lOMoARcPSD| 54339004
CRC EXAM QUESTIONS AND ANSWERS WITH
VERIFIED SOLUTIONS 100% CORRECT
(GRADED A+)NEWLY UPDATED 2025/2026
Risk Adjustment (a Prospective Payment System)
✔✔ The process of adjusting payments to health plans based on actual or expected patient
health spending. Designed to compensate plans with sicker or older populations, discouraging
them from selecting only healthier patients.
What is the goal when coding for risk adjustment?
✔✔ Code ALL current diagnoses.
What is the purpose of collecting diagnoses in risk adjustment coding?
✔✔ Adjust potential risk measures and evaluate all patients on an equal scale. Levels the
playing field across factors like age, race, gender, and socioeconomics.
What is the acronym for risk adjustment coding?
✔✔ HCC (Hierarchical Condition Category)
What elements would NOT be considered for risk adjustment?
✔✔ Number of years the patient has been covered under Medicare Advantage.
Which medical records can be submitted for HCC validation?
✔✔
MD office progress notes
Outpatient hospital records
Critical access hospital records
What is the purpose of risk adjustment values?
✔✔ To budget and manage the care of a patient for the upcoming year.
What are risk adjustment models used for?
✔✔ To determine projected healthcare costs based on the health conditions of patients.
Which factor is NOT considered for risk adjustment?
✔✔ Frequency of office visits.
How is predictive modeling used in risk adjustment?
✔✔ It helps determine suspected diagnoses based on data elements (such as claims and medical
history).
, lOMoARcPSD| 54339004
What is the reporting period for risk adjustment coding?
✔✔ January through December.
What risk adjustment model is used by Medicaid?
✔✔ CDPS (Chronic Illness & Disability Payment System)
What is CDPS?
✔✔ Chronic Illness & Disability Payment System, used for Medicaid.
What risk adjustment model incorporates High, Medium, & Low risk in the numeric
value?
✔✔ CDPS.
What is the default diagnosis if the type of diabetes mellitus (DM) is not specified?
✔✔ DM2 (Type 2 Diabetes Mellitus).
How to code when a patient is seen for management of anemia due to malignancy?
✔✔
1st code: Malignancy (primary condition)
2nd code: Anemia (secondary condition)
How to code for tobacco use AND dependence on tobacco?
✔✔ Only code for dependence on tobacco (F17.2-).
What is the length of time for a myocardial infarction (MI) to be considered "acute"?
✔✔ 4 weeks or 28 days.
How is glaucoma reported?
✔✔ Only code for the stage of glaucoma, not the underlying cause unless specified.
What is the sequencing order when coding a sequela (late effect)?
✔✔
1st: Residual condition
2nd: Cause of the late effect (e.g., stroke leading to hemiplegia)
What is reported by a provider for beneficiaries in Medicare Advantage plans? - ANSWER✔✔
presenting problems, &
all chronic conditions
How often should a provider see a Pt. to validate amputation status? - ANSWER✔✔ once a
year
PEG Tube - ANSWER✔✔ +percutaneous endoscopic gastrostomy tube
, lOMoARcPSD| 54339004
+G-tube
+gastrostomy
All conditions listed on the problem list for DM patients are coded as complications of DM:
True or False? - ANSWER✔✔ False
What is true regarding hierarchies? - ANSWER✔✔ Utilized by some private payers
Quality Measures like Star Ratings and HEDIS have NO correlation with the medical record
that is collected to support risk adjustment. TRUE or FALSE? - ANSWER✔✔ FALSE
Is HEDIS a division of CMS or Medicaid? - ANSWER✔✔ NO
Who developed HEDIS? - ANSWER✔✔ NCQA (National Committee for Quality Assurance)
How is HEDIS data collected? - ANSWER✔✔ +surveys
+medical chart reviews
+insurance claims
What is the goal of HEDIS (Health Plan Employer Data Info Set)? - ANSWER✔✔ for
consumers to compare health plans
How often are HEDIS measures revised? - ANSWER✔✔ Annually
Which payers uses HEDIS measures? - ANSWER✔✔ a variety
RADV - ANSWER✔✔ Risk Adjustment Data Validation
What is the purpose of a RADV audit? - ANSWER✔✔ Verify accuracy of dx submitted for
payment
When submitting records for RADV audit, will additional current dx that were not originally
reported by considered when documentation is submitted for the audit? - ANSWER✔✔ Yes!
additional current dx not included on claims data may be approved during the audit. The
submission of all dx (w/HCCs) are cumulative, so there may be a neg. or a pos. outcome
overall from a $ perspective
What info is verified during RADV audit? - ANSWER✔✔ All dx codes are supported in the
medical record
Which of the following criteria would be components of an acceptable medical record in a
RADV? - ANSWER✔✔ +encounter must be a face-to-face visit
CRC EXAM QUESTIONS AND ANSWERS WITH
VERIFIED SOLUTIONS 100% CORRECT
(GRADED A+)NEWLY UPDATED 2025/2026
Risk Adjustment (a Prospective Payment System)
✔✔ The process of adjusting payments to health plans based on actual or expected patient
health spending. Designed to compensate plans with sicker or older populations, discouraging
them from selecting only healthier patients.
