Clinical Review (CRC) – Final Exam Study Guide with Key
Concepts and Practice Questions
2. ANS: A
Rationale: Prospective reviews are similar to concurrent, but are called prospective because
when considering the current year's encounters, these will affect the next year and not the
current year where payment is concerned. - correct answer ✔✔ 2. When are prospective
reviews performed?
a. Prior to the diagnosis and risk factor data being reported to CMS.
b. After the diagnosis and risk factor data has been reported to CMS.
c. Once the patient is enrolled in a Medicare Part C plan
d. Once the provider has finalized the documentation to submit diagnosis codes.
PTS: 1
3. ANS: B
Rationale: Each year, CMS publishes the list of diagnosis codes that risk adjust, and the HCC that
it adjusts to in the model. The information can be found at
https://www.cms.gov/Medicare/Health-Plans/MedicareAdvtgSpecRateStats/Risk-Adjustors-
Items/Risk2018.html?DLPage=1&DLEntries=10&DLSort=0&DLSortDir=descending - correct
answer ✔✔ 3. Where can a list of diagnosis mappings to HCCs be located?
a. OIG website
b. CMS website
c. OCR website
d. QPP website
6. ANS: B
,Rationale: From a payment perspective, risk adjustment models adjust health plan revenue to
better reflect the projected costs of the patient population and compensate plans that enroll
high-cost patients. - correct answer ✔✔ 6. Risk adjustment models are used to:
a. Limit coverage of chronic conditions.
b. Determine projected costs of health care based on the condition(s) of patients.
c. Determine the return on investment for developing proactive disease prevention outreach.
d. Limit the coverage of hospital admissions.
7. ANS: C
Rationale: Not all ICD codes carry value in risk adjustment models, including the Medicare
model. Typically diagnoses that are costly to manage from a medical management or
prescription drug treatment perspective are more likely to be found in risk adjustment models.
Each year CMS publishes the list of diagnosis codes that risk adjust and the HCC it adjusts to.
The information can be found at
www.cms.gov/Medicare/Health-Plans/MedicareAdvtgSpecRateStats/Risk-Adjustors.html. -
correct answer ✔✔ 7. Which statement is TRUE regarding diagnosis codes and assigned HCCs?
a. All diagnosis codes are assigned a HCC.
b. All chronic illnesses are assigned a HCC.
c. Not all diagnosis codes are assigned a HCC.
d. All acute exacerbations of an acute illness are assigned a HCC.
8. ANS: C
Rationale: CMS is required to make an adjustment to reflect "differences in coding patterns
between Medicare Advantage plans and providers under Part A and B to the extent that the
Secretary has identified such differences." - correct answer ✔✔ 8. What is the purpose of the
coding intensity adjustment?
I. Determine different coding patterns in HCC compared to inpatient claims covered by Part A.
II. Determine different coding patterns in HCC compared to outpatient claims covered by Part B.
III. Determine different coding patterns in HCC compared to claims processed under CDPS.
a. I
,b. II
c. I and II
d. I, II, and III
9. ANS: C
Rationale: Any provider may validate any diagnosis, as diagnoses are not dependent upon the
specialty - correct answer ✔✔ 9. When reporting a code for retinopathy, must the coder find
documentation from an ophthalmologist in order to code the condition as an active condition?
a. Yes, specialty specific diagnoses can only be reported by a specialist.
b. Yes, ophthalmologists must diagnosis all eye related conditions.
c. No, any approved provider can validate any diagnosis.
d. No, only primary care providers can provide supporting documentation for reported
diagnoses.
10. ANS: C
Rationale: Risk adjustment must be compared to average FFS expenses and rates. The purpose
of the FFS normalization adjustment is so that CMS payments are based on a population with an
average risk score of 1.0. This is the national average. Annually, Medicare normalizes the risk
scores to maintain an average risk score of 1.0. - correct answer ✔✔ 10. How often is the
normalization factor adjusted?
a. Monthly
b. Twice per year
c. Yearly
d. As needed
11. ANS: B
Rationale: The adult model includes those individuals 21 and over, the child model includes
individuals 2 to 20 and infant includes individuals through age 1. - correct answer ✔✔ 11. For
the HHS Hierarchical Conditions Category model, who is included in the adult model?
, a. Individuals who are 18 and over.
b. Individuals who are 21 and over.
c. Individuals who are the head of household.
d. Individuals who are making more than $13,000 per year.
12. ANS: C
Rationale: MACRA also laid the framework for a new reimbursement system set to begin in
2019 called the Quality Payment Program, which includes two tracks:
· Merit-based Incentive Payment System (MIPS)
· Advanced alternative payment models (APMs) - correct answer ✔✔ 12. What are the
participation tracks available through MACRA?
I. Merit-based Incentive Payment Systems
II. Sustainable Growth System
III. Advanced Alternative Payment Models
a. I
b. II and III
c. I and III
d. I, II, and III
13. ANS: C
Rationale: There are 9 domains. The 5 for Part C for Medicare Advantage only and Medicare
Advantage Prescription Drug plans and 4 for Part D measures for Medicare Advantage
Prescriptions Drug plans:
· Staying Healthy: Screenings, Tests and Vaccines
· Managing Chronic (Long Term) Conditions
· Member Experience with Health Plan
· Member Complaints and Changes in the Health Plan's Performance
Concepts and Practice Questions
2. ANS: A
Rationale: Prospective reviews are similar to concurrent, but are called prospective because
when considering the current year's encounters, these will affect the next year and not the
current year where payment is concerned. - correct answer ✔✔ 2. When are prospective
reviews performed?
a. Prior to the diagnosis and risk factor data being reported to CMS.
b. After the diagnosis and risk factor data has been reported to CMS.
c. Once the patient is enrolled in a Medicare Part C plan
d. Once the provider has finalized the documentation to submit diagnosis codes.
