2025–2026 CRC Exam Prep | AAPC
Certified Risk Adjustment Specialist
Study Guide, Hierarchical Condition
Categories (HCC) Newest Version 2026
Complete Guide With Complete
Solutions
Risk Adjustment Data Element - ANSWER-Age, Gende, Socioeconomic status,
Disability status, Insurance status(Medicaid, dual-eligible,) Claims data elements such
as procedure codes, place of service codes, special patient-specific conditions hospice,
ESRD
RAF - ANSWER-Risk Adjustment Factor Scores
Three main types of reviews - ANSWER-Retrospective, Concurrent and prospective
Retrospective - ANSWER-reviews are performed after the information has been
reported and in risk adjustment these are prior years dos
Concurrent reviews - ANSWER-performed ongoing as patients are seen prior to
reporting and in risk adjustment the current year
Prospective reviews - ANSWER-will effect the next year and not the current year where
payment is concerned. They are used to forcast
Types of Risk Adjustment Models(HHS) - ANSWER-HHS hEALTH AND HUMAN
SERVICES hIERARCHICAL CONDITION(Commercial, individual and small grooup
Types of Risk Adjustment Modles(CDPS) - ANSWER-Chronic Illness and Disability
payment systems(Medicaid)
Types of Risk Adjustment Models(HCC-C) - ANSWER-Hierarchical Condition Category,
Part C
Types of Risk Adjustment model (DRG) - ANSWER-Diagnosis Related Group
(Inpatient)
,Types of Risk Adjustment model (ACG) - ANSWER-Adjusted Clinical
Groups(Outpatient)
Prescription based program risk adjustment examples:UCSD - ANSWER-Medicaid
Rx(UCSD)
Prescription based program risk adjustment examples(Dxcg) - ANSWER-
RxGroups(DxCG)
Prescription based program risk adjustment examples(HCC-D) - ANSWER-Hierarchical
Condition Category, Part D(HCC-D
Trump List - ANSWER-Families or hierarchies set a value base on severity of illness
with more severe diagnoses carrying the overall risk score for that family.
Stage 1 Pressure Ulcer - ANSWER-Persistent focal erythema
stage 2 pressure ulcer - ANSWER-Partial thickness skin loss involving epidermis,
dermis, or both
Stage 3 pressure ulcer - ANSWER-Full Thickness skin loss extending through
subcutaneous tissue
Stage 4 Pressure ulcer - ANSWER-Necrosis of soft tissue extending to muscle and
bone
Unstageable Ulce - ANSWER-is covered in eschar or slough it cannot be determine
how deep
Pathologic Fractures - ANSWER-Broken bone that occures in an area of weakened
bone. The cause typically due to another disease such as neoplasm or osteoporosis
Stress Fractures - ANSWER-repeated force or overuse. these fractures are considered
non-traumatic
malunion fracture - ANSWER-a healed fracture in a undesirable position resulting in a
deformity or crooked limb.
nonunion fracture - ANSWER-fracture is not healing New bone tissure is not growing to
bridge the gap between the broken bones
FFS Normalization adjustment - ANSWER-CMS payments are based on a population
with an average risk score
Special population for normalization factores - ANSWER-Pace Mode, ESRD and Part D
, History of CDPS - ANSWER-Began using RA in 1996 utilizing claims from disabled
beneficiaries information from the disability payment system from Colorado, Michiganm
Missouri, New York, and Ohio
Star Ratings - ANSWER-Medicare Advantage plan would received a bonus if they
receive 4 or more stars in 5 star quality ratings
5 star - ANSWER-Excellent performance
4 star - ANSWER-Above Average Performance
3 star - ANSWER-average performance
2 star - ANSWER-Below average performance
1 star - ANSWER-Poor Performance
Part C Plan - ANSWER-Domain 1 Staying Helathy Screenings, test, and vaccines (7
measures
Domain 2 Managing Chronic (Long Term) Conditions (12Measures)
Domain 3 Member Experience with Health Plan (6 measures)
Domain 4: Member complaints, problems getting service and improvement in the Health
Plan's Performance (4 measures)
Domain 5 Health Plan customer service (3 measures
Part D Plans - ANSWER-Domain 1Drug plan customer service (3 measures)
Domain 2 Member Complaints, Problems Getting Services, and improvement in the
Drug Plan's Performance (4 measures)
Domain 3 Member Experience with Drug Plan (2 measures)
Domain 4 Patient afety and drug pricing (6measures)
Star Rating penalize - ANSWER-when plans are not obtaining four stars or better
PQRS - ANSWER-Physician Quality Reporting System
PQRS 2 - ANSWER-A Reporting program using a combination of incentive payments
and payment adjustments to promote reporting of quality information by eligible
professionals (EP)
Valued-Based Payment Modifier Program - ANSWER-Provide Performance information
to physicians as part of Medicare's efforts to improve the quality and efficiency of
medical care
HEDIS - ANSWER-The Healthcare Effectiveness Data and Information Set)
HEDIS 3 - ANSWER-Tract year to year performance
