CRC Assessment - Mock I

1. Which of the following medications are prescribed to cancer patients to eradicate the cancer or
for prophylaxis?
I. Tamoxifen
II. Anastrozole
III. Januvia
IV. Crestor

A. I and II
B. I and III
C. II and III
D. I, II, III and IV

View Rationale
Anastrozole is used to treat breast cancer in women who have gone through menopause. It
works by lowering estrogen hormone levels to help shrink tumors and slow their growth.
Tamoxifen is prescribed for women who have breast cancer with tumors fueled by estrogen. The
medication blocks the action of estrogen.

2. The definition of a best medical record for a RADV audit is:

A. Documentation validates the CMS requested HCCs, contains all the necessary documentation
elements and has an additional HCC not requested by CMS
B. Documentation that validates all the requested HCCs
C. Documentation that validates the requested HCC, but there is no provider signature
D. Documentation that validates the requested HCC plus validates an additional HCC, contains all
the necessary documentation elements, but is missing the provider signature, for which a signed
CMS attestation was provided but not signed by the provider

View Rationale
RADV guidelines state that the Best Medical Record contains documentation that supports HCC
and all elements of proper documentation are followed, for example, signed by provider. Proper
documentation is the first aspect that must be reviewed to determine if the record could be
considered a Best Medical Record. After proper documentation is determined, the additional
HCC (which can decrease the amount owed to CMS) within the note makes this the Best Medical
Record.

3. Which of the following are reported by a provider for beneficiaries in a Medicare Advantage
Plan?
I. Nature of the presenting problem
II. Resolved conditions that have been treated in the past
 CRC Assessment - Mock I
III. Family history for all conditions
IV. All chronic conditions
A. I
B. II and III
C. I and IV
D. I, II, III and IV

View Rationale
Providers must report all diagnoses that affect the patient’s evaluation, care, and treatment,
including: Nature of the presenting problem All chronic conditions (such as atrial fibrillation,
congestive heart failure (CHF), chronic kidney disease (CKD), rheumatoid arthritis, diabetes with
manifestations, chronic obstruction pulmonary disease (COPD), all active cancers) History on any
relevant past conditions ZV-codes (factors that influence health/status codes) E-codes (external
causes of injury and poisoning, and certain other consequences of external causes) HCC scores
on individual members determine CMS reimbursement to the plan. Diagnosis and demographic
information should be captured at each face-to-face encounter to obtain a health-based
measure of that member’s future medical needs.

4. Which of the following records would be a good source for a retrospective chart audit?
A. DME documentation
B. Cardiologist records
C. Dietician notes
D. RN notes

View Rationale
A cardiologist is the only approved provider provided as an answer option according to CMS for
Risk Adjustment

5. Retrospective audits should include the following attributes:

I. Provider signatures
II. Supporting documentation of the patient's diagnoses
III. DOS

A. I
B. II
C. I and II
D. I, II and III

View Rationale
 CRC Assessment - Mock I
Retrospective chart audits should follow RADV guidelines for Best Medical Record
documentation; chart should be signed by provider, provider should follow proper
documentation guidelines including DOS, and supporting documentation.

6. Which type of audit evaluates appropriate risk scores of patients?

A. ZPIC
B. RADV
C. RAC
D. CERT

View Rationale
RADV (Risk Adjustment Data Validation) and IVA (Independent Validation Audit) are audits used
in risk adjustment models to verify submitted diagnoses of patients.

7. What information is required when submitting documentation to support a diagnosis for a

RADV/IVA?
A. All patient records for the calendar year resulting in care for a chronic condition
B. All inpatient hospital records where a readmission occurred
C. A single DOS for outpatient records and the full inpatient set for hospital records
D. All professional provider documentation for the previous year

View Rationale
When submitting documentation for a RADV/IVA, the submission should be the single date of
service for physician and other outpatient records, and the full hospital record from admission to
discharge for inpatient records supporting a diagnosis.

8. What is TRUE regarding the code assignment requirement for chronic kidney disease requiring
dialysis (N18.6)?
A. The diagnosis should only be reported when the patient is admitted to the hospital.
B. The diagnosis should only be reported when the patient is diagnosed with CKD and is actively
being treated by a specialist.
C. The patient should be diagnosed with CKD and is on chronic dialysis or receiving kidney
transplants are associated with this diagnosis.
D. The diagnosis should only be reported when the patient is diagnosed with chronic renal
insufficiency.

View Rationale
This code assignment is supported by the inclusion terms under code N18.6, which state Chronic
kidney disease requiring chronic dialysis. Patients who are on chronic dialysis or receiving kidney
transplants may be considered as having end-stage renal disease (ESRD). Assign code N18.6.
 CRC Assessment - Mock I
9. Joey is prescribed Oxycodone for a back injury by his orthopedic surgeon two years ago. The
surgeon documents he would like to try another medication to dull the pain. Joey attempts to
change to the newer medication but there is breakthrough pain and he goes back to the
Oxycodone. Would code from category F11.2 be appropriate?
A. Yes, Joey has been on the Oxycodone for two years

B. Yes, Joey's pain could not be controlled by the second medication

C. No, a person must be on a medication a minimal of 3 years before "dependency" can be
implied
D. No, the surgeon did not document that Joey was dependent on the Oxycodone

View Rationale
If the patient is prescribed a narcotic for long-term use and the provider does not document
"drug dependence," assign code Z79.899, Other long-term current drug therapy.

10. Diagnoses must be based on face-to face encounters between members and an MD, PA, or NP
and status conditions like a below knee amputation, must be assessed and documented for
payment adjustments to be received. How often should a provider see and assess a patient in a
calendar year to validate amputation status?
A. Twice a year
B. Once a year
C. Four times a year
D. Every two years

View Rationale
Status conditions must reflect active conditions that require treatment or influence medical
decision making and be assessed at minimum, once per calendar year.

