CRC Final Exam Questions and
Answers 100% PASS
2. ANS: A
Rationale: Prospective reviews are similar to concurrent, but are called prospective
because when considering the current year's encounters, these will affect the next
year and not the current year where payment is concerned. - CORRECT
ANSWER-2. When are prospective reviews performed?
a. Prior to the diagnosis and risk factor data being reported to CMS.
b. After the diagnosis and risk factor data has been reported to CMS.
c. Once the patient is enrolled in a Medicare Part C plan
d. Once the provider has finalized the documentation to submit diagnosis codes.
PTS: 1
3. ANS: B
Rationale: Each year, CMS publishes the list of diagnosis codes that risk adjust, and
the HCC that it adjusts to in the model. The information can be found at
,https://www.cms.gov/Medicare/Health-
Plans/MedicareAdvtgSpecRateStats/Risk-Adjustors-
Items/Risk2018.html?DLPage=1&DLEntries=10&DLSort=0&DLSortDir=desce
nding - CORRECT ANSWER-3. Where can a list of diagnosis mappings to HCCs
be located?
a. OIG website
b. CMS website
c. OCR website
d. QPP website
6. ANS: B
Rationale: From a payment perspective, risk adjustment models adjust health plan
revenue to better reflect the projected costs of the patient population and
compensate plans that enroll high-cost patients. - CORRECT ANSWER-6. Risk
adjustment models are used to:
a. Limit coverage of chronic conditions.
b. Determine projected costs of health care based on the condition(s) of patients.
c. Determine the return on investment for developing proactive disease prevention
outreach.
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,d. Limit the coverage of hospital admissions.
7. ANS: C
Rationale: Not all ICD codes carry value in risk adjustment models, including the
Medicare model. Typically diagnoses that are costly to manage from a medical
management or prescription drug treatment perspective are more likely to be
found in risk adjustment models. Each year CMS publishes the list of diagnosis
codes that risk adjust and the HCC it adjusts to. The information can be found at
www.cms.gov/Medicare/Health-Plans/MedicareAdvtgSpecRateStats/Risk-
Adjustors.html. - CORRECT ANSWER-7. Which statement is TRUE regarding
diagnosis codes and assigned HCCs?
a. All diagnosis codes are assigned a HCC.
b. All chronic illnesses are assigned a HCC.
c. Not all diagnosis codes are assigned a HCC.
d. All acute exacerbations of an acute illness are assigned a HCC.
8. ANS: C
Rationale: CMS is required to make an adjustment to reflect "differences in coding
patterns between Medicare Advantage plans and providers under Part A and B to
the extent that the Secretary has identified such differences." - CORRECT
ANSWER-8. What is the purpose of the coding intensity adjustment?
, I. Determine different coding patterns in HCC compared to inpatient claims
covered by Part A.
II. Determine different coding patterns in HCC compared to outpatient claims
covered by Part B.
III. Determine different coding patterns in HCC compared to claims processed
under CDPS.
a. I
b. II
c. I and II
d. I, II, and III
9. ANS: C
Rationale: Any provider may validate any diagnosis, as diagnoses are not dependent
upon the specialty - CORRECT ANSWER-9. When reporting a code for
retinopathy, must the coder find documentation from an ophthalmologist in order
to code the condition as an active condition?
a. Yes, specialty specific diagnoses can only be reported by a specialist.
b. Yes, ophthalmologists must diagnosis all eye related conditions.
c. No, any approved provider can validate any diagnosis.
COPYRIGHT ©️ 2025 ALL RIGHTS RESERVED
Answers 100% PASS
2. ANS: A
Rationale: Prospective reviews are similar to concurrent, but are called prospective
because when considering the current year's encounters, these will affect the next
year and not the current year where payment is concerned. - CORRECT
ANSWER-2. When are prospective reviews performed?
a. Prior to the diagnosis and risk factor data being reported to CMS.
b. After the diagnosis and risk factor data has been reported to CMS.
c. Once the patient is enrolled in a Medicare Part C plan
d. Once the provider has finalized the documentation to submit diagnosis codes.
PTS: 1
3. ANS: B
Rationale: Each year, CMS publishes the list of diagnosis codes that risk adjust, and
the HCC that it adjusts to in the model. The information can be found at
,https://www.cms.gov/Medicare/Health-
Plans/MedicareAdvtgSpecRateStats/Risk-Adjustors-
Items/Risk2018.html?DLPage=1&DLEntries=10&DLSort=0&DLSortDir=desce
nding - CORRECT ANSWER-3. Where can a list of diagnosis mappings to HCCs
be located?
a. OIG website
b. CMS website
c. OCR website
d. QPP website
6. ANS: B
Rationale: From a payment perspective, risk adjustment models adjust health plan
revenue to better reflect the projected costs of the patient population and
compensate plans that enroll high-cost patients. - CORRECT ANSWER-6. Risk
adjustment models are used to:
a. Limit coverage of chronic conditions.
b. Determine projected costs of health care based on the condition(s) of patients.
c. Determine the return on investment for developing proactive disease prevention
outreach.
COPYRIGHT ©️ 2025 ALL RIGHTS RESERVED
,d. Limit the coverage of hospital admissions.
7. ANS: C
Rationale: Not all ICD codes carry value in risk adjustment models, including the
Medicare model. Typically diagnoses that are costly to manage from a medical
management or prescription drug treatment perspective are more likely to be
found in risk adjustment models. Each year CMS publishes the list of diagnosis
codes that risk adjust and the HCC it adjusts to. The information can be found at
www.cms.gov/Medicare/Health-Plans/MedicareAdvtgSpecRateStats/Risk-
Adjustors.html. - CORRECT ANSWER-7. Which statement is TRUE regarding
diagnosis codes and assigned HCCs?
a. All diagnosis codes are assigned a HCC.
b. All chronic illnesses are assigned a HCC.
c. Not all diagnosis codes are assigned a HCC.
d. All acute exacerbations of an acute illness are assigned a HCC.
8. ANS: C
Rationale: CMS is required to make an adjustment to reflect "differences in coding
patterns between Medicare Advantage plans and providers under Part A and B to
the extent that the Secretary has identified such differences." - CORRECT
ANSWER-8. What is the purpose of the coding intensity adjustment?
, I. Determine different coding patterns in HCC compared to inpatient claims
covered by Part A.
II. Determine different coding patterns in HCC compared to outpatient claims
covered by Part B.
III. Determine different coding patterns in HCC compared to claims processed
under CDPS.
a. I
b. II
c. I and II
d. I, II, and III
9. ANS: C
Rationale: Any provider may validate any diagnosis, as diagnoses are not dependent
upon the specialty - CORRECT ANSWER-9. When reporting a code for
retinopathy, must the coder find documentation from an ophthalmologist in order
to code the condition as an active condition?
a. Yes, specialty specific diagnoses can only be reported by a specialist.
b. Yes, ophthalmologists must diagnosis all eye related conditions.
c. No, any approved provider can validate any diagnosis.
COPYRIGHT ©️ 2025 ALL RIGHTS RESERVED