PTS: 1
3. ANS: B
Rationale: Each year, CMS publishes the list of diagnosis codes that risk adjust, and the HCC that
it adjusts to in the model. The information can be found at
https://www.cms.gov/Medicare/Health-Plans/MedicareAdvtgSpecRateStats/Risk-Adjustors-
Items/Risk2018.html?DLPage=1&DLEntries=10&DLSort=0&DLSortDir=descending - correct
answer ✔✔ 3. Where can a list of diagnosis mappings to HCCs be located?
a. OIG website
b. CMS website
c. OCR website
d. QPP website
6. ANS: B
,Rationale: From a payment perspective, risk adjustment models adjust health plan revenue to
better reflect the projected costs of the patient population and compensate plans that enroll
high-cost patients. - correct answer ✔✔ 6. Risk adjustment models are used to:
a. Limit coverage of chronic conditions.
b. Determine projected costs of health care based on the condition(s) of patients.
c. Determine the return on investment for developing proactive disease prevention outreach.
d. Limit the coverage of hospital admissions.
7. ANS: C
Rationale: Not all ICD codes carry value in risk adjustment models, including the Medicare
model. Typically diagnoses that are costly to manage from a medical management or
prescription drug treatment perspective are more likely to be found in risk adjustment models.
Each year CMS publishes the list of diagnosis codes that risk adjust and the HCC it adjusts to.
The information can be found at
www.cms.gov/Medicare/Health-Plans/MedicareAdvtgSpecRateStats/Risk-Adjustors.html. -
correct answer ✔✔ 7. Which statement is TRUE regarding diagnosis codes and assigned HCCs?
a. All diagnosis codes are assigned a HCC.
b. All chronic illnesses are assigned a HCC.
c. Not all diagnosis codes are assigned a HCC.
d. All acute exacerbations of an acute illness are assigned a HCC.
8. ANS: C
Rationale: CMS is required to make an adjustment to reflect "differences in coding patterns
between Medicare Advantage plans and providers under Part A and B to the extent that the
Secretary has identified such differences." - correct answer ✔✔ 8. What is the purpose of the
coding intensity adjustment?
I. Determine different coding patterns in HCC compared to inpatient claims covered by Part A.
II. Determine different coding patterns in HCC compared to outpatient claims covered by Part B.
III. Determine different coding patterns in HCC compared to claims processed under CDPS.
a. I
,b. II
c. I and II
d. I, II, and III
9. ANS: C
Rationale: Any provider may validate any diagnosis, as diagnoses are not dependent upon the
specialty - correct answer ✔✔ 9. When reporting a code for retinopathy, must the coder find
documentation from an ophthalmologist in order to code the condition as an active condition?
a. Yes, specialty specific diagnoses can only be reported by a specialist.
b. Yes, ophthalmologists must diagnosis all eye related conditions.
c. No, any approved provider can validate any diagnosis.
d. No, only primary care providers can provide supporting documentation for reported
diagnoses.
10. ANS: C
Rationale: Risk adjustment must be compared to average FFS expenses and rates. The purpose
of the FFS normalization adjustment is so that CMS payments are based on a population with an
average risk score of 1.0. This is the national average. Annually, Medicare normalizes the risk
scores to maintain an average risk score of 1.0. - correct answer ✔✔ 10. How often is the
normalization factor adjusted?
a. Monthly
b. Twice per year
c. Yearly
d. As needed
11. ANS: B
Rationale: The adult model includes those individuals 21 and over, the child model includes
individuals 2 to 20 and infant includes individuals through age 1. - correct answer ✔✔ 11. For
the HHS Hierarchical Conditions Category model, who is included in the adult model?
, a. Individuals who are 18 and over.
b. Individuals who are 21 and over.
c. Individuals who are the head of household.
d. Individuals who are making more than $13,000 per year.
12. ANS: C
Rationale: MACRA also laid the framework for a new reimbursement system set to begin in
2019 called the Quality Payment Program, which includes two tracks:
· Merit-based Incentive Payment System (MIPS)
· Advanced alternative payment models (APMs) - correct answer ✔✔ 12. What are the
participation tracks available through MACRA?
I. Merit-based Incentive Payment Systems
II. Sustainable Growth System
III. Advanced Alternative Payment Models
a. I
b. II and III
c. I and III
d. I, II, and III
13. ANS: C
Rationale: There are 9 domains. The 5 for Part C for Medicare Advantage only and Medicare
Advantage Prescription Drug plans and 4 for Part D measures for Medicare Advantage
Prescriptions Drug plans:
· Staying Healthy: Screenings, Tests and Vaccines
· Managing Chronic (Long Term) Conditions
· Member Experience with Health Plan
· Member Complaints and Changes in the Health Plan's Performance
