CRC CERTIFICATION EXAM PREP 2026 Latest Comprehensive
Study Guide — Certified Risk Adjustment Coder Review Risk
Adjustment Coding • Detailed Rationales • Verified Answers •
Success Workbook
DOMAIN 1: RISK ADJUSTMENT FUNDAMENTALS AND MODELS
(Questions 1–15)
Question 1
What is the primary purpose of risk adjustment in Medicare Advantage?
A) To reduce the number of diagnoses documented
B) To predict healthcare costs and adjust payments based on patient health
status and risk scores
C) To eliminate the need for coding
D) To increase the number of hospital admissions
Rationale: Risk adjustment predicts healthcare costs and adjusts payments based
on patient health status and risk scores. It ensures that Medicare Advantage plans
receive appropriate payment for the health status of their enrolled members,
accounting for differences in patient complexity. The goal is to pay plans more for
sicker patients and less for healthier patients, ensuring fair compensation.
Question 2
What does HCC stand for in risk adjustment coding?
A) Healthcare Coding Compliance
B) Hospital Care Coordination
C) Hierarchical Condition Category
D) Health Cost Calculation
Rationale: HCC stands for Hierarchical Condition Category. The CMS-HCC risk
adjustment model groups diagnoses into condition categories that are
hierarchical—meaning that within a disease family, higher-severity conditions
override lower-severity ones. The model uses HCCs to predict healthcare costs and
calculate risk adjustment factor (RAF) scores.
,Question 3
Which of the following is the MOST important coding guideline for risk
adjustment?
A) Code only acute conditions
B) Code all documented chronic conditions that affect the patient's health
status
C) Code only conditions that are currently being treated
D) Code only conditions with a specific treatment plan
Rationale: Risk adjustment requires coding ALL documented chronic conditions
that affect the patient's health status, regardless of whether they are the primary
reason for the encounter. This ensures that the patient's full disease burden is
captured for accurate risk score calculation.
Question 4
A patient has diabetes with complications, diabetic nephropathy, and hypertension.
According to HCC hierarchy rules, which condition should be captured?
A) Only the diabetes
B) Both the diabetes with complications and the diabetic nephropathy
(higher-severity hierarchy applies)
C) Only the hypertension
D) Only the diabetic nephropathy
Rationale: In the CMS-HCC model, hierarchy rules apply within disease families.
Higher-severity HCCs override lower-severity ones in the same family, but the
hierarchy is a condition hierarchy, not a diagnosis hierarchy. Different disease
families are not hierarchical—both diabetes and diabetic nephropathy are in the
same family, so the higher-severity one is captured.
Question 5
A patient has CKD stage 4 (HCC 136) and CKD stage 5 (HCC 137). According to
HCC hierarchy rules, which HCC should be reported?
,A) Both HCC 136 and HCC 137
B) Only HCC 137 (higher severity overrides lower severity)
C) Only HCC 136
D) Neither HCC
Rationale: In the CMS-HCC model, when a patient has multiple conditions in the
same disease family, the hierarchy applies: the higher-severity condition overrides
the lower-severity one. CKD stage 5 (HCC 137) is higher severity than CKD stage
4 (HCC 136), so only HCC 137 should be captured.
Question 6
A patient is diagnosed with both diabetes without complications (HCC 19) and
diabetes with complications (HCC 18). Which HCC should be reported?
A) Both HCC 18 and HCC 19
B) Only HCC 18 (higher severity overrides lower severity)
C) Only HCC 19
D) Neither HCC
Rationale: Diabetes with complications (HCC 18) is higher severity than diabetes
without complications (HCC 19). According to HCC hierarchy rules, when a
patient has both, only the higher-severity HCC (HCC 18) should be captured.
Question 7
What is the relationship between ICD-10-CM codes and HCCs?
A) ICD-10-CM codes replace HCCs
B) ICD-10-CM codes map to HCCs through the CMS-HCC mapping
algorithm
C) HCCs replace ICD-10-CM codes
D) There is no relationship
Rationale: ICD-10-CM diagnosis codes are mapped to HCCs through the CMS-
HCC mapping algorithm. The diagnosis codes that are documented and coded
determine which HCCs are captured, and the HCCs determine the risk adjustment
factor (RAF) score.
, Question 8
What is a Risk Adjustment Factor (RAF) score?
A) The number of diagnoses a patient has
B) A numeric value that reflects a patient's predicted healthcare costs relative
to the average
C) The patient's age and gender only
D) The number of hospital admissions in a year
Rationale: A RAF score is a numeric value that reflects a patient's predicted
healthcare costs relative to the average. It is calculated based on demographic
factors (age, gender, Medicaid status) and disease burden (captured through
HCCs). A RAF score of 1.0 represents the average predicted cost.
Question 9
A 75-year-old male with diabetes and heart failure has a RAF score of 1.8. What
does this indicate?
A) The patient is healthier than average
B) The patient's predicted healthcare costs are 80% higher than the average
beneficiary
C) The patient has no chronic conditions
D) The patient's costs are exactly average
Rationale: A RAF score of 1.8 indicates that the patient's predicted healthcare
costs are 80% higher than the average beneficiary (RAF = 1.0). This reflects the
patient's age, gender, and chronic conditions (diabetes and heart failure).
Question 10
Which of the following is a key feature of the CMS-HCC V28 model?
