MEDICARE, HCC, AND RISK ADJUSTMENT: KEY CONCEPTS
FOR HEALTHCARE CODING | FROM QUESTION TO
PERFECTION| STUDY WITH CONFIDENCE!
Course Code:
Course Title:
Programme:
Academic Year: 2026/2027
Duration: 2 Hours
Total Marks: 70%
Candidate Instructions:
1) Write your Registration Number on every answer booklet used.
2) Answer ALL questions in Section A and ANY TWO (2) questions in Section B.
3) Read each question carefully before answering.
4) Begin each question on a new page.
5) The marks for each question are indicated in brackets.
6) This paper consists of several printed pages, including this page.
7) Ensure your copy is complete before the examination begins.
8) Unauthorized materials and communication with other candidates are not permitted.
Turn Over.
APPHIA – Crafted with Care and Precision for Academic Excellence.
1
, Parentheses ( ) Answer: Nonessential modifiers
Brackets [ ] Answer: Manifestation codes
Fraud Answer: Purposely bill for services never given
Star ratings Answer: October each year; outcomes is highest weight
CRC Answer: CMS reimburses Medicare Advantage (Medicare Part C) using risk adjustment
Health care plans Answer: Covered entity under HIPAA; key provision under HIPAA is the
minimum necessary requirement
Medicare Part C Answer: Medicare Advantage combines Part A + B (sometimes D)
Medicaid Answer: Health insurance assistance program (low income: pregnant, children); state
by state; sponsored by federal and state governments
OGCR Answer: Official Guidelines for Coding and Reporting; purpose is to standardize
diagnosis coding; updated annually
OGCR published by Answer: CMS and NCHS publish the OGCR
OGCR sections (Structure & conventions) Answer: Section I
OGCR sections (Principal diagnosis) Answer: Section II
OGCR sections (Additional diagnoses) Answer: Section III
OGCR sections (Physician office/outpatient) Answer: Section IV
OGCR sections (General coding conventions) Answer: I.A
Outpatient uncertain diagnoses Answer: Code symptoms
Burns Answer: Code highest first
Chronic conditions Answer: To be coded if documented
Extra RA values/factors Answer: Added when patient has more than one major significant
diagnosis (interactions)
MIPS collection types/categories Answer: Quality; Promoting Interoperability; Improvement
Activity; Cost
Medicare risk scores Answer: Medicare normalizes risk scores every year to average 1.0
Commercial plans funding Answer: Funding is allocated based on current year's known
diagnoses
RADV submissions Answer: Health plans submit records per patient in RADV audit(s)
RADV audits Answer: Purpose is to validate submitted HCC data
APPHIA – Crafted with Care and Precision for Academic Excellence.
2
FOR HEALTHCARE CODING | FROM QUESTION TO
PERFECTION| STUDY WITH CONFIDENCE!
Course Code:
Course Title:
Programme:
Academic Year: 2026/2027
Duration: 2 Hours
Total Marks: 70%
Candidate Instructions:
1) Write your Registration Number on every answer booklet used.
2) Answer ALL questions in Section A and ANY TWO (2) questions in Section B.
3) Read each question carefully before answering.
4) Begin each question on a new page.
5) The marks for each question are indicated in brackets.
6) This paper consists of several printed pages, including this page.
7) Ensure your copy is complete before the examination begins.
8) Unauthorized materials and communication with other candidates are not permitted.
Turn Over.
APPHIA – Crafted with Care and Precision for Academic Excellence.
1
, Parentheses ( ) Answer: Nonessential modifiers
Brackets [ ] Answer: Manifestation codes
Fraud Answer: Purposely bill for services never given
Star ratings Answer: October each year; outcomes is highest weight
CRC Answer: CMS reimburses Medicare Advantage (Medicare Part C) using risk adjustment
Health care plans Answer: Covered entity under HIPAA; key provision under HIPAA is the
minimum necessary requirement
Medicare Part C Answer: Medicare Advantage combines Part A + B (sometimes D)
Medicaid Answer: Health insurance assistance program (low income: pregnant, children); state
by state; sponsored by federal and state governments
OGCR Answer: Official Guidelines for Coding and Reporting; purpose is to standardize
diagnosis coding; updated annually
OGCR published by Answer: CMS and NCHS publish the OGCR
OGCR sections (Structure & conventions) Answer: Section I
OGCR sections (Principal diagnosis) Answer: Section II
OGCR sections (Additional diagnoses) Answer: Section III
OGCR sections (Physician office/outpatient) Answer: Section IV
OGCR sections (General coding conventions) Answer: I.A
Outpatient uncertain diagnoses Answer: Code symptoms
Burns Answer: Code highest first
Chronic conditions Answer: To be coded if documented
Extra RA values/factors Answer: Added when patient has more than one major significant
diagnosis (interactions)
MIPS collection types/categories Answer: Quality; Promoting Interoperability; Improvement
Activity; Cost
Medicare risk scores Answer: Medicare normalizes risk scores every year to average 1.0
Commercial plans funding Answer: Funding is allocated based on current year's known
diagnoses
RADV submissions Answer: Health plans submit records per patient in RADV audit(s)
RADV audits Answer: Purpose is to validate submitted HCC data
APPHIA – Crafted with Care and Precision for Academic Excellence.
2
