Certified Risk Adjustment Coder (CRC®) Exam Prep 2026
Updated Practice Questions — Comprehensive Risk
Adjustment Medical Coding Review Detailed Explanations,
Verified Answers, Complete Success Workbook
SECTION 1: RISK ADJUSTMENT FUNDAMENTALS & MODELS
Question 1
A risk adjustment coder is reviewing a Medicare Advantage patient's record.
Which of the following best describes the primary purpose of the CMS-HCC risk
adjustment model?
A) To penalize providers for treating high-risk patients
B) To predict healthcare costs for Medicare beneficiaries based on their
health status
C) To eliminate coverage for patients with chronic conditions
D) To standardize reimbursement across all providers
Rationale: The CMS-HCC (Hierarchical Condition Category) risk adjustment
model is designed to predict healthcare costs for Medicare beneficiaries based
on their health status. It ensures that Medicare Advantage plans receive appropriate
reimbursement for enrollees with chronic conditions, incentivizing accurate
documentation and coding of all active diagnoses.
Question 2
A patient with diabetes without complications has a RAF score of 0.116. A patient
with diabetes with complications has a RAF score of 0.313. What does this
difference in RAF scores represent?
A) The patient with complications is younger
B) The patient with complications is expected to have higher healthcare costs
C) The patient without complications is sicker
D) The RAF score is unrelated to cost prediction
Rationale: RAF (Risk Adjustment Factor) scores represent the relative
expected cost of a patient compared to the average Medicare beneficiary. A higher
RAF score indicates that the patient is expected to have higher healthcare
,costs due to more severe or complex conditions. Diabetes with complications
(0.313) predicts higher costs than diabetes without complications (0.116).
Question 3
Which of the following risk adjustment models is used for Medicare Advantage
plans?
A) CDPS (Chronic Illness and Disability Payment System)
B) CMS-HCC (Hierarchical Condition Categories)
C) HHS-ACA (Health and Human Services - Affordable Care Act)
D) Hybrid model
Rationale: The CMS-HCC model is the risk adjustment model used
for Medicare Advantage (Part C) plans. CDPS is used for some Medicaid
programs, HHS-ACA is used for the Affordable Care Act marketplace, and Hybrid
models combine elements of multiple models.
Question 4
Under the CMS-HCC model, what happens when a patient has two conditions in
the same disease hierarchy (e.g., diabetes without complications and diabetes with
complications)?
A) Both conditions are coded and contribute full RAF weight
B) Only the higher-severity condition in the hierarchy contributes RAF
weight
C) Neither condition contributes RAF weight
D) The RAF weight is averaged between the two conditions
Rationale: The CMS-HCC model uses a hierarchical structure where higher-
severity HCCs override lower-severity ones in the same disease family. When a
patient has both diabetes without complications and diabetes with complications,
only the higher-severity condition (diabetes with complications) contributes RAF
weight.
Question 5
A risk adjustment coder is auditing a patient record for the current calendar year.
,Which of the following is TRUE regarding the coding of chronic conditions in risk
adjustment?
A) Chronic conditions only need to be coded once and carried over each year
B) Chronic conditions must be documented and coded at least once per
calendar year
C) Chronic conditions do not need to be coded for Medicare Advantage
D) Chronic conditions are coded only at the initial visit
Rationale: In risk adjustment, chronic conditions do NOT carry over from year
to year. They must be documented and coded at least once per calendar year to
be included in that year's risk score calculation. This ensures that the patient's
current health status is accurately reflected.
Question 6
Which of the following best describes the difference between the V24 and V28
CMS-HCC models?
A) V24 uses ICD-9 codes; V28 uses ICD-10 codes
B) V28 is the updated model that better aligns with ICD-10-CM and includes
refinements to HCC groupings
C) V24 is used for commercial plans; V28 is used for Medicare
D) There is no difference between the models
Rationale: The CMS-HCC V28 model is the updated risk adjustment model
that better aligns with ICD-10-CM and includes refinements to HCC groupings
and coefficient weights. It replaced earlier versions to improve predictive accuracy
and reflect current healthcare costs.
Question 7
A patient is enrolled in a Medicare Advantage plan and has the following
conditions: chronic obstructive pulmonary disease (COPD), congestive heart
failure (CHF), and depression. According to the CMS-HCC model, which
condition would typically have the highest RAF weight?
A) Depression
B) COPD
, C) Congestive heart failure (CHF)
D) All conditions have equal weight
Rationale: In the CMS-HCC model, cardiovascular conditions such as CHF
typically have higher RAF weights than COPD and depression due to their
higher associated healthcare costs. RAF weights are based on the relative
expected cost of treating each condition.
Question 8
A risk adjustment coder is reviewing documentation for a patient with a history of
cancer. Which of the following is TRUE regarding cancer coding in risk
adjustment?
A) A history of cancer is always coded regardless of treatment status
B) Active cancer or cancer being treated within the calendar year should be
coded
C) Cancer is never coded for risk adjustment
D) Only metastatic cancer is coded
Rationale: In risk adjustment, cancer should be coded when it is active or being
treated within the calendar year. A history of cancer without current treatment
does not contribute to the risk score. The coder must determine from the
documentation whether the cancer is active, in remission, or resolved.
Question 9
A patient has end-stage renal disease (ESRD) and is on dialysis. Which risk
adjustment model includes special provisions for ESRD?
A) CDPS
B) HHS-ACA
C) CMS-HCC (with ESRD-specific coefficients)
D) Hybrid model
Rationale: The CMS-HCC model includes ESRD-specific coefficients and risk
adjustment provisions for patients with end-stage renal disease. ESRD is a high-
cost condition that significantly impacts RAF scores and requires accurate
documentation of dialysis status.
