CRC PRACTICE EXAM C ;QUESTIONS AND
ACCURATE ANSWERS
Do the HCC category hierarchies play a role in which medical record to submit for a
RADV?I. No, there are no benefits in taking hierarchies into considerationII. No, CMS will
treat all diagnosis with the same financial weightIII. Yes, CMS will accept a lower or
higher HCC to validate an HCC within the same categoryIV. Yes, there can be a financial
gain by submitting a higher hierarchy HCC
A. I
B. II
C. III
D. III and IV
D
Retrospective audits provide insurance companies with ability to scrub/correct their data
which accomplishes which of the following? I. Provides opportunities to increase revenue
by submitting additional codesII. Provides opportunities to compare claims data to the
documentation and submit deletions if the documentation does not support what was on
the claimIII. Provides opportunities to correct coding errors prior to data being submitted
A. I and II
B. I
C. II
D. II and III
A
Which one of the following is an example of fraud?
A. Reporting a diabetic manifestation to increase the risk score.
B. Submitting a record for a RADV audit which includes diagnoses that were not
previously reported.
C. Training physicians to document causal relationships for manifestations for chronic
illnesses when present.
D. Setting a policy to report all patients with DM and CKD as a diabetic manifestation.
A
What payment system does Medicare Risk Adjustment represent?
A. Prospective payment system
B. Retrospective payment system
C. Fee-for-service payment system
D. Case rate payment system
A
, Which medical record (chart) is best for a RADV audit to include all the diagnoses?
• CMS is requesting diabetes mellitus with neuropathy to be validated
• Assume all the notes are signed by the provider and the diagnoses are supported by the
documentation
A. Chart #1: DOS 1/1/20XX—Diagnoses: DM, polyneuropathy
B. Chart #2: DOS 4/2/20XX—Diagnoses: DM with neurologic manifestations,
polyneuropathy, CKD
C. Chart # 3: DOS 7/7/20XX—Diagnoses: DM with neurologic manifestations
D. Chart # 4: DOS 9/9/20XX—Diagnosis: DM, HTN
B
Which statement is TRUE regarding RADV audits?
A. A cover page is not necessary
B. The purpose is to validate submitted HCC data
C. Conducted randomly throughout the year
D. CMS doesn't create a special cover page for each patient being audited
B
What are the differences between a CMS RADV (Medicare Advantage) and an HHS
RADV (commercial risk adjustment)?
I. CMS RADV is typically two to three years after payment, while HHS RADV occurs
typically six months after year-end.
II. CMS RADV involves choosing health plans by random sampling or targeting efforts,
while HHS RADV is an annual requirement of all plans
III. CMS RADV allows any face-to-face encounter for audit support, while HHS RADV
allows only those DOS that were submitted on the Edge server with an exception to allow
encounters that would normally be accepted on the Edge server.
IV. CMS RADV uses a stratified sample of three strata while HHS RADV uses 10 strata
A. I and II
B. I, II, and III
C. I and III
D. All are differences between CMS RADV and HHS RADV
D
In order for a MA Plan to improve their revenue, which statement describes the correct
approach a plan should take to accomplish this?
A. Code all diagnoses listed in the patient's problem list
B. Develop a prospective and retrospective review to capture all accurate diagnoses
C. Target diagnosis code selection for the highest diagnoses which yield more
reimbursement
D. Transfer healthy patients out of the network and focus on treating patients with chronic
conditions
ACCURATE ANSWERS
Do the HCC category hierarchies play a role in which medical record to submit for a
RADV?I. No, there are no benefits in taking hierarchies into considerationII. No, CMS will
treat all diagnosis with the same financial weightIII. Yes, CMS will accept a lower or
higher HCC to validate an HCC within the same categoryIV. Yes, there can be a financial
gain by submitting a higher hierarchy HCC
A. I
B. II
C. III
D. III and IV
D
Retrospective audits provide insurance companies with ability to scrub/correct their data
which accomplishes which of the following? I. Provides opportunities to increase revenue
by submitting additional codesII. Provides opportunities to compare claims data to the
documentation and submit deletions if the documentation does not support what was on
the claimIII. Provides opportunities to correct coding errors prior to data being submitted
A. I and II
B. I
C. II
D. II and III
A
Which one of the following is an example of fraud?
A. Reporting a diabetic manifestation to increase the risk score.
B. Submitting a record for a RADV audit which includes diagnoses that were not
previously reported.
C. Training physicians to document causal relationships for manifestations for chronic
illnesses when present.
D. Setting a policy to report all patients with DM and CKD as a diabetic manifestation.
A
What payment system does Medicare Risk Adjustment represent?
A. Prospective payment system
B. Retrospective payment system
C. Fee-for-service payment system
D. Case rate payment system
A
, Which medical record (chart) is best for a RADV audit to include all the diagnoses?
• CMS is requesting diabetes mellitus with neuropathy to be validated
• Assume all the notes are signed by the provider and the diagnoses are supported by the
documentation
A. Chart #1: DOS 1/1/20XX—Diagnoses: DM, polyneuropathy
B. Chart #2: DOS 4/2/20XX—Diagnoses: DM with neurologic manifestations,
polyneuropathy, CKD
C. Chart # 3: DOS 7/7/20XX—Diagnoses: DM with neurologic manifestations
D. Chart # 4: DOS 9/9/20XX—Diagnosis: DM, HTN
B
Which statement is TRUE regarding RADV audits?
A. A cover page is not necessary
B. The purpose is to validate submitted HCC data
C. Conducted randomly throughout the year
D. CMS doesn't create a special cover page for each patient being audited
B
What are the differences between a CMS RADV (Medicare Advantage) and an HHS
RADV (commercial risk adjustment)?
I. CMS RADV is typically two to three years after payment, while HHS RADV occurs
typically six months after year-end.
II. CMS RADV involves choosing health plans by random sampling or targeting efforts,
while HHS RADV is an annual requirement of all plans
III. CMS RADV allows any face-to-face encounter for audit support, while HHS RADV
allows only those DOS that were submitted on the Edge server with an exception to allow
encounters that would normally be accepted on the Edge server.
IV. CMS RADV uses a stratified sample of three strata while HHS RADV uses 10 strata
A. I and II
B. I, II, and III
C. I and III
D. All are differences between CMS RADV and HHS RADV
D
In order for a MA Plan to improve their revenue, which statement describes the correct
approach a plan should take to accomplish this?
A. Code all diagnoses listed in the patient's problem list
B. Develop a prospective and retrospective review to capture all accurate diagnoses
C. Target diagnosis code selection for the highest diagnoses which yield more
reimbursement
D. Transfer healthy patients out of the network and focus on treating patients with chronic
conditions