11. A PEG Tube is:

I. Percutaneous Endoscopic Gastrostomy
II. G tube
III. Gastrostomy
IV. Colostomy
A. I
B. I and III
C. I, II, and III
D. IV

View Rationale
 CRC Assessment - Mock I
A PEG tube is called by all these various names except colostomy.

12. Patient is here for follow up. She was seen in the ER two weeks ago where she had an MRI of the
brain which showed significant cerebral arteriosclerosis. She was diagnosed with a TIA. She has
been experiencing slight memory loss. Select the correct code(s).
A. I67.2, Z86.73
B. G45.9
C. Z86.73, R41.3
D. G45.9, I67.2, R41.3

View Rationale
I67.2 Cerebral atherosclerosis is the correct primary ICD-10-CM code. The personal history TIA
code Z86.73 is reported as the second code. Memory loss (R41.3) would not be reported as it is a
symptom of cerebral arteriosclerosis.

13. Patient is here for follow up after her dialysis yesterday. What is the ICD-10-CM code for
presence of an AV fistula for dialysis?
A. T82.818D
B. I77.0
C. Z49.31
D. Z99.2
View Rationale
In the ICD-10-CM Alphabetic Index look for Status/dialysis

14. A patient presents for a routine checkup for his hypertensive heart failure. He is to continue with
his current medication and diet. Select the diagnosis code(s).
A. I50.40, I10
B. I11.0, I50.9
C. I50.9, I10
D. I50.9

View Rationale
There is a causal relationship between hypertension and heart failure report code I11.0. The
heart failure is reported as a second code, because of the instructional note under code I11.0
which indicates to “use additional code to identify type of heart failure (I50.-)."

15. Today a 54-year-old man presents for his routine follow up after renal transplant two years ago.
The patient has CKD stage 2 and reports no other complaints. Assign the correct ICD-10-CM
code(s).
A. N18.2, Z94.0
 CRC Assessment - Mock I
B. T86.10, Z94.0
C. T86.10
D. Z94.0, N18.2
View Rationale
ICD-10-CM guideline I.C.14.a.2, indicates that the presence of CKD after a transplant alone does
not constitute a transplant complication. Also, there is an instructional note below code category
N18 in the Tabular List indicating to use additional code to report transplant status.

16. A Type 2 diabetic presents with an insulin pump malfunction. What are the correct codes?
A. T85.694A, E11.9, Z79.4
B. T85.694A, E11.620, Z79.4
C. T82.598A, E11.9, Z79.4
D. T82.598A, E11.620, Z79.4

View Rationale
ICD-10-CM guideline I.C.4.a.5, indicates insulin pump malfunctions are coded to T85.6-. Insulin
pump malfunction can be an under dose or overdose of medication. With documentation that is
non-specific such as this, the only known element is pump malfunction.

17. What is the correct ICD-10-CM code for a patient with COPD exacerbation?
A. J44.1
B. J44.9
C. J45.909
D. J44.9

View Rationale
To locate the correct code, look in the ICD-10-CM Alphabetic Index for Disease,
diseased/pulmonary/chronic obstructive/with/exacerbation.

18. The patient had hip replacement surgery three days ago. The provider documents the patient
has had a “iatrogenic cerebrovascular infarction due to recent hip replacement surgery during
her current hospital stay." Assign the appropriate ICD-10-CM code for the cardiovascular event.
A. I63.50
B. G45.9
C. I97.821
D. I63.9

View Rationale
ICD-10-CM guideline I.C.9.c., indicates cerebrovascular infarction that occurs as a result of
medical intervention is coded based on whether it was intraoperative or postprocedural. This
 CRC Assessment - Mock I
was postprocedural. Look in the in the ICD-10-CM Alphabetic Index for
Stroke/postprocedural/following other surgery referring you to I97.821. The Tabular List for
subcategory I97.8 indicates to use an additional code, if applicable, to further specify the
disorder. We have not been given further information such the location of the infarct, so no
other code is required.

19. What is/are the correct code(s) for a nursing home patient with severe dementia often caught
wandering off from the floor?
A. F03.91, Z91.83
B. F02.81, Z91.83
C. F03.90, Z91.83
D. Z91.83

View Rationale
In the ICD-10-CM Alphabetic Index look for Dementia/with behavioral disturbance. The
behavioral disturbance is the wandering. There is an instructional note under code Z91.83
indicates to code first underlying disorder.

20. Patient presents to OB for routine obstetric care. The nurse takes the patient’s blood pressure
and it reads 140/80. The physician sees the patient and documents the following in the
assessment and plan: “A/P: Hypertension, Transient, Check BP at home daily and return to clinic
in two days for nurse BP check”. Assign the correct ICD-10-CM code(s).
A. I10
B. R03.0
C. O10.919, Z3A.00
D. O13.9, Z3A.00

View Rationale
ICD-10-CM guideline I.C.9.a.7, indicates to assign a code from category O13 for transient
hypertension in pregnancy. The trimester and the weeks of gestation are not documented
resulting in use of unspecified codes.

21. Which of the following is NOT true?

A. Conditions listed on the problem list for a diabetic patient are coded as complications of the
diabetes.
B. If documentation does not state, the type of diabetes but indicates the patient uses insulin
report Type 2 diabetes code (E11.-).
C. Documentation that indicates a cause and effect relationship includes “due to,” “caused by,”
“with” and “secondary to.”
 CRC Assessment - Mock I
D. A causal relationship is assumed between diabetes and a complication when the term “with”
links the two together in the Alphabetic Index.

View Rationale
Conditions listed on the problem list are not coded as complications of the diabetes unless the
documentation supports the causal relationship.

