RISK ADJUSTMENT CRC GUIDE STUDY EXAM 2026/2027
QUESTIONS AND SOLUTIONS RATED A+
✔✔use of signs and symptoms - ✔✔ccan be used if there is no dx for patient
✔✔Syndromes - ✔✔assign codes for te documented manifestations of the syndrome in
absence of alpha index guidance.
✔✔HIV - ✔✔Code on confirmed cases
admitted for HIV- code b20 first
admitted for other and has HIV-code other first then B20
asymptomatic -z21
inconclusive serology-R75
HIV in Pregnancy- O98.7 then B20
HIV testing Z11.4
HIV counseling z71.7
✔✔Severe Sepsis - ✔✔Code for underlying systemic infection
Code from category R65.2 Severe Sepsis (can NEVER be sequenced first)
assign if severe sepsis or an associated acute organ dysfunction is documented
✔✔Acceptable facilities inpatient - ✔✔short term, religious non medical health care,
long erm hospitals, rehabilitation hospitals, children's hospitals, psychiatric hospitals.
✔✔acceptable outpatient facilities - ✔✔short term, hospitals, medical assitance
facilities, critical access, community mental health centers, federally qyalified health
centers, psyicatric hospitals, rutal health clinic(free standing and provider based)
✔✔ Interactions - ✔✔What are extra RA values or factors added when a patient has
more than one major significant dx identified in model ?
✔✔Quality, Promoting Interoperability, Improvement Activity, Cost - ✔✔MIPS Collection
Types Categories
✔✔When are Star Ratings publicly published? - ✔✔October of each year
✔✔HEDIS types of collection - ✔✔Surveys, Medical Chart Reviews, Insurance Claims,
Medical Office Visits, Procedures
✔✔What does Abbreviation MAC stand for? - ✔✔Medicare Administrative Contractor
✔✔Each year, Medicare normalizes risk scores to maintain an average of what? -
✔✔1.0
, ✔✔Which type of documentation can be used to support diagnoses reported under risk
adjustment models? - ✔✔Inpatient admission note
✔✔Risk adjustment models are used to: - ✔✔Determine projected costs of health care
based on the condition(s) of patients
✔✔When submitting records for RADV audit, will additional current diagnoses that were
not originally reported be considered when documentation is submitted for the audit? -
✔✔Yes, additional current diagnoses not included on claims data may be approved
during the audit.
✔✔For commercial plans, funding is allocated based on - ✔✔Current year's known
diagnoses
✔✔What is the impact on reimbursement under the risk adjustment model if chronic
conditions are not coded properly? - ✔✔Failure to code for a chronic condition the
patient has may result in an inaccurate RAF.
✔✔What is the purpose of a RADV - ✔✔To evaluate the appropriateness of risk scores
to patients.
✔✔How many records are submitted by health plans per patient in a RADV audit? -
✔✔5
✔✔Each record submitted for a RADV should include: - ✔✔I. Complete list and legible
records
2. Credential for the rendering provider
3.Provider signature or attestation
✔✔How is predictive modeling used in risk adjustment? - ✔✔Determine suspected
diagnoses based on data elements.
✔✔What might happen as a result of predictive modeling? - ✔✔Disease Management
Programs
✔✔In the CMS Star Ratings program, which measure is given the highest weight? -
✔✔Outcomes
✔✔The results of a RADV audit are extrapolated across all members of the plan that
was audited. What does this mean? - ✔✔Financial penalties will be averaged over the
plan membership
QUESTIONS AND SOLUTIONS RATED A+
✔✔use of signs and symptoms - ✔✔ccan be used if there is no dx for patient
✔✔Syndromes - ✔✔assign codes for te documented manifestations of the syndrome in
absence of alpha index guidance.
✔✔HIV - ✔✔Code on confirmed cases
admitted for HIV- code b20 first
admitted for other and has HIV-code other first then B20
asymptomatic -z21
inconclusive serology-R75
HIV in Pregnancy- O98.7 then B20
HIV testing Z11.4
HIV counseling z71.7
✔✔Severe Sepsis - ✔✔Code for underlying systemic infection
Code from category R65.2 Severe Sepsis (can NEVER be sequenced first)
assign if severe sepsis or an associated acute organ dysfunction is documented
✔✔Acceptable facilities inpatient - ✔✔short term, religious non medical health care,
long erm hospitals, rehabilitation hospitals, children's hospitals, psychiatric hospitals.
✔✔acceptable outpatient facilities - ✔✔short term, hospitals, medical assitance
facilities, critical access, community mental health centers, federally qyalified health
centers, psyicatric hospitals, rutal health clinic(free standing and provider based)
✔✔ Interactions - ✔✔What are extra RA values or factors added when a patient has
more than one major significant dx identified in model ?
✔✔Quality, Promoting Interoperability, Improvement Activity, Cost - ✔✔MIPS Collection
Types Categories
✔✔When are Star Ratings publicly published? - ✔✔October of each year
✔✔HEDIS types of collection - ✔✔Surveys, Medical Chart Reviews, Insurance Claims,
Medical Office Visits, Procedures
✔✔What does Abbreviation MAC stand for? - ✔✔Medicare Administrative Contractor
✔✔Each year, Medicare normalizes risk scores to maintain an average of what? -
✔✔1.0
, ✔✔Which type of documentation can be used to support diagnoses reported under risk
adjustment models? - ✔✔Inpatient admission note
✔✔Risk adjustment models are used to: - ✔✔Determine projected costs of health care
based on the condition(s) of patients
✔✔When submitting records for RADV audit, will additional current diagnoses that were
not originally reported be considered when documentation is submitted for the audit? -
✔✔Yes, additional current diagnoses not included on claims data may be approved
during the audit.
✔✔For commercial plans, funding is allocated based on - ✔✔Current year's known
diagnoses
✔✔What is the impact on reimbursement under the risk adjustment model if chronic
conditions are not coded properly? - ✔✔Failure to code for a chronic condition the
patient has may result in an inaccurate RAF.
✔✔What is the purpose of a RADV - ✔✔To evaluate the appropriateness of risk scores
to patients.
✔✔How many records are submitted by health plans per patient in a RADV audit? -
✔✔5
✔✔Each record submitted for a RADV should include: - ✔✔I. Complete list and legible
records
2. Credential for the rendering provider
3.Provider signature or attestation
✔✔How is predictive modeling used in risk adjustment? - ✔✔Determine suspected
diagnoses based on data elements.
✔✔What might happen as a result of predictive modeling? - ✔✔Disease Management
Programs
✔✔In the CMS Star Ratings program, which measure is given the highest weight? -
✔✔Outcomes
✔✔The results of a RADV audit are extrapolated across all members of the plan that
was audited. What does this mean? - ✔✔Financial penalties will be averaged over the
plan membership
