RISK ADJUSTMENT CRC MAIN EXAMINATION SET
2026/2027 QUESTIONS AND SOLUTIONS RATED A+
✔✔Where in the documentation diagnosis is can be pulled for HCC coding? - ✔✔Code
can be assigned from documentation from the entire note.
Rational: The codes can be a sign from documentation in the entire note. The
documentation should be evaluated carefully to determine if the conditions are actively
treated or a history of condition. Wording use by the treating provider does not always
correctly reflect active versus history of. When coding diagnoses for risk adjustment, the
goal is to honestly report all current diagnosis a patient has an a face to face and
counter by a pool provider type store in each calendar year )January_December).
Following ICD 10 CM guidelines, it is appropriate to call for all coexisting diagnosis is
that were a part of the medical decision-making of the visit or encounter. Do not code
any diagnosis previously treated, no longer existing, or only historic in nature.
✔✔What is the purpose of collecting diagnosis in risk adjustment coding? - ✔✔For risk
adjustment factor
RATIONAL: collecting these diagnoses is not the purpose of submitting a claim, but
rather to send the diagnoses in a supplemental file or updated claim to account for all
the conditions the patient has documented as a current diagnosis each year. These
diagnoses codes are converted to a risk adjustment factor ( for example, HCC value or
CDPS value) and the patient risk adjustment is steadily and yearly adjusted according
to those risk adjustment associated diagnosis codes.
✔✔Types of Diagnosis-based program risk adjustment models - ✔✔1) Health and
human services hierarchy condition category (HHS HCC)- commercial, individual, and
small group.
2) medicaid chronic illness and disability payment systems (CDPS)
3) medicare hierarchical conditions category, part C (Medicare HCC)
4) diagnosis related groups (DRG)- inpatient
5) adjusted clinical groups (ACG)- outpatient
✔✔Prescription-based program risk adjustment examples: - ✔✔1) MedicaidRx (UCSD)
2) RxGroups (DxCG)
3) medicare hierarchal condition category, part D (RxHCC)
4) Health and human service hierarchical condition category, part D (HHS HCC)
✔✔When our retrospective review usually performed? - ✔✔After and risk factor data
has been reported to CMS
, ✔✔Which risk adjustment model is most commonly used by Medicaid? - ✔✔CDPS-
Medicaid chronic illness and disability payment system
✔✔What does the abbreviation CDPS indicate? - ✔✔Chronic disability payment system
Rational: chronic illness and disability payment system is the risk adjustment model
used by Medicaid.
✔✔Which risk adjustment model is used for commercial plan and uses metal levels to
classify patients? - ✔✔HHS-Health & Human service
✔✔How is fee-for-service data use for the purpose of risk adjustment? - ✔✔The
average FFS expenses and rates are used to determine the FFS normalization
adjustment.
✔✔Risk adjustment model by HHS - ✔✔States can either use the federal mythology or
propose an alternate for certification by HHS.
Rational: A state operating risk adjustment may use the federal methodology or propose
alternate risk methodologies for certification by HHS. HHS operates a risk adjustment
program on the behalf of any state not operating a risk adjustment model.
✔✔Each year, Medicare normalize his risk scores to maintain an average of what? -
✔✔1.0
Rational: risk adjustment must be compared to average FFS expenses and rates. The
purpose of the FFS normalization adjustment is so that CMS payments are based on a
population with an average risk score of 1.0. This is the national average. Annually,
Medicare normalizes the risk scores to maintain an average risk score of 1.0
✔✔Risk adjustment models are used to: - ✔✔Determine projected cost of health care
based on the condition(s) of patients.
Rational: from a payment perspective, risk adjustment models adjust health plan
revenue to better reflect the project cost of the patient population and compensate plans
that in rawhide cost patients.
✔✔What is the purpose of the coding intensity adjustment? - ✔✔1) determine different
coding patterns in HCC compared to inpatient claims covered by part A.
2) Determine different coding patterns in HCC compare to outpatient claims covered by
part B.