22. What is the correct ICD-10-CM code for an uncertain gastrointestinal stromal tumor?
A. C49.4
B. C26.9
C. D48.1
D. D37.8

View Rationale
In the Alphabetic Index look for Tumor/stromal/gastrointestinal/uncertain behavior. Coders are
referred to D48.1.
23. A 66-year-old male patient with AIDS presents with new onset of shortness of breath. Tests
confirm the patient has pneumocystis carinii pneumonia. Select the appropriate diagnosis
code(s).
A. B59
B. B59, B20, R06.02
C. B20, B59
D. B20

View Rationale
The Official ICD-10-CM guideline I.C.1.a.2., indicates if a patient is admitted with an HIV-related
condition you first sequence B20 followed the code for the HIV-related condition. Shortness of
breath is a symptom of the pneumonia and not reported (ICD-10-CM guideline I.B.5).

24. S. Patient returns for follow up of her osteoporosis on anabolic therapy. She continues on
TERIPARATIDE shots daily and will complete her two years of that in August of this year. She
remains on VITAMIN D reduced to once a week 50,000 units. O: Vital signs are recorded. Despite
the above, she seems to be in good spirits today. Moderate kyphotic posture of the thoracic
spine noted. Lungs clear, cardiac exam regular rate and rhythm. Vitamin D level was over 40 last
time, having been undetectable in March. A: Postmenopausal osteoporosis exacerbated by
Vitamin D deficiency and suspected calcium malabsorption. Seems to be stable at this point in
that regard. P: 1. CBC, comprehensive metabolic panel. May be able to back off further on her
VITAMIN D. 2. When she returns next time in September will obtain DXA to compare with the
one she had a year ago. 3. She will complete her two years of TERIPARATIDE injections in August.
Select the diagnosis code(s).
 CRC Assessment - Mock I
A. M81.0
B. M81.0, E55.9
C. M81.0, E55.9, K90.89
D. M81.8, K90.89

View Rationale
The patient is diagnosed with postmenopausal osteoporosis. In the ICD-10-CM Alphabetic Index,
look for Osteoporosis/postmenopausal. Next report the Vitamin D deficiency. Look for
Deficiency/vitamin/D. A code for calcium malabsorption is not reported because the condition is
documented as suspected. Verify code selection in the Tabular List.

25. Sex: Female. Age: 69 years old. Nurse Note: Patient presents today with wanting to get back on
track. Also wants to go back on Synthroid, also wants to lose weight, otherwise no other
complaints.
Subjective CC: Stopped meds, feels tired, gained 20 pounds in a year.
HPI: above
ROS: Constitution: Reports weight change, but denies chills, fatigue and fever, tired. Eyes: Denies
visual disturbance. Cardiovascular: Denies chest pain and palpitations. Respiratory: Denies
cough, dyspnea and wheezing. Gastrointestinal: Denies constipation, diarrhea, dyspepsia,
dysphagia, hematochezia, melena, nausea and vomiting. Genitourinary: Denies dysuria,
frequency, hematuria, incontinence, nocturia and urgency. Musculoskeletal: Denies arthralgia
and myalgia. Skin: Denies rashes, no pain or bleed. Neuro: Denies neurologic symptoms. Psych:
Denies symptoms other than stated above. Stress caring for others. Current Meds: None.
Allergies: NKDA
PMH: Mammogram: (5/2008). Pelvic/Pap Exam: (5/2008). Blood Test: (5/2007). Bone Density
Test: never within 10 years. Dental: (4/2008). Eye Exam: (2/2007) Reviewed and updated. Family
History: Father: Hypertension; MI. Mother: Hypertension. Reviewed and updated.
Social History: Highest level of education completed is 12th grade. Marital status: Married. Lives
with spouse and grandson. Household pets include fish. Personal Habits: Cigarette Use: None.
Alcohol: Rare. Daily Caffeine: Consumes on average three cups of coffee per day. Reviewed and
updated.

Objective BP: 142/84 P: 68 T: 98.5 RR: 16 HT: 65" 5'5" WT: 2241b BMI: 37.3 LMP:
HYSTERECTOMY Exam: Constitution: Appears overweight. No signs of apparent distress present.
Neck: Palpation reveals no lymphadenopathy. No masses appreciated. Thyroid exhibits no
thyromegaly. No JVD. Respiratory: Respiration rate is normal. No wheezing. Auscultate good
airflow. Lungs are clear bilaterally. Cardiovascular: Rate is regular. Rhythm is regular. No heart
murmur appreciated. Extremities: No clubbing, cyanosis or edema. Abdomen: Bowel sounds are
normoactive. Palpation of the abdomen reveals no CVA tenderness. Muscle guarding, rebound
 CRC Assessment - Mock I
tenderness or tenderness. No abdominal masses. No palpable hepatosplenomegaly. Skin: Skin is
warm and dry.

Assessment #1: Hypothyroidism Plan for #1: Lab: Comp Metabolic Panel I/P TSH (Ultra-Sensitive)
Urinalysis Routine T4
Assessment #2: Obesity Plan for #2: Follow-up: Fasting labs then return one month to review and
do annual GYN then. At that visit, will arrange biopsy face/temple lesion, order mammogram and
she's considering screen c scope.
A. E03.9, E66.9
B. E03.9, E66.01, Z68.37
C. E03.9, E66.9, Z68.37
D. I10, I25.2, E03.9, E66.9

View Rationale
The patient is diagnosed with hypothyroidism and obesity. As documented the obesity is
unspecified. A code is reported for the BMI that was documented in the exam. The patient has a
family history of hypertension and MI. It is not the patient's conditions.

