Question 1
1. _____ regulations determine the coding requirements for Medicare Advantage plans.
A. FEHB
B. HIAA
C. CMS
D. ERISA
CORRECT ANSWER
D. ERISA
Question 2
2. When are prospective reviews performed?
a. Prior to the diagnosis and risk factor data being reported to CMS.
b. After the diagnosis and risk factor data has been reported to CMS.
c. Once the patient is enrolled in a Medicare Part C plan
d. Once the provider has finalized the documentation to submit diagnosis codes.
CORRECT ANSWER
2. ANS: A
Rationale: Prospective reviews are similar to concurrent, but are called prospective
because when considering the current year's encounters, these will affect the next year
and not the current year where payment is concerned.
1
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,Question 3
3. Where can a list of diagnosis mappings to HCCs be located?
a. OIG website
b. CMS website
c. OCR website
d. QPP website
CORRECT ANSWER
PTS: 1
3. ANS: B
Rationale: Each year, CMS publishes the list of diagnosis codes that risk adjust, and the
HCC that it adjusts to in the model. The information can be found at
https://www.cms.gov/Medicare/Health-Plans/MedicareAdvtgSpecRateStats/Risk-
Adjustors-
Items/Risk2018.html?DLPage=1&DLEntries=10&DLSort=0&DLSortDir=descending
Question 4
6. Risk adjustment models are used to:
a. Limit coverage of chronic conditions.
b. Determine projected costs of health care based on the condition(s) of patients.
c. Determine the return on investment for developing proactive disease prevention
outreach.
d. Limit the coverage of hospital admissions.
CORRECT ANSWER
6. ANS: B
Rationale: From a payment perspective, risk adjustment models adjust health plan
revenue to better reflect the projected costs of the patient population and compensate
plans that enroll high-cost patients.
2
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,Question 5
7. Which statement is TRUE regarding diagnosis codes and assigned HCCs?
a. All diagnosis codes are assigned a HCC.
b. All chronic illnesses are assigned a HCC.
c. Not all diagnosis codes are assigned a HCC.
d. All acute exacerbations of an acute illness are assigned a HCC.
CORRECT ANSWER
7. ANS: C
Rationale: Not all ICD codes carry value in risk adjustment models, including the
Medicare model. Typically diagnoses that are costly to manage from a medical
management or prescription drug treatment perspective are more likely to be found in
risk adjustment models. Each year CMS publishes the list of diagnosis codes that risk
adjust and the HCC it adjusts to. The information can be found at
www.cms.gov/Medicare/Health-Plans/MedicareAdvtgSpecRateStats/Risk-
Adjustors.html.
Question 6
8. What is the purpose of the coding intensity adjustment?
I. Determine different coding patterns in HCC compared to inpatient claims covered by Part
A.
II. Determine different coding patterns in HCC compared to outpatient claims covered by
Part B.
III. Determine different coding patterns in HCC compared to claims processed under CDPS.
a. I
b. II
c. I and II
d. I, II, and III
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, CORRECT ANSWER
8. ANS: C
Rationale: CMS is required to make an adjustment to reflect "differences in coding
patterns between Medicare Advantage plans and providers under Part A and B to the
extent that the Secretary has identified such differences."
Question 7
9. When reporting a code for retinopathy, must the coder find documentation from an
ophthalmologist in order to code the condition as an active condition?
a. Yes, specialty specific diagnoses can only be reported by a specialist.
b. Yes, ophthalmologists must diagnosis all eye related conditions.
c. No, any approved provider can validate any diagnosis.
d. No, only primary care providers can provide supporting documentation for reported
diagnoses.
CORRECT ANSWER
9. ANS: C
Rationale: Any provider may validate any diagnosis, as diagnoses are not dependent
upon the specialty
Question 8
10. How often is the normalization factor adjusted?
a. Monthly
b. Twice per year
c. Yearly
d. As needed
CORRECT ANSWER
10. ANS: C
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1. _____ regulations determine the coding requirements for Medicare Advantage plans.
