Ultimate Risk Adjustment CRC Exam 2025-2026: 86 actual Questions & Answers with Detailed Rationales | Comprehensive Test Bank for Certified Risk Adjustment Coders | HCC Coding, ICD-10-CM Guidelines & Compliance Review

Risk Adjustment Model

Calculates risk scores for all beneficiaries with available data

What are the three submission deadlines?

1. First Friday in September = Initial Risk Score

2. First Friday in March = Mid-year Update

3. January 31 after the payment year = Final reconcilation

Medicare risk adjustment model is prospective. This means?

Diagnoses reported in the prior year and demographic information are utilized to "predict" future costs and adjust payments accordingly

Risk Scores.

Measures individual beneficiaries' relative risk and are used to adjust payments for each beneficiary's expected expenditures.

FERAS Response Report.

Rejected data after it has been processed through FERAS is recorded in this report.

RAPS Return File

This is a daily report that shows all records approved and where errors occurred.

RAPS Transaction Error Report

Displays records on which errors occurred.

RAPS Transaction Summary Report

A report sent to the MA organization daily and identifies data that have been finalized in RAPS database

Duplicate Diagnosis Cluster Report

Shows diagnosis clusters submitted with information that duplicates a stored cluster.

RAPS Monthly Plan Activity Report and Cumulative Plan Activity Report

Provides a summary of all diagnoses stored for a given time period.

Error Frequency Report

This report is distributed monthly and quarterly. Provides an overview of all errors associated with files submitted in test and production.

RAPS database

Stores all finalized diagnosis clusters

Risk Adjustment System (RAS)

Executes the risk adjustment model and calculates the risk score using the SAS model.

Medicare Advantage Prescription Drug System (MARx)

Processes payments to plans and issues the MMR (Monthly Membership Report) and MOR (Model Output Report).

How often does CMS conduct data validation audits and for what purpose?

Audits are done annually on selected plans that may have to request medical record documentation from the providers to support the submitted diagnoses.

What types of data are checked in FERAS?

File-level, batch-level and first and last detailed records

RAPS Return file

Daily reports that shows all records approved and where errors occurred.

What does File-level information identified?

Submitter

What does Batch-level information identify?

MA organization

What does Detail-level information identify?

Beneficiary

Define Reconciliation

The completion of the implementation of payments with CMS calculating final risk adjustment factors and beneficiary stats based on complete data. Necessary adjustments for institutional status and demographic data for enrollees is considered.

CMS continues to allow a period (approximately 13 months after the data collection year) for submitting final RAPS data for the appropriate data collection period.

Is this condition a Probably Forever/Almost ALLS (still has condition even though mediation or device is covering up symptoms), Forever/ALLS, or a Chronic condition?

Septicemia (Category 380)

Probably Forever/Almost ALLS

Is this condition a Probably Forever/Almost ALLS (still has condition even though mediation or device is covering up symptoms), Forever/ALLS, or a Chronic condition?

Heart Failure (Category 428)

Probably Forever/Almost ALLS

Is this condition a Probably Forever/Almost ALLS (still has condition even though mediation or device is covering up symptoms), Forever/ALLS, or a Chronic condition?

Disease of Pulmonary Circulation (Categories 415-47) -Regional

Probably Forever/Almost ALLS

Is this condition a Probably Forever/Almost ALLS (still has condition even though mediation or device is covering up symptoms), Forever/ALLS, or a Chronic condition?

Enteris and Ulcerative Colitis (Categories 555-557)

Probably Forever/Almost ALLS

Is this condition a Probably Forever/Almost ALLS (still has condition even though mediation or device is covering up symptoms), Forever/ALLS, or a Chronic condition?

Perforated Gastric, Duodenal, Peptic, and Gastrojejunal Ulcers (Categories 531-534)

Probably Forever/Almost ALLS

Is this condition a Probably Forever/Almost ALLS (still has condition even though mediation or device is covering up symptoms), Forever/ALLS, or a Chronic condition?

