AAPC CRC Practice Test

Answer choices

1. A. HEDIS is an ICD-10-CM payment grouper that converts diagnoses directly into Medicare Advantage HCC coefficients.
2. B. HEDIS is a fraud-investigation program used to recoup unsupported Medicare Advantage risk-adjustment payments.
3. C. HEDIS is a standardized healthcare performance-measurement framework used to evaluate aspects of care and service quality.
4. D. HEDIS is the federal code set that determines which diagnosis must be sequenced first on inpatient claims; for this encounter, that option would prioritize convenience over the applicable coding or documentation rule.

Wrong-answer review

• A. HEDIS is an ICD-10-CM payment grouper that converts diagnoses directly into Medicare Advantage HCC coefficients.: HEDIS does not map ICD-10-CM diagnoses into CMS-HCC payment coefficients.
• B. HEDIS is a fraud-investigation program used to recoup unsupported Medicare Advantage risk-adjustment payments.: RADV and other audit/compliance programs address unsupported risk-adjustment data.
• D. HEDIS is the federal code set that determines which diagnosis must be sequenced first on inpatient claims; for this encounter, that option would prioritize convenience over the applicable coding or documentation rule.: ICD-10-CM Official Guidelines, not HEDIS, govern diagnosis coding and sequencing The scenario-specific rationale added to the option is also inconsistent with the governing rule.

Answer choices

1. A. A concurrent design because all risk models are concurrent once diagnoses are submitted electronically.
2. B. A prospective risk-adjustment design.
3. C. A retrospective audit design because any use of prior diagnoses makes the model an audit rather than a payment model.
4. D. A quality-measure design because prospective models do not use diagnoses for payment.

Answer choices

1. A. Choose the diagnosis that produces the higher risk score because the record contains clinical indicators supporting greater severity, while documenting the coder's interpretation in the audit trail so a later reviewer can understand why clarification was not requested.
2. B. Assign the most specific diagnosis suggested by test results without contacting the provider, then document the coder's reasoning.
3. C. Send a compliant, nonleading query that presents the relevant clinical indicators and asks the provider to clarify the diagnosis or specificity.
4. D. Leave the diagnosis unchanged in every case because coding professionals may never request clarification from a provider.

Answer choices

1. A. Immediately report the coder to HHS-OIG because every isolated coding error is presumed fraudulent.
2. B. Suspend the entire coding department until every chart for the year has been independently recoded, while leaving the existing submission unchanged so the plan avoids unnecessary operational disruption during the review process.
3. C. Correct the identified error, provide targeted feedback, and monitor for recurrence before escalating discipline based on a broader pattern.
4. D. Ignore the error because a single unsupported diagnosis can never affect risk-adjustment payment.

Answer choices

1. A. No. Diagnoses must come through CMS-recognized, risk-adjustment-eligible sources and satisfy the applicable submission and model rules.
2. B. Yes. Any internal diagnosis is eligible if it increases the risk score and appears somewhere in the plan's data warehouse.
3. C. Yes. Pharmacy claims alone permit coders to infer the associated condition and submit it as a risk-adjustment diagnosis.
4. D. No, because CMS prohibits all encounter-data diagnoses and accepts only manual chart abstractions for non-PACE plans; under these facts, that approach leaves the central ambiguity or compliance defect unresolved.

Answer choices

1. A. Code the suspected diagnosis as confirmed because risk adjustment uses a broader standard than outpatient ICD-10-CM reporting, because using the broader interpretation avoids delaying the claim while still preserving enough information for later chart review.
2. B. Code both the suspected diagnosis and all associated symptoms so no possible risk is omitted.
3. C. Do not code the uncertain diagnosis; report the signs, symptoms, abnormal findings, or other reason for the visit to the highest degree of certainty known.
4. D. Omit the encounter entirely because uncertain diagnoses cannot be reported in any form.

Answer choices

1. A. Continue using the appropriate acute I21 category during the defined acute MI period when the encounter concerns the MI.
2. B. Use old-MI status after discharge because acute MI coding ends as soon as the initial hospitalization is complete.
3. C. Use acute I21 coding for a full year because any MI remains acute for risk-adjustment purposes until the next model year.
4. D. Drop the MI entirely and code only follow-up status because prior acute conditions cannot be reported after the first claim.

Answer choices

1. A. Code DVT because the provider considered it likely enough to order diagnostic imaging and risk adjustment uses suspected chronic conditions.
2. B. Report the established signs and symptoms to the highest degree of certainty and do not code DVT as confirmed for the outpatient encounter.
3. C. Code DVT and the symptoms together so the risk model can decide which diagnosis to keep after hierarchy processing.
4. D. Hold all coding until a later encounter confirms or excludes DVT, because symptoms cannot be reported while diagnostic testing is pending.

Answer choices

1. A. Star Ratings are calculated only by summing each beneficiary's HCC coefficients, so higher morbidity always produces more stars, since risk adjustment and quality measurement can be combined into a single coding decision whenever both affect plan performance.
2. B. Star Ratings summarize plan performance on quality and service measures; they are not simply a restatement of the plan's HCC risk scores.
3. C. Star Ratings replace diagnosis coding rules and permit plans with high quality scores to report unsupported chronic conditions.
4. D. Star Ratings are used solely to determine whether an ICD-10-CM diagnosis is clinically valid for risk-adjustment submission.

Answer choices

1. A. Heart failure with reduced ejection fraction, reflecting impaired left-ventricular pumping.
2. B. Heart failure with preserved ejection fraction, because the ventricle pumps at least half of its blood with each beat.
3. C. Isolated right-sided heart failure caused solely by pulmonary embolism, regardless of the provider's documentation.
4. D. Normal systolic function with no heart-failure implication, because ejection fraction does not help classify heart failure.