What is the goal when coding for risk adjustment?
✔✔ Code ALL current diagnoses.
What is the purpose of collecting diagnoses in risk adjustment coding?
✔✔ Adjust potential risk measures and evaluate all patients on an equal scale. Levels the
playing field across factors like age, race, gender, and socioeconomics.
What is the acronym for risk adjustment coding?
✔✔ HCC (Hierarchical Condition Category)
What elements would NOT be considered for risk adjustment?
✔✔ Number of years the patient has been covered under Medicare Advantage.
Which medical records can be submitted for HCC validation?
✔✔
MD office progress notes
Outpatient hospital records
Critical access hospital records
What is the purpose of risk adjustment values?
✔✔ To budget and manage the care of a patient for the upcoming year.
What are risk adjustment models used for?
✔✔ To determine projected healthcare costs based on the health conditions of patients.
Which factor is NOT considered for risk adjustment?
✔✔ Frequency of office visits.
How is predictive modeling used in risk adjustment?
✔✔ It helps determine suspected diagnoses based on data elements (such as claims and medical
history).
, lOMoARcPSD| 54339004
What is the reporting period for risk adjustment coding?
✔✔ January through December.
What risk adjustment model is used by Medicaid?
✔✔ CDPS (Chronic Illness & Disability Payment System)
What is CDPS?
✔✔ Chronic Illness & Disability Payment System, used for Medicaid.
What risk adjustment model incorporates High, Medium, & Low risk in the numeric
value?
✔✔ CDPS.
What is the default diagnosis if the type of diabetes mellitus (DM) is not specified?
✔✔ DM2 (Type 2 Diabetes Mellitus).
How to code when a patient is seen for management of anemia due to malignancy?
✔✔
1st code: Malignancy (primary condition)
2nd code: Anemia (secondary condition)
How to code for tobacco use AND dependence on tobacco?
✔✔ Only code for dependence on tobacco (F17.2-).
What is the length of time for a myocardial infarction (MI) to be considered "acute"?
✔✔ 4 weeks or 28 days.
How is glaucoma reported?
✔✔ Only code for the stage of glaucoma, not the underlying cause unless specified.
What is the sequencing order when coding a sequela (late effect)?
✔✔
1st: Residual condition
2nd: Cause of the late effect (e.g., stroke leading to hemiplegia)
What is reported by a provider for beneficiaries in Medicare Advantage plans? - ANSWER✔✔
presenting problems, &
all chronic conditions
How often should a provider see a Pt. to validate amputation status? - ANSWER✔✔ once a
year
PEG Tube - ANSWER✔✔ +percutaneous endoscopic gastrostomy tube
, lOMoARcPSD| 54339004
+G-tube
+gastrostomy
All conditions listed on the problem list for DM patients are coded as complications of DM:
True or False? - ANSWER✔✔ False
What is true regarding hierarchies? - ANSWER✔✔ Utilized by some private payers
Quality Measures like Star Ratings and HEDIS have NO correlation with the medical record
that is collected to support risk adjustment. TRUE or FALSE? - ANSWER✔✔ FALSE
Is HEDIS a division of CMS or Medicaid? - ANSWER✔✔ NO
Who developed HEDIS? - ANSWER✔✔ NCQA (National Committee for Quality Assurance)
How is HEDIS data collected? - ANSWER✔✔ +surveys
+medical chart reviews
+insurance claims
What is the goal of HEDIS (Health Plan Employer Data Info Set)? - ANSWER✔✔ for
consumers to compare health plans
How often are HEDIS measures revised? - ANSWER✔✔ Annually
Which payers uses HEDIS measures? - ANSWER✔✔ a variety
RADV - ANSWER✔✔ Risk Adjustment Data Validation
What is the purpose of a RADV audit? - ANSWER✔✔ Verify accuracy of dx submitted for
payment
When submitting records for RADV audit, will additional current dx that were not originally
reported by considered when documentation is submitted for the audit? - ANSWER✔✔ Yes!
additional current dx not included on claims data may be approved during the audit. The
submission of all dx (w/HCCs) are cumulative, so there may be a neg. or a pos. outcome
overall from a $ perspective
What info is verified during RADV audit? - ANSWER✔✔ All dx codes are supported in the
medical record
Which of the following criteria would be components of an acceptable medical record in a
RADV? - ANSWER✔✔ +encounter must be a face-to-face visit
