CRC (Other exams) key terms

A payment method that adjusts a health plan's payment based on how sick its enrolled members are, so plans caring for sicker populations receive more money than plans with healthier members.

A number summarizing a member's expected health care cost relative to an average member. It combines demographic factors and diagnosed conditions, with 1.0 representing roughly average expected cost.

A fixed payment per member per month paid to a health plan or provider regardless of how much care that member actually uses. Risk adjustment modifies these payments to reflect illness burden.

The maximum amount CMS will pay a Medicare Advantage plan for an average-risk enrollee in a given county. Plan bids are compared against it to set payment rates.

Diagnosis and procedure information submitted for services delivered to a member. In risk adjustment it is a primary data source for identifying conditions that generate HCCs.

A multiplier applied so that the average risk score across a population equals 1.0. It calibrates model output so scores remain comparable year to year and across populations.

The year-over-year increase in average risk scores driven by how thoroughly diagnoses are documented and coded, rather than by real changes in member health. CMS adjusts payments for it.

A method where payment for a period is based on diagnoses documented in a prior period. Medicare Advantage uses this, so conditions must be documented again each year.

Hierarchical Condition Category. A group of clinically related diagnoses that share similar expected costs; each enrollee's diagnoses map to HCCs that generate risk score points.

The risk adjustment model CMS uses for Medicare Advantage plans. It assigns coefficients to HCCs and demographic factors to predict each member's expected cost.

The risk adjustment model used for the individual and small group health insurance markets. It uses age, sex, and diagnosis categories to redistribute funds among insurers.

The Part D risk adjustment model that predicts prescription drug costs using drug-oriented condition categories rather than medical HCCs, combined with demographic factors.

A rule that, within a related disease group, only the most severe condition counts toward the risk score. Lower-severity HCCs in the same hierarchy are suppressed.

A numeric weight assigned to an HCC or demographic factor showing how much it adds to predicted cost. Coefficients are produced by regression on historical claims and published each year.

Age, sex, and sometimes Medicaid or disability status used in the model to adjust expected cost independently of any diagnosed condition.

An extra weight added when specific combinations occur together, such as diabetes plus heart failure, reflecting cost beyond what the individual HCCs alone would predict.

The specific annual release of a risk adjustment model, such as CMS-HCC V28, with its own coefficients, HCC mapping, and diagnosis code list that must match the payment year.

The diagnosis coding system used in the United States for outpatient and physician reporting, with codes describing condition, body site, laterality, and cause in high detail.

The level of detail coded, capturing site, severity, type, and cause. Risk adjustment requires the most specific code the documentation supports, since vague codes may not map to an HCC.

A single ICD-10-CM code that reports two diagnoses together, such as a diabetic complication with the diabetes type, capturing both conditions without separate codes.

A coding instruction stating that two codes cannot be reported together because the conditions are mutually exclusive. Ignoring it can create invalid or duplicated diagnosis capture.

An extra character on certain codes indicating the encounter type, such as initial, subsequent, or sequela. Choosing the wrong value changes the meaning of the diagnosis.

A condition that remains after the acute phase of an illness or injury has ended. Coders report the residual condition first and the original cause with a sequela code.

A code used when documentation lacks the detail needed for a more specific diagnosis. Frequent use signals documentation gaps and may fail to establish a risk-adjustable condition.

A Z code indicating a patient's current status, such as amputation, transplant, or long-term drug use, which may itself be risk-adjustable or affect care management.

The process of reviewing clinical documentation and extracting diagnoses, dates, and supporting evidence under defined rules, usually into a standardized data set for submission.

The original clinical record, such as an office note or hospital discharge summary, that supports a reported diagnosis. Auditors require it to validate any submitted code.

A written or electronic request asking a clinician to clarify or add documentation when the record is ambiguous, without steering the provider to a specific answer.

A provider's signed statement confirming that a member's conditions are current and being managed. It must be supported by the medical record to be valid for risk adjustment.

Monitoring, Evaluation, Assessment, and Treatment. Documenting at least one of these for a condition each year supports that the condition is active and should be captured.

Analytic rules that flag members whose claims, medications, or lab results suggest an undocumented condition, prompting chart review or outreach to confirm and document it.

The need to document and code chronic conditions again every year, because a diagnosis from a prior year does not generate risk score points in the current payment year.

An active condition is currently being managed and generates risk score points. A resolved condition coded as history generally does not, unless a specific status code applies.

Risk Adjustment Data Validation. A CMS audit comparing submitted diagnoses to medical records and computing an error rate that can require the plan to repay overpayments.

Submitting a diagnosis or code that is more severe or better reimbursed than the documentation supports. It is a compliance violation and can constitute fraud.

A federal law imposing liability for knowingly submitting false claims, including unsupported risk adjustment diagnoses, with civil penalties, treble damages, and whistleblower provisions.

The activities, controls, and audits that prevent and detect improper payments, including data monitoring, provider education, internal chart review, and correction of identified errors.

Classifying chronic kidney disease by glomerular filtration rate into stages 1 through 5, with stage 5 distinct from end-stage renal disease. The documented stage determines which HCC applies.

Distinguishing systolic from diastolic heart failure and specifying acuity, since these variations map to different HCCs and severity levels and change predicted cost.

Diabetes coded together with its associated complication, such as nephropathy, retinopathy, or neuropathy. Adding the complication usually moves the member to a higher-paying HCC.