2026/2027 QUESTIONS AND SOLUTIONS RATED A+
✔✔Where in the documentation diagnosis is can be pulled for HCC coding? - ✔✔Code
can be assigned from documentation from the entire note.
Rational: The codes can be a sign from documentation in the entire note. The
documentation should be evaluated carefully to determine if the conditions are actively
treated or a history of condition. Wording use by the treating provider does not always
correctly reflect active versus history of. When coding diagnoses for risk adjustment, the
goal is to honestly report all current diagnosis a patient has an a face to face and
counter by a pool provider type store in each calendar year )January_December).
Following ICD 10 CM guidelines, it is appropriate to call for all coexisting diagnosis is
that were a part of the medical decision-making of the visit or encounter. Do not code
any diagnosis previously treated, no longer existing, or only historic in nature.
✔✔What is the purpose of collecting diagnosis in risk adjustment coding? - ✔✔For risk
adjustment factor
RATIONAL: collecting these diagnoses is not the purpose of submitting a claim, but
rather to send the diagnoses in a supplemental file or updated claim to account for all
the conditions the patient has documented as a current diagnosis each year. These
diagnoses codes are converted to a risk adjustment factor ( for example, HCC value or
CDPS value) and the patient risk adjustment is steadily and yearly adjusted according
to those risk adjustment associated diagnosis codes.
✔✔Types of Diagnosis-based program risk adjustment models - ✔✔1) Health and
human services hierarchy condition category (HHS HCC)- commercial, individual, and
small group.
2) medicaid chronic illness and disability payment systems (CDPS)
3) medicare hierarchical conditions category, part C (Medicare HCC)
4) diagnosis related groups (DRG)- inpatient
5) adjusted clinical groups (ACG)- outpatient
✔✔Prescription-based program risk adjustment examples: - ✔✔1) MedicaidRx (UCSD)
2) RxGroups (DxCG)
3) medicare hierarchal condition category, part D (RxHCC)
4) Health and human service hierarchical condition category, part D (HHS HCC)
✔✔When our retrospective review usually performed? - ✔✔After and risk factor data
has been reported to CMS
, ✔✔Which risk adjustment model is most commonly used by Medicaid? - ✔✔CDPS-
Medicaid chronic illness and disability payment system
✔✔What does the abbreviation CDPS indicate? - ✔✔Chronic disability payment system
Rational: chronic illness and disability payment system is the risk adjustment model
used by Medicaid.
✔✔Which risk adjustment model is used for commercial plan and uses metal levels to
classify patients? - ✔✔HHS-Health & Human service
✔✔How is fee-for-service data use for the purpose of risk adjustment? - ✔✔The
average FFS expenses and rates are used to determine the FFS normalization
adjustment.
✔✔Risk adjustment model by HHS - ✔✔States can either use the federal mythology or
propose an alternate for certification by HHS.
Rational: A state operating risk adjustment may use the federal methodology or propose
alternate risk methodologies for certification by HHS. HHS operates a risk adjustment
program on the behalf of any state not operating a risk adjustment model.
✔✔Each year, Medicare normalize his risk scores to maintain an average of what? -
✔✔1.0
Rational: risk adjustment must be compared to average FFS expenses and rates. The
purpose of the FFS normalization adjustment is so that CMS payments are based on a
population with an average risk score of 1.0. This is the national average. Annually,
Medicare normalizes the risk scores to maintain an average risk score of 1.0
✔✔Risk adjustment models are used to: - ✔✔Determine projected cost of health care
based on the condition(s) of patients.
Rational: from a payment perspective, risk adjustment models adjust health plan
revenue to better reflect the project cost of the patient population and compensate plans
that in rawhide cost patients.
✔✔What is the purpose of the coding intensity adjustment? - ✔✔1) determine different
coding patterns in HCC compared to inpatient claims covered by part A.
2) Determine different coding patterns in HCC compare to outpatient claims covered by
part B.