Intestinal Obstruction without mention of Hernia (Category 560)

Probably Forever/Almost ALLS

Is this condition a Probably Forever/Almost ALLS (still has condition even though mediation or device is covering up symptoms), Forever/ALLS, or a Chronic condition?

Osteomyelititis, Periostitis an Infections involving Bone (Category 730)

Probably Forever/Almost ALLS

Is this condition a Probably Forever/Almost ALLS (still has condition even though mediation or device is covering up symptoms), Forever/ALLS, or a Chronic condition?

Pathologic Fractures of Vertebrae, Neck of Femur, other specified part of Femur (Category 733)

Probably Forever/Almost ALLS

Is this condition a Probably Forever/Almost ALLS (still has condition even though mediation or device is covering up symptoms), Forever/ALLS, or a Chronic condition?

Acute Kidney Failure, Chronic Kidney Disease (Categories 584-585)

Probably Forever/Almost ALLS

Is this condition a Probably Forever/Almost ALLS (still has condition even though mediation or device is covering up symptoms), Forever/ALLS, or a Chronic condition?

Amputations, Organ Transplant, History of MI

Probably Forever/Almost ALLS

Is this condition a Probably Forever/Almost ALLS (still has condition even though mediation or device is covering up symptoms), Forever/ALLS, or a Chronic condition?

Alcoholism in Remission

Probably Forever/Almost ALLS

Is this condition a Probably Forever/Almost ALLS (still has condition even though mediation or device is covering up symptoms), Forever/ALLS, or a Chronic condition?

Schizoprenia

Probably Forever/Almost ALLS

Is this condition a Probably Forever/Almost ALLS (still has condition even though mediation or device is covering up symptoms), Forever/ALLS, or a Chronic condition?

CHF (compensated)

Probably Forever/Almost ALLS

Is this condition a Probably Forever/Almost ALLS (still has condition even though mediation or device is covering up symptoms), Forever/ALLS, or a Chronic condition?

Residual Late Effects of Stroke

Forever/ALLS

Is this condition a Probably Forever/Almost ALLS (still has condition even though mediation or device is covering up symptoms), Forever/ALLS, or a Chronic condition?

Upper Limb Amputation status

Forever/ALLS

Is this condition a Probably Forever/Almost ALLS (still has condition even though mediation or device is covering up symptoms), Forever/ALLS, or a Chronic condition?

Lower limb amputation status (including toe)

Forever/ALLS

Is this condition a Probably Forever/Almost ALLS (still has condition even though mediation or device is covering up symptoms), Forever/ALLS, or a Chronic condition?

Malignant Neoplasm (except skin and lip) but including melanoma

Forever/ALLS

Define Moderate Risk

One or more chronic illnesses with mild exacerbation, progression or side effects of treatment

Two or more chronic stable illnesses

Define High Risk

One or more chronic illnesses with severe exacerbation, progression or side effects of treatment

Acute or Chronic illnesses or injuries that pose a threat to life or body function

In HCC coding the payment to the Health Plan is based on?

Risk Score, which is determined through diagnosis coding

What if the average risk score CMS suggest for an average healthy senior?

1.00

What does a risk score above 1.00 suggest?

A patient with chronic conditions

A lower RAF Score may indicate (3 things)?

1. false information due to lack of adequate chart documentation or incomplete and/or inaccurate ICD coding

2. Patients not seen

3. Indicative of insufficient claims data submission

What is the another name for the RxHCC model?

Plan Liability Model

What are the 4 key components (combination of measures) of a RAF Score?

1. Accurate coding and capture of all chronic conditions

2. Only the physician or NPP can document in the patient chart.

3. At minimum, diagnosis/HCC codes should be captured every 6 months.

4. CMS "drops" the codes from the prior year every December 31 and starts over again with each member's conditions for the new year.

Name 3 ways to maximize Risk Scores?

