records may support a diagnosis but do not themselves constitute provider documentation of the condition. Member questionnaires are self-reported and not codable.

Question 31Core risk adjustment knowledge

A provider documents only 'history of pneumonia' with no indication of active disease. How should the coder treat this for risk adjustment?

  1. Code it as a personal history code, which does not map to a payment condition category Correct answer.
  2. Code it as active pneumonia for the current year
  3. Query the member directly to confirm current symptoms
  4. Code it as an acute respiratory condition with a high weight

Explanation

A condition documented only as history indicates resolution and is reported with a history code, which does not map to a hierarchical condition category. Active disease must be documented currently to be captured. Coders cannot upgrade a history statement to an active diagnosis.

Question 32Core risk adjustment knowledge

Which provider type is authorized to document diagnoses that can be captured for risk adjustment?

  1. A member's family caregiver
  2. A health plan customer service representative
  3. A licensed physician or other qualified healthcare provider Correct answer.
  4. A billing specialist reviewing the claim

Explanation

Diagnoses must be documented by a physician or other qualified healthcare provider who is treating the member. Non-clinical staff and caregivers cannot establish diagnoses for coding. Their notes may provide context but are not codable sources.

Question 33Core risk adjustment knowledge

A coder is reviewing a record where the assessment lists 'congestive heart failure' but the body of the note describes only fatigue and edema with no cardiac findings. What is the most appropriate action?

  1. Assign the heart failure code and add a query note to the record later
  2. Assign the heart failure code because it appears in the assessment
  3. Query the provider to clarify whether heart failure is supported and current Correct answer.
  4. Assign only a symptom code for edema and ignore the assessment

Explanation

When a diagnosis in the assessment lacks clinical support in the body of the record, the coder should query the provider rather than assume or ignore it. A diagnosis must be supported by documented clinical findings. Assigning the code without support risks an invalid submission.

Question 34Core risk adjustment knowledge

How does a hierarchical condition category hierarchy affect a member who has both a more severe and a less severe condition within the same disease group?

  1. Neither condition is counted until both are documented twice
  2. Both conditions are counted and their weights are added together
  3. The more severe condition is counted and the less severe one is not Correct answer.
  4. Only the less severe condition is counted to avoid overpayment

Explanation

The hierarchy is designed so that only the most severe condition within a related group contributes to the score, preventing duplicate payment for conditions on the same clinical continuum. The less severe condition in that group is not separately counted. This is why documenting the most specific, severe condition matters.

Question 35Core risk adjustment knowledge

A member's record documents type 2 diabetes with diabetic retinopathy in the assessment. Which coding approach best supports accurate risk adjustment?

  1. Code diabetes without complications and add a separate eye code
  2. Code the diabetes with the retinopathy combination code reflecting the complication Correct answer.
  3. Code only the retinopathy and omit the diabetes
  4. Code only a symptom code for vision change

Explanation

When a provider documents diabetes with a complication such as retinopathy, a combination code captures both the diabetes and the complication, and this is what maps to the appropriate condition category. Coding diabetes as uncomplicated would understate the member's condition burden. Symptom codes do not substitute for the documented diagnosis.

Question 36Core risk adjustment knowledge

Why does documenting laterality and specific site matter for certain diagnoses in risk adjustment?

  1. Laterality changes the payment year of the encounter
  2. Specific site and laterality may determine whether a diagnosis maps to a higher-weighted condition category Correct answer.
  3. Laterality is required only for inpatient claims
  4. Site specificity affects only quality reporting, not risk scores

Explanation

For some conditions, such as certain vascular or neurologic diagnoses, the specific site and laterality can determine the assigned condition category and its weight. Greater specificity supports accurate mapping and reduces audit risk. Laterality does not change the payment year.

Question 37Core risk adjustment knowledge

A provider documents 'major depressive disorder, recurrent, moderate' in the assessment with supporting symptoms. How should the coder proceed?

  1. Code unspecified depression to avoid over-specifying
  2. Decline to code because mental health conditions are excluded
  3. Code only the symptom of low mood
  4. Code the most specific documented depression diagnosis that is supported Correct answer.