26. ANESTHESIA: General. PREOPERATIVE DIAGNOSIS: Diabetic ulcer right upper thigh with exposed
fat layer. POSTOPERATIVE DIAGNOSIS: Diabetic ulcer right upper thigh with exposed fat layer.
PROCEDURE: Debridement of ulcer, right upper thigh. INDICATIONS: This 76-year-old female has
developed an ulcer on the upper right thigh. She is here for debridement. The patient has a
current history of type 2 diabetes and hypertension. DESCRIPTION OF PROCEDURE: Under
general laryngeal mask anesthesia, the patient was placed in left lateral decubitus position and
the right lateral thigh and hip was appropriately prepped and draped. Sharp Mayo scissor
dissection was used to debride skin, subcutaneous tissue and excise the edges of the wound
down to the tensor fascia. Some undermining with fat necrosis was also debrided. It was covered
with gauze and a dressing. She tolerated the procedure well. Select the diagnosis code(s).
A. L97.112
B. L97.102, E11.9
C. L97.112, E11.622, I10
D. L97.112, E11.9, I10

View Rationale
The indication for the procedure is a skin ulcer with fat layer exposed. The patient also has two
chronic diseases, diabetes type 2 and hypertension, which are reported. There is causal
relationship between diabetes and the skin ulcer. Look in the ICD-10-CM Alphabetic Index for
Diabetes/with/skin ulcer NEC referring you to E11.622
 CRC Assessment - Mock I
27. Patient Name: JS Male. Physician: HO, MD Report Type: HOSPITAL CONSULTATION REPORT
Admit Date: 4/26/XX. Discharge Date: 4/30/XX. DATE OF INPATIENT CONSULTATION: 4/27/XX.
CHIEF COMPLAINT: Pulmonary emboli. HISTORY OF PRESENT ILLNESS: I am seeing this patient
today in Consultation regarding the recurrent pulmonary emboli. The patient is a 42 year-old
gentleman who has a history of recurrent pulmonary emboli. He had his first pulmonary emboli
in 05/20XX. The patient was on Coumadin when he was involved in an accident on 10/01/XX. He
sustained second-degree burns to more than 50 percent of his body. The patient was
hospitalized for several months. He did not have any skin grafts. There was a question of him
developing a heparin antibody during that admission. The patient has been on Coumadin for the
past three months. Over the last several days, he has developed some pain behind his left knee
and some chest discomfort. He brought himself to the emergency department where an
ultrasound of his leg revealed a clot in the left thigh, a CT angiogram revealed bilateral
pulmonary emboli. He has been given Coumadin 10 milligrams and Arixtra 7.5 milligrams SubQ
daily. At this time, he is feeling well. He is not complaining of any leg pain or chest pain. He
denies any hemoptysis. REVIEW OF SYSTEMS: Significant for the leg pain and chest discomfort.
The further review of systems including the general, eyes, ears and throat, cardiac, respiratory,
gastrointestinal, genitourinary, musculoskeletal, neurological, hematological and emotional
systems is otherwise negative, except for that stated above. ALLERGIES: The patient has a
possible allergy to HEPARIN with a possible heparin antibody. MEDICATIONS: The patient is not
on any medications at this time. PAST MEDICAL HISTORY: Significant only for his previous
pulmonary emboli and his severe second-degree burn to more than 70 percent of his body.
SURGICAL HISTORY: The patient has no prior surgical history. SOCIAL HISTORY: The patient is
single, never married. He does not smoke tobacco or drink alcohol. He has his own consulting
firm. FAMILY HISTORY: The patient states there is no family history of blood clots. PHYSICAL
EXAMINATION: His BP is 133/68, pulse 89, respirations 16, temperature 96.5. The patient is a
well-nourished, well-developed white male, in no acute distress, consistent with his stated age of
42. The HEENT examination reveals no oral lesions, no oropharyngeal lesions, no neck masses,
no thyromegaly. Heart examination reveals a regular rate and rhythm without murmur or gallop.
There are no palpable heaves or thrills. Chest examination is clear to auscultation. There are no
wheezes or crackles heard. Abdominal examination reveals positive bowel sounds. The abdomen
is soft and non-tender. There is no palpable hepatosplenomegaly, no palpable masses. Lymphatic
examination reveals no cervical, axillary, inguinal or epi-trochlear lymph nodes palpable. Skin
examination reveals the scars from his burns. There are no nodules or rashes seen. No nodules
palpated. Neurologically, his deep tendon reflexes are plus 2/4 in the upper and lower
extremities. Motor and sensory are intact. Extremity examination reveals full range of motion in
the upper and lower extremities, without cyanosis or edema. The patient is alert and oriented
times three and has a normal affect. PERTINENT LABORATORY VALUES: Include hemoglobin of
14.0, WBC of 7.7, platelets of 134,000. Sodium was 139, potassium 4.0, chloride 103, bicarb 29,
BUN of 20, creatinine 1.12. The protime is 11.5 seconds and the activated partial thromboplastin
time is 30 seconds. CT angiogram reveals bilateral pulmonary emboli. Doppler ultrasound reveals
 CRC Assessment - Mock I
a clot in the left lower extremity. IMPRESSION: 1. Deep venous thrombosis with bilateral
pulmonary emboli with a history of a previous pulmonary embolus in 05/2007. 2. Possible
heparin antibodies while hospitalized. 3. History of second-degree burns. PLAN: 1 Arixtra 10
milligrams SubQ daily, especially given his possible history of heparin antibody. 2.The patient
does require very large doses of Coumadin. He was on 17.5 milligrams alternating with 15
milligrams before he was removed from Coumadin. We will dose him at 17.5 milligrams today. 3.
CBC and protime in the morning. 4. The patient will require lifelong anticoagulation as this is his
second pulmonary emboli. I appreciate this opportunity to participate in this patient's care.
Please do not hesitate to contact me if you have any further question regarding my care of the
patient.
Select the diagnosis code(s).
A. I26.99
B. I82.402, T82.818A
C. I26.99, I82.402, Z86.718, Z79.01
D. I26.99, T50.995A, I82.402, Z79.01, T45.525A

View Rationale
The patient is diagnosed with bilateral pulmonary emboli and deep vein thrombosis. He also has
a history of a previous pulmonary embolism and use of Coumadin. From the ICD-10-CM
Alphabetic Index, look for Embolism/pulmonary. You are referred to I26.99. From the Alphabetic
Index, look for Thrombosis/vein/deep/lower extremity/. You are referred to I82.40-. This code
requires a 6th character to identify laterality. The correct code is I82.402. From the Alphabetic
Index, look for History/personal (of)/embolism/pulmonary. You are referred to Z86.718. From
the Alphabetic Index, look for Long-term (current) (prophylactic) drug therapy (use
of)/anticoagulants. You are referred to Z79.01. Refer to all the codes in the Tabular List to verify
the code descriptions.

