RISK ADJUSTMENT CRC COMPREHENSIVE EXAM
2026/2027 QUESTIONS AND SOLUTIONS RATED A+
✔✔medical record review - ✔✔validate risk adjusted payments
*service provided by an acceptable ra provider type and physician specialty
*dos within collection period
*provider signature and credentials on each note
*acceptable documentaiton based on documentation guidance
*dx supported by medical record documentation
✔✔inpatient medical record documentation - ✔✔*fact sheet
*history and physcial exam
*physician orders
*progress notes
*operative/pathology reports
*consultation reports
*diagnostic testing reports
*discharge summary
✔✔outpatient medical record documentation - ✔✔*fact sheet
*history and physical exam
*physician orders
*progress notes
*diagnostic reports (to support documentation)
*consultation reports
✔✔unacceptable sources of medical records - ✔✔*skilled nursing facility (SNF)
*diagnostic readiology
*freestanding ambulatory surgical center (ASC)
*alternative data sources
*unacceptable physician extenders
*durable medical equipment (DME)
✔✔unacceptable types of medical rec documentation - ✔✔*superbill
*physician-signed attestation
*list of patient conditions
*diagnostic report that has not been interpreted
*documentation for dos outside the data collection period
✔✔unacceptable types of dx (outpatient hospital/physician settings) - ✔✔*probable,
suspected, questionable, rule out, working
✔✔nursing home resident medical records - ✔✔*encounter must be face to face
*provider rendering services must be an acceptable provider
*medical record must clearly document provider's signature and credentials
, *beneficiary in minimum data set (MDS) as long term institutional resident
✔✔ra errors - ✔✔*unacceptable provider type and physician specialty
*dos submitted does not fall within ra data collection period
*missing provider signature and credentials
*incomplete: diagnosis code cannot be assigned for dos if documentation is insufficient
or incomplete
*never sent: no medical record documentation was received
*diagnosis code does not match ra diagnosis at teh 3rd, 4th, or 5th digit level
✔✔MRR findings/contract level payment adjustments - ✔✔*CMS provides MA of RADV
findings
✔✔documentation disputes/appeal - ✔✔*enrollee HCC level discrepancy findings will
be allowed for dispute
*MA may dispute for particular medical record dos submitted during medical record
request stage
*MA organizations will be given 60 days to submit a documentation dispute
*expert coding panel reviews every dispute; panel consists of senior medical reviewer,
senior coder, physician
✔✔document dispute/appeal process - ✔✔*does not accept first time submission of
medical record
*does not accept missing medical records
*medical record resulted in coding discrepancy
*clearly document reason for disagreement
✔✔payment adjustment - ✔✔*findings will be recalculated based on findings and
payment error will be re-estimated.
*MA will be notified of revised payment error estimate resulting in payment adjustment
✔✔appeal stage - ✔✔*CMS will implement formal appeal process facilitated by CMS
office of Hearings.
✔✔ purpose of risk adjustment - ✔✔allows CMS to pay plans for the risk of the
beneficiaries they enroll, instead of an average amount for Medicare beneficiaries
✔✔adjusting payment plans - ✔✔CMS able to make appropriate and accurate
payments for enrollees with differences in expected costs
✔✔risk scores - ✔✔measure individual beneficiaries' relative risk and are used to adjust
payments for each beneficiary's expected expenditures
✔✔risk scores - ✔✔allows CMS to use standardized bids as base payments to plans
2026/2027 QUESTIONS AND SOLUTIONS RATED A+
✔✔medical record review - ✔✔validate risk adjusted payments
*service provided by an acceptable ra provider type and physician specialty
*dos within collection period
*provider signature and credentials on each note
*acceptable documentaiton based on documentation guidance
*dx supported by medical record documentation
✔✔inpatient medical record documentation - ✔✔*fact sheet
*history and physcial exam
*physician orders
*progress notes
*operative/pathology reports
*consultation reports
*diagnostic testing reports
*discharge summary
✔✔outpatient medical record documentation - ✔✔*fact sheet
*history and physical exam
*physician orders
*progress notes
*diagnostic reports (to support documentation)
*consultation reports
✔✔unacceptable sources of medical records - ✔✔*skilled nursing facility (SNF)
*diagnostic readiology
*freestanding ambulatory surgical center (ASC)
*alternative data sources
*unacceptable physician extenders
*durable medical equipment (DME)
✔✔unacceptable types of medical rec documentation - ✔✔*superbill
*physician-signed attestation
*list of patient conditions
*diagnostic report that has not been interpreted
*documentation for dos outside the data collection period
✔✔unacceptable types of dx (outpatient hospital/physician settings) - ✔✔*probable,
suspected, questionable, rule out, working
✔✔nursing home resident medical records - ✔✔*encounter must be face to face
*provider rendering services must be an acceptable provider
*medical record must clearly document provider's signature and credentials
, *beneficiary in minimum data set (MDS) as long term institutional resident
✔✔ra errors - ✔✔*unacceptable provider type and physician specialty
*dos submitted does not fall within ra data collection period
*missing provider signature and credentials
*incomplete: diagnosis code cannot be assigned for dos if documentation is insufficient
or incomplete
*never sent: no medical record documentation was received
*diagnosis code does not match ra diagnosis at teh 3rd, 4th, or 5th digit level
✔✔MRR findings/contract level payment adjustments - ✔✔*CMS provides MA of RADV
findings
✔✔documentation disputes/appeal - ✔✔*enrollee HCC level discrepancy findings will
be allowed for dispute
*MA may dispute for particular medical record dos submitted during medical record
request stage
*MA organizations will be given 60 days to submit a documentation dispute
*expert coding panel reviews every dispute; panel consists of senior medical reviewer,
senior coder, physician
✔✔document dispute/appeal process - ✔✔*does not accept first time submission of
medical record
*does not accept missing medical records
*medical record resulted in coding discrepancy
*clearly document reason for disagreement
✔✔payment adjustment - ✔✔*findings will be recalculated based on findings and
payment error will be re-estimated.
*MA will be notified of revised payment error estimate resulting in payment adjustment
✔✔appeal stage - ✔✔*CMS will implement formal appeal process facilitated by CMS
office of Hearings.
✔✔ purpose of risk adjustment - ✔✔allows CMS to pay plans for the risk of the
beneficiaries they enroll, instead of an average amount for Medicare beneficiaries
✔✔adjusting payment plans - ✔✔CMS able to make appropriate and accurate
payments for enrollees with differences in expected costs
✔✔risk scores - ✔✔measure individual beneficiaries' relative risk and are used to adjust
payments for each beneficiary's expected expenditures
✔✔risk scores - ✔✔allows CMS to use standardized bids as base payments to plans