Explanation

Coders assign the most specific diagnosis that the provider has documented and supported, which here is recurrent moderate major depressive disorder. Mental health conditions are included in risk adjustment models. Coding unspecified or symptom-only would understate the condition.

Question 38Core risk adjustment knowledge

What is the effect of a diagnosis that is documented but never reported on a claim submitted to the plan?

  1. It cannot contribute to the risk score for that payment year Correct answer.
  2. It is captured automatically from the medical record
  3. It is captured in the following payment year without further action
  4. It is captured only if the member reports it

Explanation

Risk adjustment relies on diagnoses submitted on claims and encounter data, so a condition documented but never reported is not captured for that payment year. Chart review or coding processes may later identify such gaps. Documentation alone does not automatically adjust payment.

Question 39Core risk adjustment knowledge

A coder sees 'end-stage renal disease' documented in a hospital discharge summary but no supporting dialysis or lab findings anywhere in the record. What is the best next step?

  1. Assign the ESRD code based on the discharge summary alone
  2. Assign a chronic kidney disease code instead without documentation
  3. Query the provider for clarification and supporting clinical detail Correct answer.
  4. Defer coding entirely and close the review

Explanation

An unsupported diagnosis statement should prompt a provider query to confirm the condition and obtain supporting clinical detail before coding. Coders may not substitute a different diagnosis that the provider did not document. Assigning based on an isolated statement increases audit risk.

Question 40Core risk adjustment knowledge

Which situation most clearly represents a documentation gap that could affect a member's risk score?

  1. A diagnosis in the assessment that is fully supported by findings and reported on the claim
  2. A diagnosis reported with the most specific code available
  3. A chronic condition managed by a specialist but never noted in the primary care record or reported Correct answer.
  4. A condition documented and reported in the correct payment year

Explanation

A chronic condition that is actively managed but never documented in a codable record or reported represents a gap that can lower the captured risk score. Complete, specific documentation that is reported does not create a gap. Identifying such gaps is a core function of risk adjustment review.

Question 41Core risk adjustment knowledge

A member has both diabetes with complications and a separate documented condition in the same hierarchical group. How does the model generally handle the interaction?

  1. It counts every condition in the group at full weight
  2. It averages the weights of all conditions in the group
  3. It applies the hierarchy so only the highest-ranked condition in the group is counted Correct answer.
  4. It excludes all conditions in the group from the score

Explanation

Within a hierarchy, the model counts the highest-ranked condition in the disease group and does not add lower-ranked conditions in that same group. This avoids double counting related conditions. Conditions in different groups are handled independently.

Question 42Core risk adjustment knowledge

A coder is deciding between two diagnosis codes for the same condition, one more specific and one less specific, both supported by the record. Which principle applies?

  1. Select the least specific code to leave room for later clarification
  2. Select the code with the lowest weight to reduce audit exposure
  3. Select the code that reflects the greatest documented specificity Correct answer.
  4. Select whichever code was used on a prior claim

Explanation

Coding guidelines direct coders to the most specific code supported by the documentation, which also supports accurate risk adjustment. Choosing a lower-weight or less specific code misrepresents the record. Prior claim history does not govern current coding.

Question 43Core risk adjustment knowledge

What is the primary risk of upcoding a diagnosis that is not supported by the medical record?

  1. The diagnosis will automatically be corrected in the next payment year
  2. The plan may face audit findings, payment recovery, and compliance penalties Correct answer.
  3. The claim will be rejected before payment in all cases
  4. The member's premium will decrease

Explanation

Submitting unsupported diagnoses inflates risk scores and exposes the plan to data validation findings, payment recovery, and potential civil or administrative penalties. Not all unsupported claims are rejected upfront, which is why validation audits exist. Premium effects on members are not the direct consequence.

Question 44Core risk adjustment knowledge

During a risk adjustment data validation audit, a sampled diagnosis lacks a legible provider signature. What is the most likely outcome?

  1. The diagnosis is removed from the validated record Correct answer.
  2. The diagnosis is moved to the following payment year
  3. The diagnosis is accepted because the condition is plausible
  4. The diagnosis is replaced with a related code by the auditor

Explanation

Validation requires that each submitted diagnosis be supported by an acceptable, authenticated record. A missing or illegible provider signature undermines authentication, so the diagnosis is typically not validated and is removed. Auditors do not substitute codes or shift diagnoses between years.

