Certified Risk Adjustment Coder (CRC) AAPC Exam 2026:
Professional Certification Practice Examination — ICD-10-CM
Coding, Risk Adjustment, HCC Classification, Medical
Documentation, Compliance & Audit Principles — 190 Multiple-
Choice Questions with Answers & Detailed Rationales
Section 1: Risk Adjustment Fundamentals and CMS-HCC Model
Question 1
A 68-year-old Medicare Advantage enrollee has documented diagnoses of Type 2 diabetes
with diabetic nephropathy (E11.21) and chronic kidney disease stage 4 (N18.4). How do
these conditions interact within the CMS-HCC model?
A. Both conditions map to separate HCCs and accumulate without hierarchy constraints.
B. The diabetes with nephropathy HCC is trumped by the CKD HCC because CKD carries
higher severity.
C. The diabetes with nephropathy HCC assigns to a higher-severity diabetes category that
supersedes uncomplicated diabetes coding.
D. Neither condition contributes to the risk score because they are chronic conditions.
Correct Answer: C
Explanation: Diabetes with nephropathy maps to a more severe diabetes HCC than
uncomplicated diabetes, reflecting increased clinical complexity and cost. This specificity is
critical for accurate risk capture.
Question 2
A risk adjustment coder is reviewing a medical record where the provider documents
"history of myocardial infarction" without any current symptoms or treatment. How should
this be coded?
,A. I21.9 (Acute myocardial infarction, unspecified)
B. I25.2 (Old myocardial infarction)
C. Z86.74 (Personal history of myocardial infarction)
D. I25.10 (Atherosclerotic heart disease of native coronary artery without angina)
Correct Answer: B
Explanation: Old myocardial infarction (I25.2) is appropriate when the condition is no longer
acute but requires ongoing monitoring. History codes (Z86) are used when the condition no
longer exists and no treatment is required.
Question 3
What is the primary purpose of the CMS-HCC risk adjustment model?
A. To limit coverage for patients with multiple chronic conditions
B. To predict healthcare costs based on demographic and diagnostic information
C. To determine which patients qualify for Medicare Advantage enrollment
D. To establish uniform national reimbursement rates for all providers
Correct Answer: B
Explanation: The CMS-HCC model predicts expected healthcare expenditures using
diagnoses and demographics, ensuring plans are paid appropriately for their enrolled
population's health burden.
Question 4
A coder identifies that a patient has both "Diabetes with acute complications" and "Diabetes
with chronic complications" documented in the same encounter. According to HCC hierarchy
rules, how should this be coded?
,A. Code both conditions separately to capture full complexity
B. Code only the acute complications as this is the highest severity in the hierarchy
C. Code only the chronic complications as this is the more specific diagnosis
D. Query the provider to determine which condition is primary
Correct Answer: B
Explanation: In the CMS-HCC hierarchy, only the most severe manifestation within a disease
family is coded. Acute complications trump chronic complications, which trump
uncomplicated diabetes.
Question 5
Which of the following best describes a "prospective" risk adjustment review?
A. Reviewing diagnoses after claims have been submitted to CMS
B. Conducting reviews before diagnoses are reported to CMS for payment
C. Auditing medical records from the previous calendar year
D. Validating risk scores during the current payment year
Correct Answer: B
Explanation: Prospective reviews occur before diagnosis data is submitted to CMS, allowing
for corrections that affect the next payment year's risk scores rather than the current year.
Question 6
A patient with COPD is documented as having "acute exacerbation" during an office visit.
What is the correct ICD-10-CM code?
, A. J44.9 (Chronic obstructive pulmonary disease, unspecified)
B. J44.0 (COPD with acute lower respiratory infection)
C. J44.1 (COPD with acute exacerbation)
D. J45.909 (Unspecified asthma, uncomplicated)
Correct Answer: C
Explanation: J44.1 specifically captures COPD with acute exacerbation, which carries distinct
HCC assignment and reflects the acute worsening requiring clinical intervention.
Question 7
Which statement accurately describes how resolved conditions should be coded in risk
adjustment?
A. Resolved conditions are always coded as current if on the problem list
B. Resolved conditions are coded for one year after resolution
C. Resolved conditions are coded as history when no longer requiring treatment
D. Resolved conditions are never coded in risk adjustment
Correct Answer: C
Explanation: Per ICD-10-CM guidelines, conditions that no longer exist or require treatment
are coded as history (Z codes). These generally do not map to HCCs and do not affect risk
scores.
Question 8
A 72-year-old female patient has both rheumatoid arthritis and breast cancer documented.
