2026–2027 CRC Exam Prep | AAPC Certified Risk Adjustment
Specialist Study Guide, Hierarchical Condition Categories
(HCC) 55 Practice Questions & Verified Answers
EXAM INFORMATION
Total Questions: 55
Recommended Time: 82 Minutes
Passing Threshold: 85%
Exam Format: Multiple Choice Questions (MCQs)
Question Style: Scenario-Based, Applied, and Coding Decision-Making Questions
Difficulty Level: Comprehensive and Technical
==============================
SECTION 1: Risk Adjustment Fundamentals
Question 1
A 72-year-old Medicare Advantage enrollee has the following conditions documented in
the current calendar year: Type 2 diabetes mellitus with diabetic nephropathy (E11.21),
chronic obstructive pulmonary disease with acute exacerbation (J44.1), and congestive
heart failure unspecified (I50.9). The patient's demographic data indicates an aged
community enrollee status. Which statement accurately describes how these conditions
interact within the CMS-HCC risk adjustment model for payment year 2026?
A. All three conditions map to separate HCCs and accumulate additively without any
interaction effects.
B. The diabetes and congestive heart failure HCCs trigger a disease interaction that
increases the risk score beyond the sum of individual HCC coefficients.
,C. The COPD exacerbation code maps to the same HCC as stable COPD, and the
diabetes with nephropathy maps to a more severe HCC than diabetes without
complications.
D. The congestive heart failure code is excluded from risk score calculation because the
patient already has a higher-severity pulmonary condition.
Correct Answer: B
Rationale: In the CMS-HCC model, certain condition pairs trigger disease interaction
coefficients that increase the risk score beyond simple additive accumulation. Diabetes
and congestive heart failure represent one such interaction. Option A is incorrect
because the model includes interaction effects, not purely additive scoring. Option C is
partially true about HCC mapping but does not address the interaction mechanism, and
COPD with acute exacerbation maps to a different HCC than stable COPD in current
models. Option D is incorrect because heart failure is not excluded due to pulmonary
conditions; both contribute to the risk score.
Question 2
A risk adjustment coder is reviewing enrollment data for a Medicare Advantage plan.
The plan has 10,000 members with an average RAF of 1.05. CMS announces a 2%
reduction in the normalization factor for the upcoming payment year. Assuming no
change in member health status or coding patterns, which outcome is most likely?
A. The average RAF will decrease to approximately 1.03, resulting in lower capitation
payments.
,B. The average RAF will increase to approximately 1.07, resulting in higher capitation
payments.
C. The normalization factor change does not affect RAF values; only the benchmark rate
changes.
D. The plan must recode all members to maintain the same payment level.
Correct Answer: B
Rationale: The normalization factor divides the raw risk score to produce the RAF. If
CMS reduces the normalization factor (divisor), the resulting RAF increases, leading to
higher capitation payments for the same raw risk. Option A reverses the mathematical
relationship. Option C is incorrect because the normalization factor directly affects RAF
calculation. Option D is incorrect because coding patterns are independent of
normalization factor adjustments.
Question 3
A health plan's actuarial department is analyzing risk scores for the Affordable Care Act
(ACA) risk adjustment program. Which fundamental difference between the CMS-HCC
model and the HHS-HCC model must the analysts consider when comparing risk scores
across programs?
A. The HHS-HCC model uses concurrent diagnosis coding, while the CMS-HCC model
uses only prospective coding from the prior year.
B. The HHS-HCC model includes separate age-sex risk score calculations for adults and
children, while the CMS-HCC model primarily focuses on aged and disabled Medicare
populations.
, C. The HHS-HCC model excludes all prescription drug data, while the CMS-HCC model
requires pharmacy claims for risk score calculation.
D. The HHS-HCC model uses only inpatient diagnoses, while the CMS-HCC model uses
all encounter settings.
Correct Answer: B
Rationale: The HHS-HCC model (used for ACA plans) calculates separate risk scores for
adults (21-64) and children (0-20), incorporating age-sex factors differently than the
CMS-HCC model, which focuses on Medicare aged, disabled, and dual-eligible
populations. Option A is incorrect because both models use concurrent year diagnoses
for payment. Option C is incorrect because the HHS-HCC model does not exclude
prescription data considerations in all contexts, and CMS-HCC does not require
pharmacy claims for standard risk scoring. Option D is incorrect because both models
use diagnoses from all applicable encounter settings.
Question 4
During a risk adjustment education session, a physician asks why capturing all
documented chronic conditions during an annual wellness visit impacts Medicare
Advantage revenue. Which explanation best describes the relationship between
complete diagnostic capture and payment methodology?
A. Medicare Advantage plans receive capitated payments based on enrollee health
status, and risk scores derived from documented diagnoses directly adjust the
per-member-per-month payment amount.