Question 45Core risk adjustment knowledge

A member's record documents both a current malignancy and a history of a different malignancy that is no longer active. How should the coder handle these for risk adjustment?

  1. Code neither until the malignancy is treated surgically
  2. Code only the history of malignancy because it is more specific
  3. Code the active malignancy and also code the history of the resolved malignancy Correct answer.
  4. Code the active malignancy only and omit the resolved history

Explanation

The active malignancy is coded because it is a current condition, and the resolved malignancy is coded with an appropriate history code to reflect that it is no longer active. Both statements are documented and each has its own code. The history code does not map to an active cancer category.

Question 46Core risk adjustment knowledge

A coder notices that a specialist's note documents a significant chronic condition, but the primary care record never mentions it and no claim reports it. What does this most likely indicate?

  1. The condition represents a capture gap that may lower the member's risk score Correct answer.
  2. The specialist note should be disregarded as non-codable
  3. The condition should be excluded because only primary care documents count
  4. The condition will be captured automatically through pharmacy data

Explanation

When a legitimate condition is documented by a treating specialist but never reported, the diagnosis is a capture gap that can understate the risk score. Specialist documentation is codable when it reflects a face-to-face encounter. Pharmacy data alone does not establish a diagnosis for coding.

Question 47Core risk adjustment knowledge

A provider documents 'acute on chronic systolic heart failure' in the assessment with supporting findings. Which coding outcome best reflects accurate risk adjustment capture?

  1. Code chronic systolic heart failure only, since acute and chronic cannot be combined
  2. Code a symptom such as dyspnea instead of the heart failure
  3. Code the combined acute on chronic systolic heart failure diagnosis Correct answer.
  4. Code acute heart failure only, since it is the more severe element

Explanation

When the provider documents both acute and chronic systolic heart failure, the combined diagnosis is coded to reflect the documented severity and type. Coding only one element or a symptom understates the condition. The combined code supports the appropriate condition category.

Question 48Core risk adjustment knowledge

A provider's note states 'probable diabetic nephropathy' and no confirmatory testing is documented. How should the coder respond for risk adjustment?

  1. Code chronic kidney disease without diabetes linkage
  2. Code diabetes without complications and ignore the nephropathy
  3. Query the provider to resolve whether the condition is confirmed Correct answer.
  4. Code diabetic nephropathy because probable means likely present

Explanation

Unconfirmed language such as probable or suspected does not support coding the condition, so the coder should query the provider to establish whether it is confirmed. Coding a probable diagnosis as confirmed is inaccurate. Substituting a different condition is not appropriate.

Question 49Core risk adjustment knowledge

Which combination best describes the two components that together produce a member's risk score in a typical CMS-HCC model?

  1. Diagnosis condition category weights and demographic factors such as age and sex Correct answer.
  2. Claim volume and average charge per visit
  3. Quality star ratings and member satisfaction scores
  4. Procedure codes and place of service

Explanation

The risk score combines demographic factors, such as age, sex, and enrollment status, with weighted condition categories derived from diagnoses. Procedure codes, charges, and quality ratings are not the components of the risk score. Both demographic and diagnostic elements are needed to produce the final value.

Question 50Core risk adjustment knowledge

A member's chart for the current payment year contains a diagnosis of chronic systolic heart failure documented only in a prior-year note, with no documentation of the condition anywhere in the current year's records. How should the coder handle this diagnosis for risk adjustment purposes?

  1. Submit the diagnosis but append a modifier indicating it was carried forward from a prior year
  2. Submit the diagnosis only if the prior-year note was signed by a specialist rather than a primary care provider
  3. Do not submit the diagnosis, because it lacks current-year documentation supporting continued presence Correct answer.
  4. Submit the diagnosis because chronic conditions carry forward automatically each year once documented

Explanation

Risk adjustment captures diagnoses that are documented and supported in the current payment year; chronic conditions do not roll forward on their own. Even a permanent condition such as heart failure must be re-documented and re-coded each year to be reported. Without current-year support, submitting the diagnosis would create an unsupported code subject to validation audit removal.