1. Encourage patients to go to the doctor for AWV/HRA annually

2. Periodic chart audits with payback of reimbursement associated with unsupported coding

3. Audit your diagnosis codes

What two models are used to calculate a RAF score properly? What do these models allow to happen to the final risk score?

Additive and Hierarchical.

Allows for more than one disease to impact the final risk score.

What is diagnostic hierarchies?

Prevents multiple diagnoses in the same disease group from skewing the risk score with a higher score. The more severe diagnoses "trumps" the lower diagnoses within the same disease group.

What is the point of risk adjustment?

To allow for adjustments in capitated (set amount for each enrolled person assigned to them, per period of time, whether or not that person seeks care) payment amounts so that MA plans pay out fairly and accurately and minimize questionable incentives in order to avoid enrolling sicker beneficiaries.

In Predictive Modeling, CMS-HCC predicts?

Full Part A and Part B Medicare expenditures

In Predictive Modeling, the RxHCC predicts?

Expenditures for which Part D sponsors are responsible, i.e., drug costs excluding cost sharing amounts for which the enrollee or the government is responsible for paying.

RxHCC model adjusts standardized payments for?

Monthly Part D direct subsidy

CMS-HCC model adjusts standardized payments for?

Monthly payments to Medicare Advantage plans and PACE organizations.

CFR

Code of Federal Regulations

NCDs

CMS National Coverage Determinations

LCDs

Local coverage determinations

What are the 4 focal points of a MA Plan?

1. Early detection of chronic conditions

2. Coordination of care

3. Accurate reporting of conditions

4. Improvement of health conditions

What does AWV stand for?

Annual Wellness Visit

What does PPPS stand for?

Personalized Prevention Plan Services

What does IPPE stand for?

Initial Preventive Physical Exam

What does HRA stand for?

Health Risk Assessment

What is the ICD-9 code for AWV?

V70.0 - Preventative Medicine

CPT code for provider's reimbursement for AWV?

99213-Mid-level, face to face visit (this is not AWV code).

If E/M service provided must be a separate service and use modifier -25.

What does CNS (medical professional) stands for?

Clinical Nurse Specialist

What does KPI stand for?

Key Performance Indicators

G0438 is a code for?

Initial AWV visit

G0439 is a code for?

Subsequent AWV visit

Case Mix/Risk Adjustment

Is the overall health status and risk of a provider panel of member, which utilizes combined data from the following areas and provides a depiction of member heath risk profile for a plan, which is used to predict future costs and payments.

Predictive Modeling

The prospective application of risk measures along with statistical techniques to identify "high risk" individuals who greatly would benefit from targeted care management interventions, such as being moved to a SNP.

It provides a potential RAF score for each claim, which can in turn be used to target claims which indicate a "suspect" patterns.

Suspect Generation

Identifies members with suspected and undocumented conditions.

Suspected conditions are based on prescribed medications, previously reported conditions, DME, lab tests, therapy, etc.

Undocumented conditions are diagnosis codes that link to an HCC, but for which there is no M.E.A.T. that supports reporting it in the chart.

What is the "Suspect Generation List"?

It is a list of providers who we think we might be able to obtain a HCC

What is the significance of December 31 in HCC coding?

All HCCs are dropped.

What are two categories that are defined by Predictive Modeling that indicate aberrant behavior?

1. Billing for services not provided

2. Billing for a higher reimbursed diagnosis code when a less costly diagnosis code is the most specific and appropriate for the service performed.

What are the combined data areas used to depict member health risk profiles for Case Mix and Risk Adjustment?

1. Provider Performance Assessment

2. Patient Outcome Monitoring

What are the 11 key components on a Suspect Generation List that MA plans rely on their coders to look for when reviewing charts?

