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Section 1
Compliance: prospective audits
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Preview: Compliance
Preview includes- 4 of 5 lesson topics
- 1 overview segment
- 3 core concepts
- 2 exam tips
Lesson Topics
- prospective audits — governing rule
- prospective audits — documentation checkpoint
- prospective audits — A-versus-B distinction
- prospective audits — common exam trap
Overview
High-yield CRC objective: prospective audits. This card replaces generic review language with the governing coding, documentation, or risk-adjustment rule.
Core Concepts
- A prospective audit reviews documentation and coding before risk-adjustment data are submitted, so unsupported diagnoses can be stopped or clarified before they enter the payment data stream.
- The review asks whether the diagnosis is documented, coded under current ICD-10-CM rules, and comes from an eligible encounter/source for the applicable model.
- Clinical plausibility, medication lists, problem lists, or test results do not replace required provider documentation when a diagnosis must be established by the provider.
Exam Tips
- Anchor the decision on the documented facts and the current governing rule, not on payment impact.
- Watch for this trap: Treating a prospective audit as education-only with no correction authority.
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Section 2
Compliance: retrospective audits
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Section 3
Compliance: RADV audits
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Section 4
Compliance: common RADV coding errors
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Section 5
Compliance: fraud, waste and abuse in risk adjustment
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Section 6
Compliance: documentation and compliance risk
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Section 7
Compliance: prospective versus retrospective controls
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Section 8
Compliance: corrective action and re-audit
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Section 9
Compliance: risk-score optimization versus compliant coding
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Section 10
Compliance: RADV payment consequences
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Section 11
Diagnosis coding: code assignment and clinical criteria
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Section 12
Diagnosis coding: conflicting documentation
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Section 13
Diagnosis coding: combination codes
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Section 14
Diagnosis coding: acute and chronic conditions
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Section 15
Diagnosis coding: laterality documentation
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Section 16
Diagnosis coding: outpatient uncertain diagnoses
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Section 17
Diagnosis coding: inpatient uncertain diagnoses
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Section 18
Diagnosis coding: type of diabetes not documented
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Section 19
Diagnosis coding: long-term diabetes medication use
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Section 20
Diagnosis coding: temporary insulin use
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Section 21
Diagnosis coding: hypertensive chronic kidney disease
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Section 22
Diagnosis coding: hypertensive heart disease with heart failure
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Section 23
Diagnosis coding: hypertensive heart and chronic kidney disease
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Section 24
Diagnosis coding: chronic kidney disease stage coding
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Section 25
Diagnosis coding: pressure ulcer stage documentation
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Section 26
Diagnosis coding: healed pressure ulcers
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Section 27
Diagnosis coding: pressure ulcer progression
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Section 28
Diagnosis coding: current malignancy versus history
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Section 29
Diagnosis coding: cerebrovascular sequela versus history
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Section 30
Diagnosis coding: acute myocardial infarction time frame
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Section 31
Diagnosis coding: type 2 myocardial infarction
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Section 32
Diagnosis coding: ventilator-associated pneumonia
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Section 33
Diagnosis coding: acute respiratory failure sequencing
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Section 34
Diagnosis coding: status codes and active current status
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Section 35
Diagnosis coding: severe malnutrition code specificity
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Section 36
Diagnosis coding: cardiac status code specificity
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Section 37
Diagnosis coding: kidney transplant status code
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Section 38
Diagnosis coding: dialysis dependence status
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Section 39
Diagnosis coding: diabetes with chronic kidney disease
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Section 40
Diagnosis coding: diabetes with polyneuropathy
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Section 41
Documentation improvement: nonleading provider queries
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Section 42
Documentation improvement: clinical criteria versus code assignment
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Section 43
Documentation improvement: BMI documentation
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Section 44
Documentation improvement: pressure-ulcer staging documentation
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Section 45
Documentation improvement: laterality from permitted clinicians
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Section 46
Documentation improvement: social determinants documentation
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Section 47
Documentation improvement: active malignancy versus history
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Section 48
Documentation improvement: transplant complication clarification
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Section 49
Documentation improvement: acute respiratory failure clarification
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Section 50
Documentation improvement: ventilator-associated pneumonia clarification
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Section 51
Documentation improvement: acute myocardial infarction status
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Section 52
Documentation improvement: outpatient diagnostic certainty
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Section 53
Pathophysiology, medical terminology, and anatomy: heart failure physiology
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Section 54
Pathophysiology, medical terminology, and anatomy: COPD pathophysiology
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Section 55
Pathophysiology, medical terminology, and anatomy: diabetic neuropathy
