Chapter 36 — Quiz

26 questions: multiple choice and short answer. The answer key is in the collapsed block at the bottom. Every coefficient, benchmark, and dollar figure is a constructed teaching figure — risk models, mappings, and coefficients are revised annually and the version in force differs by contract year.

1. Under a risk-adjusted capitated arrangement, a health plan's payment for a member is driven primarily by:

• A. The services furnished to that member during the month
• B. The diagnoses documented and reported for that member during the previous year
• C. The member's premium
• D. The number of claims submitted

2. The primary purpose of risk adjustment is to:

• A. Reward organizations for coding completely
• B. Remove the financial incentive to avoid enrolling sick people
• C. Replace fee-for-service payment
• D. Measure quality of care

3. A risk adjustment factor of 1.0 means the member is expected to cost:

• A. One thousand dollars per month
• B. The same as an average member
• C. Nothing, until a service is furnished
• D. The plan's benchmark, exactly

4. Short answer: state the two things a risk model predicts and does not predict, in the form "the model predicts , not ."

5. The word "hierarchical" in hierarchical condition category refers to:

• A. The ranking of plans by size
• B. The ranking of categories within one disease family, so a member is counted once at the most severe
• C. The order in which diagnoses appear on the claim
• D. The seniority of the reviewing coder

6. A chart contains fourteen accurate ICD-10-CM codes and only two map to a condition category. This indicates:

• A. A coding error
• B. A mapping failure in the software
• C. Normal operation — most ICD-10-CM codes map to no category in any risk model
• D. That the encounter was not face-to-face

7. A record reports both diabetes without complications and diabetes with chronic complications for the same member in the same collection year. The model counts:

• A. Both
• B. The average of the two coefficients
• C. One — the more severe
• D. Neither, and flags the record

8. Reporting only the least severe version of a documented condition is:

• A. The conservative and safe choice
• B. Inaccurate, and the hierarchy guarantees it costs, because the model cannot promote a category that was never reached
• C. Required when the coder is uncertain
• D. Acceptable if the claim pays

9. An interaction term in a risk model is:

• A. A code appended to the claim
• B. A modifier
• C. Computed by the model when two underlying conditions are each documented and reported
• D. Assigned by the plan's medical director

10. Compute: a member's demographic component is 0.346 and her surviving disease coefficients are 0.328 and 0.302. There is no interaction. Her RAF is:

• A. 0.630
• B. 0.976
• C. 1.278
• D. 0.674

11. Compute: a member's RAF is 1.28 and the benchmark is \$1,050.00 per member per month. The payment for the year is:

• A. \$1,344.00
• B. \$12,600.00
• C. \$16,128.00
• D. \$13,440.00

12. Under the annual reset, a chronic condition documented in detail last year and not documented this year:

• A. Carries forward automatically for permanent conditions
• B. Is gone for next year's payment
• C. Is carried forward for three years
• D. Triggers a query from the plan

13. Short answer: which year's diagnoses set which year's payment?

14. Which of the following recaptures a chronic condition for the collection year?

• A. An entry on the reviewed problem list
• B. A laboratory result documenting the abnormality
• C. A face-to-face encounter at which a diagnosing provider assesses the condition and states a plan
• D. A medication refill authorized without an encounter

15. G0439 reports:

• A. A subsequent annual wellness visit
• B. A risk adjustment data validation audit
• C. A quality measure numerator
• D. A prolonged service

16. The MEAT criteria stand for:

• A. Monitor, Evaluate, Assess/Address, Treat
• B. Measure, Evaluate, Attest, Transmit
• C. Medicare, Employer, Advantage, TRICARE
• D. Monitor, Escalate, Audit, Track

17. How many of the four MEAT criteria must a note satisfy before a condition is reportable as addressed?

• A. All four
• B. Three
• C. Two
• D. Any one

18. Short answer: MEAT is not a federal regulation. What is the binding authority the mnemonic operationalizes?

19. A note reads "History of CHF." Reporting active chronic heart failure from that phrase is:

• A. Correct, because the condition is chronic
• B. Incorrect — "history of" is read by the classification as a past condition, and inferring an active one is a clinical judgment
• C. Correct if the patient is on a diuretic
• D. Correct only in the inpatient setting

20. The single design feature that separates a legitimate prospective chart review from an improper one is whether the prompt asks the clinician to:

• A. Sign the note
• B. Evaluate rather than affirm
• C. Complete the visit within a time standard
• D. Use the practice's preferred template

21. A retrospective chart review program has reviewed thousands of charts across several years and has never deleted a diagnosis. The most useful description of that program is:

• A. Highly accurate
• B. A one-way ratchet, and the first thing an external reviewer will ask about
• C. Compliant, since deletions are optional
• D. Understaffed

22. CMS's mechanism for auditing the diagnoses submitted for risk adjustment in Medicare Advantage is:

• A. CERT
• B. RADV — risk adjustment data validation
• C. The Outpatient Code Editor
• D. The MS-DRG Definitions Manual

23. CMS's contract-level RADV final rule, published in January 2023, provides that audit findings:

• A. Will not be extrapolated
• B. Will be extrapolated, beginning with payment year 2018, with no fee-for-service adjuster
• C. Apply only to hospitals
• D. Are advisory only

24. CPT Category II codes such as 0001F and 3044F:

• A. Carry relative values and are paid at a reduced rate
• B. Carry no relative value, are not paid, and exist to report quality measures
• C. Replace the ICD-10-CM diagnosis on the claim
• D. Are assigned only in the inpatient setting

25. 3044F reports a hemoglobin A1c below 7.0%. As a measure component, this is:

• A. A process measure — an action taken
• B. An outcome measure — a result achieved
• C. A structural measure
• D. A balancing measure

26. Short answer: in a shared-savings arrangement, why does more complete diagnosis coding usually not manufacture savings the way it raises revenue in a capitated arrangement?