28. 01/01/XX SUBJECTIVE: CC: This 43 year-old Caucasian male is here today for a follow-up visit. The
patient's past medical history is notable for diabetes, hypertension, and mixed hyperlipidemia.
HPI: Patient presents with type 2 diabetes. Specifically, this is type 2, non-insulin requiring
diabetes without complications. Compliance with treatment has been good. In regard to the
essential hypertension, benign, this was first diagnosed several years ago. He is tolerating the
medication well without side effects. Concerning mixed hyperlipidemia, compliance with
treatment has been good; he takes his medication as directed, maintains his low cholesterol diet,
follows up as directed, and maintains his exercise regimen. ROS: CONSTITUTIONAL: Negative for
chills, fatigue, fever and night sweats. CARDIOVASCULAR: Negative for chest pain, claudication,
dizziness, palpitations and pedal edema. RESPIRATORY: Negative for dyspnea, hemoptysis and
pleuritic chest pain. GASTROINTESTINAL: Negative for abdominal pain, dysphagia, constipation,
diarrhea, heartburn, nausea and vomiting. Past Medical, Family, Social History (PFSH): Past
 CRC Assessment - Mock I
Medical History: Coronary Artery Disease Hyperlipidemia Hypertension Surgical History:
Appendectomy: at age 27; Tobacco/Alcohol/Supplements: Tobacco: Currently smokes more than
three packs per day. An extensive list of the risks of smoking (and reasons to quit) have been
reviewed with the patient; these include increased risk of cancer and increased risk of heart
attack. Is unwilling to consider quitting tobacco at this time. Alcohol: Patient has a past history of
alcoholism. His last drink was over 10 years ago. Substance Abuse History: NEGATIVE Allergies:
Nitroglycerin: chest pain Aspirin: Current Medications: Zocor 80mg Tablet 1 tab(s) po hs, Altace
10mg Capsules 1 cap(s) po qd, Insulin, Lispro (Analog rDNA) 100units/1ml Pen System,
Disposable 25-30 U Sq AC meals, Norvasc 10mg Tablet 1 tab(s) po qd, Tenormin 100mg Tablet 1
tab(s) po qd, Heal with Steel Health Center. OBJECTIVE: Vitals: BP: 118/78 mm Hg; P: 46 bpm
(regularly irregular); R: 12 bpm. Exams: GENERAL: moderately obese; well groomed; anxious;
diaphoretic. EYES: lids and lacrimal system are normal in appearance; conjunctiva and cornea are
normal. ENT: Oropharynx: normal dentition and gingiva; normal palate; normal oral mucosa.
NECK: thyroid is non-palpable; jugular veins are normal. RESPIRATORY: normal respiratory rate
and pattern with no distress; normal breath sounds with no rales, rhonchi, wheezes or rubs.
CARDIOVASCULAR: normal rate and rhythm without murmurs; normal S1 and S2 heart sounds
with no S3, S4, rubs, or clicks; carotids: 2+ amplitude, no bruits; abdominal aorta appears to be of
normal size and is without bruits; femoral pulses: 2+ amplitude, no bruits; 2+ pedal pulses; no
edema or significant varicosities. GASTROINTESTINAL: no masses or tenderness; no
organomegaly. SKIN: no clubbing, cyanosis, ulcerations, or vascular skin lesions.
MUSCULOSKELETAL: spine: no scoliosis, kyphosis, or other abnormal spinal curvatures; normal
gait; grossly normal tone and muscle strength. NEUROLOGIC/PSYCHIATRIC: mental status: alert
and oriented x 3; Mood/Affect: anxious. ASSESSMENT: E11.9 Type 2 diabetes, I10 Essential
hypertension, E78.2 Mixed hyperlipidemia. PLAN: Type 2 diabetes LAB ORDERS: hgbA1C, fasting
lipid profile, TSH, urinalysis, urine micro-albumin. MEDICATIONS: Over-the-counter medications
recommended include aspirin. RECOMMENDATIONS: instructed in use of glucometer (check
glucose before each meal), a daily aspirin, adherence to a 2200 calorie ADA diet, HgbA1C level
checked quarterly, urine micro albumin test yearly, daily foot self-inspection, yearly dental
exams, annual eye exams, need for yearly flu shots, and pneumovax vaccination every five years.
FOLLOW-UP: Schedule a follow-up visit in three months. Orders: Collection of venous blood by
venipuncture Handling and/or conveyance of specimen for transfer from the physician's office to
a laboratory Glycated hemoglobin Urinalysis, automated, without microscopy Dilated Eye Exam
Lipid panel (total cholesterol, HDL, triglycerides) Thyroid stimulating hormone (TSH) Urine micro
albumin, quantitative Other Orders: Collection of venous blood by venipuncture today
Electrolyte panel (Na, K, Cl, CO2) Electrocardiogram, routine with at least 12 leads; with
interpretation and report Electronically Signed: M, Jones, M.D.

After review of the record provided, what discrepancy would a coder identify?
A. The provider did not properly sign the documentation
B. The provider does not document an adequate status of the patient's chronic illnesses
 CRC Assessment - Mock I
C. There is conflicting information regarding whether the patient is being treated with insulin
D. There are no discrepancies in the documentation

View Rationale
In the HPI the provider documents the patient has non-insulin requiring diabetes without
complications. In the medication list, it is documented that the patient is being treated with
insulin. Prior to reporting Z79.4, query the provider.