A) It uses the same HCCs as V24
B) It includes updated HCC mappings, revised RAF weights, and new
conditions captured for risk adjustment
C) It eliminates all chronic conditions from risk adjustment
D) It only uses age and gender for risk scoring
Study Guide — Certified Risk Adjustment Coder Review Risk
Adjustment Coding • Detailed Rationales • Verified Answers •
Success Workbook
DOMAIN 1: RISK ADJUSTMENT FUNDAMENTALS AND MODELS
(Questions 1–15)
Question 1
What is the primary purpose of risk adjustment in Medicare Advantage?
A) To reduce the number of diagnoses documented
B) To predict healthcare costs and adjust payments based on patient health
status and risk scores
C) To eliminate the need for coding
D) To increase the number of hospital admissions
Rationale: Risk adjustment predicts healthcare costs and adjusts payments based
on patient health status and risk scores. It ensures that Medicare Advantage plans
receive appropriate payment for the health status of their enrolled members,
accounting for differences in patient complexity. The goal is to pay plans more for
sicker patients and less for healthier patients, ensuring fair compensation.
Question 2
What does HCC stand for in risk adjustment coding?
A) Healthcare Coding Compliance
B) Hospital Care Coordination
C) Hierarchical Condition Category
D) Health Cost Calculation
Rationale: HCC stands for Hierarchical Condition Category. The CMS-HCC risk
adjustment model groups diagnoses into condition categories that are
hierarchical—meaning that within a disease family, higher-severity conditions
override lower-severity ones. The model uses HCCs to predict healthcare costs and
calculate risk adjustment factor (RAF) scores.
,Question 3
Which of the following is the MOST important coding guideline for risk
adjustment?
A) Code only acute conditions
B) Code all documented chronic conditions that affect the patient's health
status
C) Code only conditions that are currently being treated
D) Code only conditions with a specific treatment plan
Rationale: Risk adjustment requires coding ALL documented chronic conditions
that affect the patient's health status, regardless of whether they are the primary
reason for the encounter. This ensures that the patient's full disease burden is
captured for accurate risk score calculation.
Question 4
A patient has diabetes with complications, diabetic nephropathy, and hypertension.
According to HCC hierarchy rules, which condition should be captured?
A) Only the diabetes
B) Both the diabetes with complications and the diabetic nephropathy
(higher-severity hierarchy applies)
C) Only the hypertension
D) Only the diabetic nephropathy
Rationale: In the CMS-HCC model, hierarchy rules apply within disease families.
Higher-severity HCCs override lower-severity ones in the same family, but the
hierarchy is a condition hierarchy, not a diagnosis hierarchy. Different disease
families are not hierarchical—both diabetes and diabetic nephropathy are in the
same family, so the higher-severity one is captured.
Question 5
A patient has CKD stage 4 (HCC 136) and CKD stage 5 (HCC 137). According to
HCC hierarchy rules, which HCC should be reported?
,A) Both HCC 136 and HCC 137
B) Only HCC 137 (higher severity overrides lower severity)
C) Only HCC 136
D) Neither HCC
Rationale: In the CMS-HCC model, when a patient has multiple conditions in the
same disease family, the hierarchy applies: the higher-severity condition overrides
the lower-severity one. CKD stage 5 (HCC 137) is higher severity than CKD stage
4 (HCC 136), so only HCC 137 should be captured.
Question 6
A patient is diagnosed with both diabetes without complications (HCC 19) and
diabetes with complications (HCC 18). Which HCC should be reported?
A) Both HCC 18 and HCC 19
B) Only HCC 18 (higher severity overrides lower severity)
C) Only HCC 19
D) Neither HCC
Rationale: Diabetes with complications (HCC 18) is higher severity than diabetes
without complications (HCC 19). According to HCC hierarchy rules, when a
patient has both, only the higher-severity HCC (HCC 18) should be captured.
Question 7
What is the relationship between ICD-10-CM codes and HCCs?
A) ICD-10-CM codes replace HCCs
B) ICD-10-CM codes map to HCCs through the CMS-HCC mapping
algorithm
C) HCCs replace ICD-10-CM codes
D) There is no relationship
Rationale: ICD-10-CM diagnosis codes are mapped to HCCs through the CMS-
HCC mapping algorithm. The diagnosis codes that are documented and coded
determine which HCCs are captured, and the HCCs determine the risk adjustment
factor (RAF) score.
, Question 8
What is a Risk Adjustment Factor (RAF) score?
A) The number of diagnoses a patient has
B) A numeric value that reflects a patient's predicted healthcare costs relative
to the average
C) The patient's age and gender only
D) The number of hospital admissions in a year
Rationale: A RAF score is a numeric value that reflects a patient's predicted
healthcare costs relative to the average. It is calculated based on demographic
factors (age, gender, Medicaid status) and disease burden (captured through
HCCs). A RAF score of 1.0 represents the average predicted cost.
Question 9
A 75-year-old male with diabetes and heart failure has a RAF score of 1.8. What
does this indicate?
A) The patient is healthier than average
B) The patient's predicted healthcare costs are 80% higher than the average
beneficiary
C) The patient has no chronic conditions
D) The patient's costs are exactly average
Rationale: A RAF score of 1.8 indicates that the patient's predicted healthcare
costs are 80% higher than the average beneficiary (RAF = 1.0). This reflects the
patient's age, gender, and chronic conditions (diabetes and heart failure).
Question 10
Which of the following is a key feature of the CMS-HCC V28 model?
A) It uses the same HCCs as V24
B) It includes updated HCC mappings, revised RAF weights, and new
conditions captured for risk adjustment
C) It eliminates all chronic conditions from risk adjustment
D) It only uses age and gender for risk scoring