A. FEHB
B. HIAA
C. CMS
D. ERISA
CORRECT ANSWER
D. ERISA
Question 2
2. When are prospective reviews performed?
a. Prior to the diagnosis and risk factor data being reported to CMS.
b. After the diagnosis and risk factor data has been reported to CMS.
c. Once the patient is enrolled in a Medicare Part C plan
d. Once the provider has finalized the documentation to submit diagnosis codes.
CORRECT ANSWER
2. ANS: A
Rationale: Prospective reviews are similar to concurrent, but are called prospective
because when considering the current year's encounters, these will affect the next year
and not the current year where payment is concerned.
1
@https://www.stuvia.com/user/thestudyvault
,Question 3
3. Where can a list of diagnosis mappings to HCCs be located?
a. OIG website
b. CMS website
c. OCR website
d. QPP website
CORRECT ANSWER
PTS: 1
3. ANS: B
Rationale: Each year, CMS publishes the list of diagnosis codes that risk adjust, and the
HCC that it adjusts to in the model. The information can be found at
https://www.cms.gov/Medicare/Health-Plans/MedicareAdvtgSpecRateStats/Risk-
Adjustors-
Items/Risk2018.html?DLPage=1&DLEntries=10&DLSort=0&DLSortDir=descending
Question 4
6. Risk adjustment models are used to:
a. Limit coverage of chronic conditions.
b. Determine projected costs of health care based on the condition(s) of patients.
c. Determine the return on investment for developing proactive disease prevention
outreach.
d. Limit the coverage of hospital admissions.
CORRECT ANSWER
6. ANS: B
Rationale: From a payment perspective, risk adjustment models adjust health plan
revenue to better reflect the projected costs of the patient population and compensate
plans that enroll high-cost patients.
2
@https://www.stuvia.com/user/thestudyvault
,Question 5
7. Which statement is TRUE regarding diagnosis codes and assigned HCCs?
a. All diagnosis codes are assigned a HCC.
b. All chronic illnesses are assigned a HCC.
c. Not all diagnosis codes are assigned a HCC.
d. All acute exacerbations of an acute illness are assigned a HCC.
CORRECT ANSWER
7. ANS: C
Rationale: Not all ICD codes carry value in risk adjustment models, including the
Medicare model. Typically diagnoses that are costly to manage from a medical
management or prescription drug treatment perspective are more likely to be found in
risk adjustment models. Each year CMS publishes the list of diagnosis codes that risk
adjust and the HCC it adjusts to. The information can be found at
www.cms.gov/Medicare/Health-Plans/MedicareAdvtgSpecRateStats/Risk-
Adjustors.html.
Question 6
8. What is the purpose of the coding intensity adjustment?
I. Determine different coding patterns in HCC compared to inpatient claims covered by Part
A.
II. Determine different coding patterns in HCC compared to outpatient claims covered by
Part B.
III. Determine different coding patterns in HCC compared to claims processed under CDPS.
a. I
b. II
c. I and II
d. I, II, and III
3
@https://www.stuvia.com/user/thestudyvault
, CORRECT ANSWER
8. ANS: C
Rationale: CMS is required to make an adjustment to reflect "differences in coding
patterns between Medicare Advantage plans and providers under Part A and B to the
extent that the Secretary has identified such differences."
Question 7
9. When reporting a code for retinopathy, must the coder find documentation from an
ophthalmologist in order to code the condition as an active condition?
a. Yes, specialty specific diagnoses can only be reported by a specialist.
b. Yes, ophthalmologists must diagnosis all eye related conditions.
c. No, any approved provider can validate any diagnosis.
d. No, only primary care providers can provide supporting documentation for reported
diagnoses.
CORRECT ANSWER
9. ANS: C
Rationale: Any provider may validate any diagnosis, as diagnoses are not dependent
upon the specialty
Question 8
10. How often is the normalization factor adjusted?
a. Monthly
b. Twice per year
c. Yearly
d. As needed
CORRECT ANSWER
10. ANS: C
4
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