29. 01/01/XX S: Here to follow up on her atrial fibrillation. No new problems. Feeling well.
Medications are reviewed and consistent with the medications that she was discharged home. O:
BP: 110/64. Pulse is regular at 72. Neck is supple. Chest is clear. Cardiac normal sinus rhythm. A:
Chronic atrial fibrillation, currently stable. P: 1. Prothrombin time. 2. Follow up with myself in 1
month, sooner as needed if has any other problems in the meantime. Will also check a creatinine
and potassium today as well. Electronically Signed: M, Jones, M.D. Based on the review of the
medical record, what discrepancy would a coder identify?
A. The list of medications was not documented which would affect coding
B. The provider did not document the chief complaint
C. The provider did not properly sign the documentation
D. There are no discrepancies with this documentation

View Rationale
Based on the patient's diagnosis of AF and the ordering of PT, it is likely the patient is being
treated with Coumadin. Without the medication list available to validate, a code for long term
use of anticoagulants cannot be reported.

30. You are reviewing provider documentation for risk adjusted diagnoses so you can provide
feedback to the provider. You are looking to validate diabetic neuropathy using the provider’s
progress note from an office visit earlier in the year. The provider documented “DM with
neuropathy controlled, continue current meds" in the body of the progress note. You should
inform the provider:
A. The diagnostic statement supports the coding of a type 1 diabetic manifestation
B. The diagnostic statement does identify the causal relationship
C. The provider must indicate the site of the neuropathy for proper coding
D. The provider must indicate the type of diabetes in order for a code to be selected

View Rationale
The word “with” should be interpreted to mean “associated with” or “due to” when it appears in
a code title, the Alphabetic Index, or an instructional note in the Tabular List. The classification
presumes a causal relationship between the two conditions linked by these terms in the
Alphabetic Index or Tabular List. These conditions should be coded as related even in the
 CRC Assessment - Mock I
absence of provider documentation explicitly linking them, unless the documentation clearly
states the conditions are unrelated. For conditions not specifically linked by these relational
terms in the classification, provider documentation must link the conditions in order to code
them as related. The word “with” in the Alphabetic Index is sequenced immediately following
the main term, not in alphabetical order

31. What is an effective way to review documentation deficiencies with a provider?

A. Have the provider read the coding guidelines prior to your training session
B. Provide the provider examples of his/her documentation and suggested improvements
C. Try to catch the provider between patients so the schedule is not interrupted
D. Start with a summary of your credentials to gain the respect of the provider

View Rationale
Providers learn best when provided examples of their own documentation with suggestions for
improvement.

32. What information is usually documented by the provider during the patient history?
I. Patient's response to current treatment
II. The reason for the encounter
III. The provider's observation of the patient's mood
IV. The patient's use of tobacco
A. I and IV
B. I and III
C. I, II, and IV
D. I, II, III and IV

View Rationale
The history includes the chief complaint, HPI, ROS and PFSH. The provider's observations of the
patient is a component of the physical exam.

33. How are resolved conditions coded?

A. Resolved conditions are reported as current if included on the problem list
B. Resolved conditions are reported as history of when appropriate
C. Resolved conditions are reported as current as a secondary diagnosis, never a first-listed
D. Resolved conditions are reported for one year after onset

View Rationale
Resolved conditions are reported using history of codes when appropriate.

34. Which of the following statements are TRUE regarding the prostate?
 CRC Assessment - Mock I
I. It is part of the male reproductive system
II. It helps make and store seminal fluid
III. It makes testosterone
IV. It is part of the female urinary system
A. I
B. I and III
C. I and IV
D. I and II

View Rationale
The prostate gland makes fluid that forms part of semen. The prostate lies just below the
bladder in front of the rectum in male patients. It surrounds the urethra (the tube that carries
urine and semen through the penis and out of the body).

35. Which organ(s) is/are contained in the thoracic cavity?

I. Heart
II. Stomach
III. Lungs
IV. Hypothalamus
A. I, III, and IV
B. I and III
C. I
D. I, II, and III

View Rationale
Thoracic cavity contains the heart and lungs

36. Which of the following is FALSE regarding Atherosclerosis?

A. Can affect the coronary (heart) arteries
B. Affects the veins
C. Is promoted by LDL (low density lipoprotein – bad cholesterol) and protected by HDL (high
density lipoprotein – good cholesterol)
D. Is a chronic disease that can remain asymptomatic for decades?

View Rationale
Atherosclerosis, or hardening of the arteries, is a condition in which plaque builds up inside the
arteries. Plaque is made of cholesterol, fatty substances, cellular waste products, calcium and
fibrin (a clotting material in the blood). Veins are not affected by atherosclerosis.
 CRC Assessment - Mock I
37. Predictive models are used to identify people who are at high risk of chronic illnesses having
higher medical claims; what can a provider do with this information to decrease the medical
costs? I. Develop disease management education programs II. Involve clinical staff to help with
coordination of care III. Refer the patients with chronic illnesses to be treated by another
provider IV. Determine the return on investment when referring to a specialist for chronic
illnesses
A. I and II
B. III and IV
C. I and III
D. I, II, III, and IV

View Rationale
Predictive modeling can help providers identify patients with chronic illnesses who would benefit
from disease management education and coordination of care.

38. If you were using a predictive model and the results were: • The member had a DME claim for
oxygen. • The member had an Rx Claim for a bronchodilator. • The member had a medical claim
which included a PFT. Which diagnosis would you predict this member has?
A. Hypertension
B. Emphysema
C. CHF
D. Diabetes

View Rationale
Patient's with emphysema are treated with medications such as bronchodilators and inhaled
steroids. Treatments also include pulmonary rehab, nutrition therapy and supplemental oxygen.
Typical tests run for emphysema include chest X-rays, lab tests and lung function tests.

