HCC Coding-Risk Adjustment Test
Questions with Answers
What two models are used to calculate a RAF score properly? What do these models
allow to happen to the final risk score? - Answer-Additive and Hierarchical.
Allows for more than one disease to impact the final risk score.
What is diagnostic hierarchies? - Answer-Prevents multiple diagnoses in the same
disease group from skewing the risk score with a higher score. The more severe
diagnoses "trumps" the lower diagnoses within the same disease group.
What is the point of risk adjustment? - Answer-To allow for adjustments in capitated (set
amount for each enrolled person assigned to them, per period of time, whether or not
that person seeks care) payment amounts so that MA plans pay out fairly and
accurately and minimize questionable incentives in order to avoid enrolling sicker
beneficiaries.
In Predictive Modeling, CMS-HCC predicts? - Answer-Full Part A and Part B Medicare
expenditures
In Predictive Modeling, the RxHCC predicts? - Answer-Expenditures for which Part D
sponsors are responsible, i.e., drug costs excluding cost sharing amounts for which the
enrollee or the government is responsible for paying.
RxHCC model adjusts standardized payments for? - Answer-Monthly Part D direct
subsidy
CMS-HCC model adjusts standardized payments for? - Answer-Monthly payments to
Medicare Advantage plans and PACE organizations.
CFR - Answer-Code of Federal Regulations
NCDs - Answer-CMS National Coverage Determinations
LCDs - Answer-Local coverage determinations
What are the 4 focal points of a MA Plan? - Answer-1. Early detection of chronic
conditions
2. Coordination of care
3. Accurate reporting of conditions
, 4. Improvement of health conditions
What does AWV stand for? - Answer-Annual Wellness Visit
What does PPPS stand for? - Answer-Personalized Prevention Plan Services
What does IPPE stand for? - Answer-Initial Preventive Physical Exam
What does HRA stand for? - Answer-Health Risk Assessment
What is the ICD-9 code for AWV? - Answer-V70.0 - Preventative Medicine
CPT code for provider's reimbursement for AWV? - Answer-99213-Mid-level, face to
face visit (this is not AWV code).
If E/M service provided must be a separate service and use modifier -25.
What does CNS (medical professional) stands for? - Answer-Clinical Nurse Specialist
What does KPI stand for? - Answer-Key Performance Indicators
G0438 is a code for? - Answer-Initial AWV visit
G0439 is a code for? - Answer-Subsequent AWV visit
Case Mix/Risk Adjustment - Answer-Is the overall health status and risk of a provider
panel of member, which utilizes combined data from the following areas and provides a
depiction of member heath risk profile for a plan, which is used to predict future costs
and payments.
Predictive Modeling - Answer-The prospective application of risk measures along with
statistical techniques to identify "high risk" individuals who greatly would benefit from
targeted care management interventions, such as being moved to a SNP.
It provides a potential RAF score for each claim, which can in turn be used to target
claims which indicate a "suspect" patterns.
Suspect Generation - Answer-Identifies members with suspected and undocumented
conditions.
Suspected conditions are based on prescribed medications, previously reported
conditions, DME, lab tests, therapy, etc.
Undocumented conditions are diagnosis codes that link to an HCC, but for which there
is no M.E.A.T. that supports reporting it in the chart.
Questions with Answers
What two models are used to calculate a RAF score properly? What do these models
allow to happen to the final risk score? - Answer-Additive and Hierarchical.
Allows for more than one disease to impact the final risk score.
What is diagnostic hierarchies? - Answer-Prevents multiple diagnoses in the same
disease group from skewing the risk score with a higher score. The more severe
diagnoses "trumps" the lower diagnoses within the same disease group.
What is the point of risk adjustment? - Answer-To allow for adjustments in capitated (set
amount for each enrolled person assigned to them, per period of time, whether or not
that person seeks care) payment amounts so that MA plans pay out fairly and
accurately and minimize questionable incentives in order to avoid enrolling sicker
beneficiaries.
In Predictive Modeling, CMS-HCC predicts? - Answer-Full Part A and Part B Medicare
expenditures
In Predictive Modeling, the RxHCC predicts? - Answer-Expenditures for which Part D
sponsors are responsible, i.e., drug costs excluding cost sharing amounts for which the
enrollee or the government is responsible for paying.
RxHCC model adjusts standardized payments for? - Answer-Monthly Part D direct
subsidy
CMS-HCC model adjusts standardized payments for? - Answer-Monthly payments to
Medicare Advantage plans and PACE organizations.
CFR - Answer-Code of Federal Regulations
NCDs - Answer-CMS National Coverage Determinations
LCDs - Answer-Local coverage determinations
What are the 4 focal points of a MA Plan? - Answer-1. Early detection of chronic
conditions
2. Coordination of care
3. Accurate reporting of conditions
, 4. Improvement of health conditions
What does AWV stand for? - Answer-Annual Wellness Visit
What does PPPS stand for? - Answer-Personalized Prevention Plan Services
What does IPPE stand for? - Answer-Initial Preventive Physical Exam
What does HRA stand for? - Answer-Health Risk Assessment
What is the ICD-9 code for AWV? - Answer-V70.0 - Preventative Medicine
CPT code for provider's reimbursement for AWV? - Answer-99213-Mid-level, face to
face visit (this is not AWV code).
If E/M service provided must be a separate service and use modifier -25.
What does CNS (medical professional) stands for? - Answer-Clinical Nurse Specialist
What does KPI stand for? - Answer-Key Performance Indicators
G0438 is a code for? - Answer-Initial AWV visit
G0439 is a code for? - Answer-Subsequent AWV visit
Case Mix/Risk Adjustment - Answer-Is the overall health status and risk of a provider
panel of member, which utilizes combined data from the following areas and provides a
depiction of member heath risk profile for a plan, which is used to predict future costs
and payments.
Predictive Modeling - Answer-The prospective application of risk measures along with
statistical techniques to identify "high risk" individuals who greatly would benefit from
targeted care management interventions, such as being moved to a SNP.
It provides a potential RAF score for each claim, which can in turn be used to target
claims which indicate a "suspect" patterns.
Suspect Generation - Answer-Identifies members with suspected and undocumented
conditions.
Suspected conditions are based on prescribed medications, previously reported
conditions, DME, lab tests, therapy, etc.
Undocumented conditions are diagnosis codes that link to an HCC, but for which there
is no M.E.A.T. that supports reporting it in the chart.
