RISK ADJUSTMENT CRC FINAL EXAM 2026/2027
QUESTIONS AND SOLUTIONS RATED A+
✔✔E codes - ✔✔supplemental classification used for reporting external causes of
injuries and poisonings
✔✔co-existing/related conditions - ✔✔physicians should code all documented
conditions that co-exist at time of visit, and require or affect patient care
✔✔conditions treated/cured - ✔✔do not code conditions previously treated or no longer
exist
✔✔symptoms/signs - ✔✔do not code if part of an integral underlying condition
✔✔"history of" - ✔✔patient no longer has the condition and dx often indexes to V code
not in HCC models
✔✔"history of" error - ✔✔coding past condition as active; coding active condition as
history of; impacts ra
✔✔cancer codes - ✔✔HCC varies depending on whether cancer is primary site or
secondary site
✔✔cancer guidelines - ✔✔if malignant status not specified, code to primary site except
for:
bone, brain, diaphragms, heart, liver, lymph nodes, mediastinum, meninges,
peritoneum, pleura, retro peritoneum, and spinal cord
✔✔cancer coding - ✔✔code only most severe and costly form of cancer.
✔✔documentation guidelines - ✔✔**reported diagnoses must be supported with
medical record documentation
**medical records and codes subject to CMS validation
**characteristics of acceptable documentation: clear, concise, consistent, complete,
legible
✔✔physician documentation/communication tips - ✔✔**document and report co-existing
diagnoses
**communicate issues regarding inadequate documentation
**adhere to proper methods for appending (late entries) or correcting inaccurate data
entries: lab/radiology results, strike through, initial, and date.
**use only standard abbreviations
**identify patient and date on each page of record
, ✔✔SOAP Notes - ✔✔Subjective: describes patient problem/illness
Objective: physician observation
Assessment: patient's current conditions and status
Plan: treatment, referrals, prescriptions, referrals, education
✔✔RADV purpose - ✔✔ensure risk adjusted payment integrity and accuracy
✔✔ra rule - ✔✔all ra diagnosis codes submitted must be supported by medical record
documentation
✔✔RADV primary objectives - ✔✔*verify enrollee CMS-HCCs used for payment
*identify risk adjustment discrepancies
*calculate enrollee-level payment error
*estimate national and contract-level payment errors
*implement contract-level payment adjustments
✔✔RADV submitted code guideline - ✔✔*face to face encounter
*code accordance to ICD 9 CM/ICD 10 CM
*dos within collection period
*acceptable RA provider type and physician specialty
✔✔RADV core process - ✔✔*stage 1: sampling and medical record request
*stage 2: medical record review (MRR)
*stage 3: MRR findings and cotract-level payment adjustments
*stage 4: documentation dispute
*stage 5: post documentation dispute payment adjustments
*stage 6: appeals
✔✔sampling selection - ✔✔*national sample: estimate national annual payment error.
consists of continuously and non-continuously enrolled beneficiaries with at least one ra
codes (CMS-HCC)
*contract specific sample: estimate annual payment error at contract level; CMS will
target or randomly select contracts;
✔✔medical record request once sampling completed - ✔✔request defined by 3
segments:
*request: initial notice of RADV selection; enrollee list, official request instructions
*submission: MA response to request
*receipt: process used by MRRC for receiving, logging and tracking of records
✔✔medical record request: initial letter - ✔✔*inform contract was selected for data
validation
*request primary and secondary points of contact
*compliance officer is given approx 5 days to respond to initial request
QUESTIONS AND SOLUTIONS RATED A+
✔✔E codes - ✔✔supplemental classification used for reporting external causes of
injuries and poisonings
✔✔co-existing/related conditions - ✔✔physicians should code all documented
conditions that co-exist at time of visit, and require or affect patient care
✔✔conditions treated/cured - ✔✔do not code conditions previously treated or no longer
exist
✔✔symptoms/signs - ✔✔do not code if part of an integral underlying condition
✔✔"history of" - ✔✔patient no longer has the condition and dx often indexes to V code
not in HCC models
✔✔"history of" error - ✔✔coding past condition as active; coding active condition as
history of; impacts ra
✔✔cancer codes - ✔✔HCC varies depending on whether cancer is primary site or
secondary site
✔✔cancer guidelines - ✔✔if malignant status not specified, code to primary site except
for:
bone, brain, diaphragms, heart, liver, lymph nodes, mediastinum, meninges,
peritoneum, pleura, retro peritoneum, and spinal cord
✔✔cancer coding - ✔✔code only most severe and costly form of cancer.
✔✔documentation guidelines - ✔✔**reported diagnoses must be supported with
medical record documentation
**medical records and codes subject to CMS validation
**characteristics of acceptable documentation: clear, concise, consistent, complete,
legible
✔✔physician documentation/communication tips - ✔✔**document and report co-existing
diagnoses
**communicate issues regarding inadequate documentation
**adhere to proper methods for appending (late entries) or correcting inaccurate data
entries: lab/radiology results, strike through, initial, and date.
**use only standard abbreviations
**identify patient and date on each page of record
, ✔✔SOAP Notes - ✔✔Subjective: describes patient problem/illness
Objective: physician observation
Assessment: patient's current conditions and status
Plan: treatment, referrals, prescriptions, referrals, education
✔✔RADV purpose - ✔✔ensure risk adjusted payment integrity and accuracy
✔✔ra rule - ✔✔all ra diagnosis codes submitted must be supported by medical record
documentation
✔✔RADV primary objectives - ✔✔*verify enrollee CMS-HCCs used for payment
*identify risk adjustment discrepancies
*calculate enrollee-level payment error
*estimate national and contract-level payment errors
*implement contract-level payment adjustments
✔✔RADV submitted code guideline - ✔✔*face to face encounter
*code accordance to ICD 9 CM/ICD 10 CM
*dos within collection period
*acceptable RA provider type and physician specialty
✔✔RADV core process - ✔✔*stage 1: sampling and medical record request
*stage 2: medical record review (MRR)
*stage 3: MRR findings and cotract-level payment adjustments
*stage 4: documentation dispute
*stage 5: post documentation dispute payment adjustments
*stage 6: appeals
✔✔sampling selection - ✔✔*national sample: estimate national annual payment error.
consists of continuously and non-continuously enrolled beneficiaries with at least one ra
codes (CMS-HCC)
*contract specific sample: estimate annual payment error at contract level; CMS will
target or randomly select contracts;
✔✔medical record request once sampling completed - ✔✔request defined by 3
segments:
*request: initial notice of RADV selection; enrollee list, official request instructions
*submission: MA response to request
*receipt: process used by MRRC for receiving, logging and tracking of records
✔✔medical record request: initial letter - ✔✔*inform contract was selected for data
validation
*request primary and secondary points of contact
*compliance officer is given approx 5 days to respond to initial request