39. Data mining is performed to:

A. Identify data that might be related to patient risk scores
B. Look for opportunities for clinical staff incentives
C. Make sure that low performing providers are penalized for poor outcomes
D. To evaluate the effectiveness of compliance plans

View Rationale
Data mining is performed to evaluate all aspects known on each member/patient to be sure that
all potential risk is identified so that all necessary health care may be potentially planned.

40. Which code set is used for HCC coding?

I. CPT
 CRC Assessment - Mock I
II. HCPCS Level II
III. ICD-10-CM
IV. ICD-10-PCS
A. III
B. III and IV
C. I and III
D. I, II, III and IV

View Rationale
All risk adjustment programs utilize diagnosis codes to “adjust” potential risks for patients. ICD-
10-CM codes are reported for dates of service 10/1/2015 and forward.

41. Which statement is TRUE regarding hierarchies?

A. Used exclusively by CMS for Medicare Advantage plans
B. Mandated to be used for all Medicaid payment models
C. Utilized by some private payers
D. All the above

View Rationale
Hierarchies are used in Medicare, some Medicaid models and commercial models for payments.

42. What does CMS' Star Ratings program monitor?

A. Performance of Medicare Advantage plans
B. Fraud and abuse
C. Adherence to state scope of practice
D. Performance of Medicare providers

View Rationale
Medicare uses a Star Rating System to measure how well Medicare Advantage and prescription
drug (Part D) plans perform. Medicare scores how well plans did in several categories, including
quality of care and customer service.

43. Which risk adjustment model is used by Medicaid programs?

A. HCC
B. CDPS
C. ZIPC
D. MIPS

View Rationale
Medicaid uses the Chronic Illness and Disability Payment System (CDPS)
 CRC Assessment - Mock I
44. Using the information provided below, which statement is TRUE:

A. When a patient is diagnosed with hepatorenal syndrome and biliary cirrhosis, HCC28 is used
B. When a patient is diagnosed with chronic hepatitis and hepatopulmonary syndrome, HCC27
is used
C. When a patient is diagnosed with alcohol liver damage and biliary cirrhosis, HCC29 is used
D. When a patient is diagnosed with autoimmune hepatitis and cirrhosis of the liver, HCC29 is
used

View Rationale
Payment will always be associated with the HCC in column one, if a HCC in column three also
occurs during the same collection period.

45. CC: Patient is here to discuss catapress Rx and also patient has a nonproductive cough, nasal
drainage and sinus congestion/pressure. Symptoms for a few days.
Subjective
HPI: She is back on her Catapress patch and doing well
Earwax, used Debrox Cough, wheezing and nasal congestion for a few days
ROS:
 CRC Assessment - Mock I
Constitutional: Denies symptoms other than stated above.
ENMT: Denies ENMT symptoms other than stated above.
Cardiovascular: Denies chest pain, edema and palpitations.
Respiratory: Denies symptoms other than stated above.
Gastrointestinal: Denies gastrointestinal symptoms.
Genitourinary: Denies urinary symptoms.
Psych: Stable w/o acute changes.
Current Meds: Lancets, Onetouch Test Strips, Citalopram Hydrobromide 40 mg, Simvastatin 40
mg, Glipizide 10 mg, Metformin HCL 1000 mg, Benztropine Mesylate 1 mg, One Touch Glucose
Monitor, Catapres-TTS- 1 0.1 mg/24hr
Allergies: NKDA
Social History: Marital status: Single. Lives in an assisted living facility. Personal Habits: Cigarette
Use: None. Alcohol: Denies alcohol use. Drug Use: Denies Drug Use. Daily Caffeine: Consumes on
average 4 sodas per day. Reviewed, no changes.

Objective
BP: 124/72. Pulse: 88. T: 97.7. RR: 20. HT: 63" 5'3", WT: 2091b
Constitutional: No signs of apparent distress present.
ENMT: Tympanic membranes: not visible due to impacted cerumen. Congestion of the nasal
mucosae. Posterior pharynx is normal.
Neck: Palpation reveals no lymphadenopathy. Thyroid exhibits no thyromegaly. No JVD.
Respiratory: Respiration rate is normal. Auscultate good airflow. Mild expiratory wheezes
appreciated over the lungs bilaterally.
CV: Rate is regular. Rhythm is regular. No heart murmur appreciated.
Extremities: No clubbing, cyanosis or edema.
Abdomen: Abdomen Is Benign.
Musculoskeletal: Walks with a normal gait.
Skin: Skin is warm and dry.
Psych: Patient's attitude is cooperative. No apparent anxiety, depression, or agitation. Patient
shows good eye contact.

Patient had increased cough response with attempted irrigation which subsided immediately.

Assessment #1: J06.9 URI Upper Respiratory Infections Acute Unspecified Sites
Plan for #1: Med Current: Zithromax Z-Pak 250 mg as directed
Proventil HFA108 mcg/act 2 puff q 4h pm
Assessment #2: E11.9 Diabetes Mellitus W/O Complication Type II or Unspecified Controlled
Plan for #2: Med Current: Glipizide 10 mg 1 po bid
Metformin HCL 1000 mg 1 po bid
Lab: Diabetic Panel
 CRC Assessment - Mock I
Follow-up: after lab work
Assessment #3: H61.23 Impacted Cerumen
Plan for #3: Referral: ENT referral
After the coder reviews the documentation, which codes are recommended to be reported that
will affect the HCC risk adjustment value?

I. J06.9
II. E11.9
III. H61.23

A. I, II and III
B. I, III
C. II
D. II and III

View Rationale
The only diagnosis the patient has that affects the HCC risk adjustment value is E11.9. Typically,
acute illnesses are not relevant for HCC risk adjustment coding. Examples of these conditions
include, URI, UTI, otitis media, impacted cerumen, cold, viral syndrome, and sinusitis.