Certified Risk Adjustment Specialist
Study Guide, Hierarchical Condition
Categories (HCC) Newest Version 2026
Complete Guide With Complete
Solutions
Risk Adjustment Data Element - ANSWER-Age, Gende, Socioeconomic status,
Disability status, Insurance status(Medicaid, dual-eligible,) Claims data elements such
as procedure codes, place of service codes, special patient-specific conditions hospice,
ESRD
RAF - ANSWER-Risk Adjustment Factor Scores
Three main types of reviews - ANSWER-Retrospective, Concurrent and prospective
Retrospective - ANSWER-reviews are performed after the information has been
reported and in risk adjustment these are prior years dos
Concurrent reviews - ANSWER-performed ongoing as patients are seen prior to
reporting and in risk adjustment the current year
Prospective reviews - ANSWER-will effect the next year and not the current year where
payment is concerned. They are used to forcast
Types of Risk Adjustment Models(HHS) - ANSWER-HHS hEALTH AND HUMAN
SERVICES hIERARCHICAL CONDITION(Commercial, individual and small grooup
Types of Risk Adjustment Modles(CDPS) - ANSWER-Chronic Illness and Disability
payment systems(Medicaid)
Types of Risk Adjustment Models(HCC-C) - ANSWER-Hierarchical Condition Category,
Part C
Types of Risk Adjustment model (DRG) - ANSWER-Diagnosis Related Group
(Inpatient)
,Types of Risk Adjustment model (ACG) - ANSWER-Adjusted Clinical
Groups(Outpatient)
Prescription based program risk adjustment examples:UCSD - ANSWER-Medicaid
Rx(UCSD)
Prescription based program risk adjustment examples(Dxcg) - ANSWER-
RxGroups(DxCG)
Prescription based program risk adjustment examples(HCC-D) - ANSWER-Hierarchical
Condition Category, Part D(HCC-D
Trump List - ANSWER-Families or hierarchies set a value base on severity of illness
with more severe diagnoses carrying the overall risk score for that family.
Stage 1 Pressure Ulcer - ANSWER-Persistent focal erythema
stage 2 pressure ulcer - ANSWER-Partial thickness skin loss involving epidermis,
dermis, or both
Stage 3 pressure ulcer - ANSWER-Full Thickness skin loss extending through
subcutaneous tissue
Stage 4 Pressure ulcer - ANSWER-Necrosis of soft tissue extending to muscle and
bone
Unstageable Ulce - ANSWER-is covered in eschar or slough it cannot be determine
how deep
Pathologic Fractures - ANSWER-Broken bone that occures in an area of weakened
bone. The cause typically due to another disease such as neoplasm or osteoporosis
Stress Fractures - ANSWER-repeated force or overuse. these fractures are considered
non-traumatic
malunion fracture - ANSWER-a healed fracture in a undesirable position resulting in a
deformity or crooked limb.
nonunion fracture - ANSWER-fracture is not healing New bone tissure is not growing to
bridge the gap between the broken bones
FFS Normalization adjustment - ANSWER-CMS payments are based on a population
with an average risk score
Special population for normalization factores - ANSWER-Pace Mode, ESRD and Part D
, History of CDPS - ANSWER-Began using RA in 1996 utilizing claims from disabled
beneficiaries information from the disability payment system from Colorado, Michiganm
Missouri, New York, and Ohio
Star Ratings - ANSWER-Medicare Advantage plan would received a bonus if they
receive 4 or more stars in 5 star quality ratings
5 star - ANSWER-Excellent performance
4 star - ANSWER-Above Average Performance
3 star - ANSWER-average performance
2 star - ANSWER-Below average performance
1 star - ANSWER-Poor Performance
Part C Plan - ANSWER-Domain 1 Staying Helathy Screenings, test, and vaccines (7
measures
Domain 2 Managing Chronic (Long Term) Conditions (12Measures)
Domain 3 Member Experience with Health Plan (6 measures)
Domain 4: Member complaints, problems getting service and improvement in the Health
Plan's Performance (4 measures)
Domain 5 Health Plan customer service (3 measures
Part D Plans - ANSWER-Domain 1Drug plan customer service (3 measures)
Domain 2 Member Complaints, Problems Getting Services, and improvement in the
Drug Plan's Performance (4 measures)
Domain 3 Member Experience with Drug Plan (2 measures)
Domain 4 Patient afety and drug pricing (6measures)
Star Rating penalize - ANSWER-when plans are not obtaining four stars or better
PQRS - ANSWER-Physician Quality Reporting System
PQRS 2 - ANSWER-A Reporting program using a combination of incentive payments
and payment adjustments to promote reporting of quality information by eligible
professionals (EP)
Valued-Based Payment Modifier Program - ANSWER-Provide Performance information
to physicians as part of Medicare's efforts to improve the quality and efficiency of
medical care
HEDIS - ANSWER-The Healthcare Effectiveness Data and Information Set)
HEDIS 3 - ANSWER-Tract year to year performance