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Section 56
Pathophysiology, medical terminology, and anatomy: diabetic kidney disease
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Section 57
Pathophysiology, medical terminology, and anatomy: DVT and pulmonary embolism
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Section 58
Purpose and use of risk adjustment models: purpose of risk adjustment
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Section 59
Purpose and use of risk adjustment models: prospective model timing
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Section 60
Purpose and use of risk adjustment models: demographic factors in risk scores
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Section 61
Purpose and use of risk adjustment models: HCC hierarchy
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Section 62
Purpose and use of risk adjustment models: disease interactions
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Section 63
Purpose and use of risk adjustment models: ICD-10 to HCC mapping
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Section 64
Purpose and use of risk adjustment models: 2026 CMS-HCC model version
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Section 65
Purpose and use of risk adjustment models: new-enrollee risk adjustment
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Section 66
Purpose and use of risk adjustment models: coding versus model optimization
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Section 67
Purpose and use of risk adjustment models: annual model mappings
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Section 68
Quality of care: HEDIS purpose
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Section 69
Quality of care: Star Ratings and quality
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Section 70
Quality of care: quality measurement versus coding accuracy
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Section 71
Risk adjustment models: CMS-HCC program population
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Section 72
Risk adjustment models: HHS-HCC market
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Section 73
Risk adjustment models: CDPS use
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Section 74
Risk adjustment models: 2026 non-PACE model implementation
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Section 75
Risk adjustment models: ESRD model status
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Section 76
Risk adjustment models: HHS-HCC age-sex factors
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Section 77
Risk adjustment models: HHS-HCC additional factors
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Section 78
Risk adjustment models: HCC construction and hierarchy
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Section 79
Risk adjustment models: model version discipline
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Section 80
Risk adjustment models: risk score coefficients versus coding
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Section 81
Risk adjustment models: prospective versus concurrent model design
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Section 82
Risk adjustment models: model interactions versus combination codes
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Section 83
Risk adjustment models: new enrollee model segments
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Section 84
Risk adjustment models: risk-adjustment eligible diagnosis sources
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Section 85
Risk adjustment models: HHS-HCC versus CMS-HCC portability
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Section 86
Cases: outpatient uncertain diagnosis and risk adjustment
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Section 87
Cases: inpatient uncertain diagnosis
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Section 88
Cases: diabetes and chronic kidney disease coding
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Section 89
Cases: hypertensive chronic kidney disease
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Section 90
Cases: hypertensive heart and chronic kidney disease
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Section 91
Cases: malignancy current versus history
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Section 92
Cases: cerebrovascular sequela versus history
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Section 93
Cases: acute myocardial infarction timeframe
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Section 94
Cases: pressure ulcer progression during admission
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Section 95
Cases: kidney transplant status and CKD
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Section 96
Cases: RADV unsupported diagnosis
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Section 97
Cases: intentional unsupported coding escalation
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Section 98
Cases: 2026 Medicare Advantage model selection
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Section 99
Cases: HCC hierarchy in an integrated case
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Section 100
Cases: new enrollee integrated case
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Section 101
Cases: HHS-HCC integrated case
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Section 102
Cases: CDPS integrated case
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Section 103
Cases: quality versus risk adjustment integrated case
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Section 104
Cases: ESRD integrated model case
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Section 105
Cases: complete coding before model calculation
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Section 106
AAPC blueprint supplement: Diagnosis coding — amputations
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Section 107
AAPC blueprint supplement: Diagnosis coding — artificial openings
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Section 108
AAPC blueprint supplement: Diagnosis coding — atherosclerosis
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Section 109
AAPC blueprint supplement: Diagnosis coding — AV fistulas and dialysis access
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Section 110
AAPC blueprint supplement: Diagnosis coding — complications of devices
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Section 111
AAPC blueprint supplement: Diagnosis coding — dementia and neurocognitive disorders
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Section 112
AAPC blueprint supplement: Diagnosis coding — depression and mental disorders
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Section 113
AAPC blueprint supplement: Diagnosis coding — pulmonary fibrosis
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Section 114
AAPC blueprint supplement: Diagnosis coding — seizures and epilepsy
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Section 115
AAPC blueprint supplement: Diagnosis coding — non-pressure skin ulcers
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Section 116
AAPC blueprint supplement: Diagnosis coding — official guidance and Coding Clinic navigation
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Section 117
AAPC blueprint supplement: Pathophysiology — anatomy, terminology, and acronym speed sheet
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Section 118
AAPC blueprint supplement: Risk adjustment models — private payer model principles
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