Specialist Study Guide, Hierarchical Condition Categories
(HCC) 55 Practice Questions & Verified Answers
EXAM INFORMATION
Total Questions: 55
Recommended Time: 82 Minutes
Passing Threshold: 85%
Exam Format: Multiple Choice Questions (MCQs)
Question Style: Scenario-Based, Applied, and Coding Decision-Making Questions
Difficulty Level: Comprehensive and Technical
==============================
SECTION 1: Risk Adjustment Fundamentals
Question 1
A 72-year-old Medicare Advantage enrollee has the following conditions documented in
the current calendar year: Type 2 diabetes mellitus with diabetic nephropathy (E11.21),
chronic obstructive pulmonary disease with acute exacerbation (J44.1), and congestive
heart failure unspecified (I50.9). The patient's demographic data indicates an aged
community enrollee status. Which statement accurately describes how these conditions
interact within the CMS-HCC risk adjustment model for payment year 2026?
A. All three conditions map to separate HCCs and accumulate additively without any
interaction effects.
B. The diabetes and congestive heart failure HCCs trigger a disease interaction that
increases the risk score beyond the sum of individual HCC coefficients.
,C. The COPD exacerbation code maps to the same HCC as stable COPD, and the
diabetes with nephropathy maps to a more severe HCC than diabetes without
complications.
D. The congestive heart failure code is excluded from risk score calculation because the
patient already has a higher-severity pulmonary condition.
Correct Answer: B
Rationale: In the CMS-HCC model, certain condition pairs trigger disease interaction
coefficients that increase the risk score beyond simple additive accumulation. Diabetes
and congestive heart failure represent one such interaction. Option A is incorrect
because the model includes interaction effects, not purely additive scoring. Option C is
partially true about HCC mapping but does not address the interaction mechanism, and
COPD with acute exacerbation maps to a different HCC than stable COPD in current
models. Option D is incorrect because heart failure is not excluded due to pulmonary
conditions; both contribute to the risk score.
Question 2
A risk adjustment coder is reviewing enrollment data for a Medicare Advantage plan.
The plan has 10,000 members with an average RAF of 1.05. CMS announces a 2%
reduction in the normalization factor for the upcoming payment year. Assuming no
change in member health status or coding patterns, which outcome is most likely?
A. The average RAF will decrease to approximately 1.03, resulting in lower capitation
payments.
,B. The average RAF will increase to approximately 1.07, resulting in higher capitation
payments.
C. The normalization factor change does not affect RAF values; only the benchmark rate
changes.
D. The plan must recode all members to maintain the same payment level.
Correct Answer: B
Rationale: The normalization factor divides the raw risk score to produce the RAF. If
CMS reduces the normalization factor (divisor), the resulting RAF increases, leading to
higher capitation payments for the same raw risk. Option A reverses the mathematical
relationship. Option C is incorrect because the normalization factor directly affects RAF
calculation. Option D is incorrect because coding patterns are independent of
normalization factor adjustments.
Question 3
A health plan's actuarial department is analyzing risk scores for the Affordable Care Act
(ACA) risk adjustment program. Which fundamental difference between the CMS-HCC
model and the HHS-HCC model must the analysts consider when comparing risk scores
across programs?
A. The HHS-HCC model uses concurrent diagnosis coding, while the CMS-HCC model
uses only prospective coding from the prior year.
B. The HHS-HCC model includes separate age-sex risk score calculations for adults and
children, while the CMS-HCC model primarily focuses on aged and disabled Medicare
populations.
, C. The HHS-HCC model excludes all prescription drug data, while the CMS-HCC model
requires pharmacy claims for risk score calculation.
D. The HHS-HCC model uses only inpatient diagnoses, while the CMS-HCC model uses
all encounter settings.
Correct Answer: B
Rationale: The HHS-HCC model (used for ACA plans) calculates separate risk scores for
adults (21-64) and children (0-20), incorporating age-sex factors differently than the
CMS-HCC model, which focuses on Medicare aged, disabled, and dual-eligible
populations. Option A is incorrect because both models use concurrent year diagnoses
for payment. Option C is incorrect because the HHS-HCC model does not exclude
prescription data considerations in all contexts, and CMS-HCC does not require
pharmacy claims for standard risk scoring. Option D is incorrect because both models
use diagnoses from all applicable encounter settings.
Question 4
During a risk adjustment education session, a physician asks why capturing all
documented chronic conditions during an annual wellness visit impacts Medicare
Advantage revenue. Which explanation best describes the relationship between
complete diagnostic capture and payment methodology?
A. Medicare Advantage plans receive capitated payments based on enrollee health
status, and risk scores derived from documented diagnoses directly adjust the
per-member-per-month payment amount.