Updated Practice Questions — Comprehensive Risk
Adjustment Medical Coding Review Detailed Explanations,
Verified Answers, Complete Success Workbook
SECTION 1: RISK ADJUSTMENT FUNDAMENTALS & MODELS
Question 1
A risk adjustment coder is reviewing a Medicare Advantage patient's record.
Which of the following best describes the primary purpose of the CMS-HCC risk
adjustment model?
A) To penalize providers for treating high-risk patients
B) To predict healthcare costs for Medicare beneficiaries based on their
health status
C) To eliminate coverage for patients with chronic conditions
D) To standardize reimbursement across all providers
Rationale: The CMS-HCC (Hierarchical Condition Category) risk adjustment
model is designed to predict healthcare costs for Medicare beneficiaries based
on their health status. It ensures that Medicare Advantage plans receive appropriate
reimbursement for enrollees with chronic conditions, incentivizing accurate
documentation and coding of all active diagnoses.
Question 2
A patient with diabetes without complications has a RAF score of 0.116. A patient
with diabetes with complications has a RAF score of 0.313. What does this
difference in RAF scores represent?
A) The patient with complications is younger
B) The patient with complications is expected to have higher healthcare costs
C) The patient without complications is sicker
D) The RAF score is unrelated to cost prediction
Rationale: RAF (Risk Adjustment Factor) scores represent the relative
expected cost of a patient compared to the average Medicare beneficiary. A higher
RAF score indicates that the patient is expected to have higher healthcare
,costs due to more severe or complex conditions. Diabetes with complications
(0.313) predicts higher costs than diabetes without complications (0.116).
Question 3
Which of the following risk adjustment models is used for Medicare Advantage
plans?
A) CDPS (Chronic Illness and Disability Payment System)
B) CMS-HCC (Hierarchical Condition Categories)
C) HHS-ACA (Health and Human Services - Affordable Care Act)
D) Hybrid model
Rationale: The CMS-HCC model is the risk adjustment model used
for Medicare Advantage (Part C) plans. CDPS is used for some Medicaid
programs, HHS-ACA is used for the Affordable Care Act marketplace, and Hybrid
models combine elements of multiple models.
Question 4
Under the CMS-HCC model, what happens when a patient has two conditions in
the same disease hierarchy (e.g., diabetes without complications and diabetes with
complications)?
A) Both conditions are coded and contribute full RAF weight
B) Only the higher-severity condition in the hierarchy contributes RAF
weight
C) Neither condition contributes RAF weight
D) The RAF weight is averaged between the two conditions
Rationale: The CMS-HCC model uses a hierarchical structure where higher-
severity HCCs override lower-severity ones in the same disease family. When a
patient has both diabetes without complications and diabetes with complications,
only the higher-severity condition (diabetes with complications) contributes RAF
weight.
Question 5
A risk adjustment coder is auditing a patient record for the current calendar year.
,Which of the following is TRUE regarding the coding of chronic conditions in risk
adjustment?
A) Chronic conditions only need to be coded once and carried over each year
B) Chronic conditions must be documented and coded at least once per
calendar year
C) Chronic conditions do not need to be coded for Medicare Advantage
D) Chronic conditions are coded only at the initial visit
Rationale: In risk adjustment, chronic conditions do NOT carry over from year
to year. They must be documented and coded at least once per calendar year to
be included in that year's risk score calculation. This ensures that the patient's
current health status is accurately reflected.
Question 6
Which of the following best describes the difference between the V24 and V28
CMS-HCC models?
A) V24 uses ICD-9 codes; V28 uses ICD-10 codes
B) V28 is the updated model that better aligns with ICD-10-CM and includes
refinements to HCC groupings
C) V24 is used for commercial plans; V28 is used for Medicare
D) There is no difference between the models
Rationale: The CMS-HCC V28 model is the updated risk adjustment model
that better aligns with ICD-10-CM and includes refinements to HCC groupings
and coefficient weights. It replaced earlier versions to improve predictive accuracy
and reflect current healthcare costs.
Question 7
A patient is enrolled in a Medicare Advantage plan and has the following
conditions: chronic obstructive pulmonary disease (COPD), congestive heart
failure (CHF), and depression. According to the CMS-HCC model, which
condition would typically have the highest RAF weight?
A) Depression
B) COPD
, C) Congestive heart failure (CHF)
D) All conditions have equal weight
Rationale: In the CMS-HCC model, cardiovascular conditions such as CHF
typically have higher RAF weights than COPD and depression due to their
higher associated healthcare costs. RAF weights are based on the relative
expected cost of treating each condition.
Question 8
A risk adjustment coder is reviewing documentation for a patient with a history of
cancer. Which of the following is TRUE regarding cancer coding in risk
adjustment?
A) A history of cancer is always coded regardless of treatment status
B) Active cancer or cancer being treated within the calendar year should be
coded
C) Cancer is never coded for risk adjustment
D) Only metastatic cancer is coded
Rationale: In risk adjustment, cancer should be coded when it is active or being
treated within the calendar year. A history of cancer without current treatment
does not contribute to the risk score. The coder must determine from the
documentation whether the cancer is active, in remission, or resolved.
Question 9
A patient has end-stage renal disease (ESRD) and is on dialysis. Which risk
adjustment model includes special provisions for ESRD?
A) CDPS
B) HHS-ACA
C) CMS-HCC (with ESRD-specific coefficients)
D) Hybrid model
Rationale: The CMS-HCC model includes ESRD-specific coefficients and risk
adjustment provisions for patients with end-stage renal disease. ESRD is a high-
cost condition that significantly impacts RAF scores and requires accurate
documentation of dialysis status.