How do these conditions affect the risk score?
Professional Certification Practice Examination — ICD-10-CM
Coding, Risk Adjustment, HCC Classification, Medical
Documentation, Compliance & Audit Principles — 190 Multiple-
Choice Questions with Answers & Detailed Rationales
Section 1: Risk Adjustment Fundamentals and CMS-HCC Model
Question 1
A 68-year-old Medicare Advantage enrollee has documented diagnoses of Type 2 diabetes
with diabetic nephropathy (E11.21) and chronic kidney disease stage 4 (N18.4). How do
these conditions interact within the CMS-HCC model?
A. Both conditions map to separate HCCs and accumulate without hierarchy constraints.
B. The diabetes with nephropathy HCC is trumped by the CKD HCC because CKD carries
higher severity.
C. The diabetes with nephropathy HCC assigns to a higher-severity diabetes category that
supersedes uncomplicated diabetes coding.
D. Neither condition contributes to the risk score because they are chronic conditions.
Correct Answer: C
Explanation: Diabetes with nephropathy maps to a more severe diabetes HCC than
uncomplicated diabetes, reflecting increased clinical complexity and cost. This specificity is
critical for accurate risk capture.
Question 2
A risk adjustment coder is reviewing a medical record where the provider documents
"history of myocardial infarction" without any current symptoms or treatment. How should
this be coded?
,A. I21.9 (Acute myocardial infarction, unspecified)
B. I25.2 (Old myocardial infarction)
C. Z86.74 (Personal history of myocardial infarction)
D. I25.10 (Atherosclerotic heart disease of native coronary artery without angina)
Correct Answer: B
Explanation: Old myocardial infarction (I25.2) is appropriate when the condition is no longer
acute but requires ongoing monitoring. History codes (Z86) are used when the condition no
longer exists and no treatment is required.
Question 3
What is the primary purpose of the CMS-HCC risk adjustment model?
A. To limit coverage for patients with multiple chronic conditions
B. To predict healthcare costs based on demographic and diagnostic information
C. To determine which patients qualify for Medicare Advantage enrollment
D. To establish uniform national reimbursement rates for all providers
Correct Answer: B
Explanation: The CMS-HCC model predicts expected healthcare expenditures using
diagnoses and demographics, ensuring plans are paid appropriately for their enrolled
population's health burden.
Question 4
A coder identifies that a patient has both "Diabetes with acute complications" and "Diabetes
with chronic complications" documented in the same encounter. According to HCC hierarchy
rules, how should this be coded?
,A. Code both conditions separately to capture full complexity
B. Code only the acute complications as this is the highest severity in the hierarchy
C. Code only the chronic complications as this is the more specific diagnosis
D. Query the provider to determine which condition is primary
Correct Answer: B
Explanation: In the CMS-HCC hierarchy, only the most severe manifestation within a disease
family is coded. Acute complications trump chronic complications, which trump
uncomplicated diabetes.
Question 5
Which of the following best describes a "prospective" risk adjustment review?
A. Reviewing diagnoses after claims have been submitted to CMS
B. Conducting reviews before diagnoses are reported to CMS for payment
C. Auditing medical records from the previous calendar year
D. Validating risk scores during the current payment year
Correct Answer: B
Explanation: Prospective reviews occur before diagnosis data is submitted to CMS, allowing
for corrections that affect the next payment year's risk scores rather than the current year.
Question 6
A patient with COPD is documented as having "acute exacerbation" during an office visit.
What is the correct ICD-10-CM code?
, A. J44.9 (Chronic obstructive pulmonary disease, unspecified)
B. J44.0 (COPD with acute lower respiratory infection)
C. J44.1 (COPD with acute exacerbation)
D. J45.909 (Unspecified asthma, uncomplicated)
Correct Answer: C
Explanation: J44.1 specifically captures COPD with acute exacerbation, which carries distinct
HCC assignment and reflects the acute worsening requiring clinical intervention.
Question 7
Which statement accurately describes how resolved conditions should be coded in risk
adjustment?
A. Resolved conditions are always coded as current if on the problem list
B. Resolved conditions are coded for one year after resolution
C. Resolved conditions are coded as history when no longer requiring treatment
D. Resolved conditions are never coded in risk adjustment
Correct Answer: C
Explanation: Per ICD-10-CM guidelines, conditions that no longer exist or require treatment
are coded as history (Z codes). These generally do not map to HCCs and do not affect risk
scores.
Question 8
A 72-year-old female patient has both rheumatoid arthritis and breast cancer documented.
How do these conditions affect the risk score?