1. HCC Description

2. Last rendering provider name

3. Last rendering provider specialty

4. Last DOS

5. Suspect Provider Name

6. Suspect Provider Specialty

7. Last Suspect provider visit

8. Current Year HCC

9. Projected Next Year Dropped

10. Projected Next Year New

11. Reoccurring

ACA

Affordable Care Act

MLR

Medical Loss Ratio Rule and Reports

Self-funded plans

The employer or other plan sponsor pays the cost of health benefits from its own assets.

Under MLR, for each state in which health insurers write coverage, they must submit data on 4 elements. They are:

1. Aggregate premiums

2. Claims experience

3. Quality improvement expenditures

4. Non-claims costs incurred in the Large Group, Small Group and Individual markets

MLR provision calls for health insurers to report annually to HHS on the percent of total premium revenue spent on activities that improve health care quality. These activities must meet 16 requirements. Name them.

1. Be designed to improve health quality

2. Enhance health information technology in a way that improves quality, transparency, or outcomes.

3. Be designed to increase the likelihood of desired health outcomes in ways that can be objectively measured and produce verifiable results

4. Be directed toward individual health plan members, incurred for the benefit of specified member segments or provide health improvements to the general population

5. Be grounded in evidence-based medicine, widely accepted best clinical practice or criteria established by recognized health care quality organizations

6. Programs to help individuals manage serious conditions such as cancer or heart disease

7. Hospital discharge planning designed to reduce hospital readmission.

8. Activities to improve patient safety and reduce medical errors

9. Health assessments and wellness coaching designed to manage a health condition or achieve measurable health improvements

10. Arranging and managing transitions

11. Medication and care compliance

12. Prospective medical and drug utilization review

13. Programs to support shared decision-making with patients, their families, and the patient's representatives

14. Use of medical homes (as defined in the ACA)

15. Nurse-line (with some exceptions)

16. Comprehensive discharge planning.

Define MLR Rule

80/20 rule. Requires health insurance companies in the individual and small group markets to spend at least 80 percent of premium dollars they collect on medical care or activities to improve health care quality, and 85 percent in the large group market.

What 9 items are not considered part of medical costs, and are considered administrative costs:

1. Retrospective and concurrent utilization review

2. Most fraud prevention activities (beyond those that recover incurred claims)

3. Provider network contracting and management costs

4. Provider credentialing

5. Costs associated with calculating and administering enrollee/employee incentives

6. Clinical data collection without data analysis

7. Claims adjudication expenses

8. Marketing expenses

9. Broker commissions

Define MLR calculation defined as:

Medical Numerator divided by the premium denominator

Define medical numerator

Incurred claims and expenses for activities that improve health care quality

Define premium denominator

Premium revenue less federal and state taxes, licensing and regulatory fees, with adjustment for risks, risk corridors and reinsurance

What does NAIC stand for?

National Association of Insurance Commissioners

How many employees are in a Small Group?

1-50 total employees

How many employees are in a Large Group?

51 or more total employees

What is the MLR Provision?

Ensures that a minimum percent of premiums are used to pay claims.

This limits the amount of insurance companies can spend on administrative expenses and profits.

When an MA Plan directs a smaller amount of premium dollars to administrative costs, generally members receive the following on their premium dollars ?

a higher return on their premium dollars

What does HEDIS stand for?

Healthcare Effectiveness Data and Information Set

What does NCQA stand for?

National Committee for Quality Assurance

What does HPO stand for?

Health Plan Organizations

What does HOQ stand for?

Health Organization Questionairre

What does PPO stand for?

Preferred Provider Organizations

What does IDSS stand for?

Interactive Data Submission System

What does CAHPS stand for?

Consumer Assessment of Healthcare Providers and Systems

This is a broad spectrum collaborative effort that combines folks from various employer groups, consumers, health plans and more, to analyze, review and collectively decide on what content make the grade for HEDIS. Together, the group governs which HEDIS measures will be included annually and delineates what field tests will determine the measures matrix.

NCQA's Committee on Performance Measurement

What is HEDIS purpose?

To provide purchases and consumers with the information they need to reliably compare the performance of health care plans.