46. Which of the following general statements is NOT TRUE regarding Risk Adjustment practices and
Quality?
A. Health Care Plans with Four Star Quality Ratings can still improve their score because the
highest rating is a Five
B. From a data discovery perspective, they are essentially inseparable
C. Data Collection for HEDIS and Star Ratings Programs can be achieved during their prospective
member evaluations
D. Quality Measures like Star Ratings and HEDIS have no correlation with the medical record
information that is collected in support of risk adjustment

View Rationale
Medicare recently began a Stars Ratings program, which will monitor quality of care endeavors
by carriers. Medicare recently began a Stars Ratings program, which will monitor quality of care
endeavors by carriers. While plans not obtaining four stars or better may be penalized, plans that
achieve higher quality ratings can achieve higher payments. CMS is also highlighting plans that
have achieved an overall quality rating of five star with a High Performer or gold star icon so that
patients with Medicare can easily find high quality plans.
47. Which statement is coded as a history of condition?
 CRC Assessment - Mock I
A. Patient presents with a history of colon cancer. He is currently getting chemotherapy
administered by his oncologist.
B. Patient has a history of osteoarthritis currently taking celebrex.
C. Patient presents with CHF complaining of shortness of breath.
D. Patient presents for a follow up of hypertension. She has a history of breast cancer.

View Rationale
A notation indicating “history of cancer,” without an indication of current cancer treatment is
codes as a history of cancer.

48. Which medical record(s) can be submitted for HCC validation?

I. Physician office progress note
II. Outpatient Hospital
III. Critical Access Hospital
IV. Laboratory test results
V. Diagnostic X-rays
A. I, II, and III
B. IV
C. I, II, III, and IV
D. I, II, III, IV, and V

View Rationale
Laboratory reports and radiology reports cannot be submitted for HCC validation.

49. Which of the following elements would NOT be taken into consideration for risk adjustment?
A. The number of years a patient has been covered under Medicare Advantage
B. Gender
C. Procedure codes
D. Place of service

View Rationale
All risk adjustment programs utilize diagnosis codes to “adjust” potential risks for patients, there
are additional elements taken into consideration, including:
Age
Gender
Socioeconomic status
Insurance status (Medicare, Medicaid, dual-eligible, etc.)
Procedure codes
Place of service codes
 CRC Assessment - Mock I
Special patient-specific conditions (i.e. such as being enrolled in hospice or being an ESRD (end
stage renal disease) patient), etc.
50. Which provider is NOT an approved provider for diagnosis code capture under the HCC model?
A. LCSW
B. CRNA
C. Podiatrist
D. Registered nurse

View Rationale
Nurses are not approved providers unless they are a clinical nurse specialist, CRNA or NP.

51. How many charts can be submitted to CMS to validate an HCC?

A. One
B. Three
C. Two
D. Five

View Rationale
RADV to permits 5 medical records to be submitted for each HCC to be validated.

52. The results of a RADV audit are extrapolated across all members of the plan that was audited.
What does this mean?
A. Financial penalties will be limited to each specific member
B. Financial penalties will be averaged over the plan membership
C. Financial penalties will be imposed across the plan membership
D. Financial penalties will not be imposed until two years post audit

View Rationale
CMS has stated that HCC risk factors will be spread across all members in that plan. Example:
Member A had HCC22 to be validated, the value of that HCC is $2, it could not be validated. The
plan membership is 200 members; that one missed HCC cost the company $400 which CMS will
take back from the company.

53. Retrospective audits generally include finding additional diagnoses, CMS has stated that the
deletion of conditions needs to be part of these audits; why is it so hard for companies to follow
CMS directives?
I. There is a potential of loss of revenue
II. Billing compliance issues might come too light
III. All companies follow CMS directives
A. I and II
 CRC Assessment - Mock I
B. I
C. I and III
D. III

These audits can mandate that insurance companies repay CMS for past revenues which will
decrease the bottom line for the stockholders. Billing compliance issues might come into play
and a deeper dive might be warranted for specific provider offices which will cause abrasion with
the providers.

54. Which of the following would prevent a chart from being coded for Medicare risk adjustment?
A. Patient's DOB is not documented on the medical record
B. The patient presented for an acute condition
C. Medical record does not include the credentials of the treating provider
D. Date of service is past 90 days

CMS RAPS Participant Guide states that all documentation must be signed by the rendering
provider.
As stated in CMS’ 2008 Call Letter (available on the CMS web site at
http://www.cms.hhs.gov/PrescriptionDrugCovContra/Downloads/CallLetter.pdf):

For purposes of risk adjustment data submission and validation, the MA organizations must
ensure that the provider of service for face-to-face encounters is appropriately identified on
medical records via their signature and physician specialty credentials. (Examples of acceptable
physician signatures are handwritten signature or initials; signature stamp that complies with
state regulations; and electronic signature with authentication by the respective provider.) This
means that the credentials for the provider of services must be somewhere on the medical
record—either next to the provider’s signature or pre-printed with the provider’s name on the
group practice’s stationery. If the provider of services is not listed on the stationery, then the
credentials must be part of the signature for that provider. In these instances, the coders are
able to determine that the beneficiary was evaluated by a physician or an acceptable physician
specialty.

55. Which diagnoses can be coded from a medical record that states a member has the condition,
but does not contain supporting documentation?
I. COPD
II. Croup
III. A-Fib
IV. GERD
V. Parkinson’s disease
VI. MS
 CRC Assessment - Mock I
A. I and II
B. III, IV, V and VI
C. II, V and VI
D. I, III, V, and VI

The Official Guidelines for Coding and Reporting for Outpatient Services, state, "Chronic diseases
treated on an ongoing basis may be coded and reported as many times as the patient receives
treatment and care for the conditions(s). "Code all documented conditions that coexist at the
time of the encounter/visit and require or affect patient care treatment or management. Do not
code conditions that were previously treated and no longer exist." This information was
previously published in Coding Clinic, Fourth Quarter 2006, pages 236-240.

CMS RAPS Participant Manual: Co-existing conditions include chronic, ongoing conditions such as
diabetes (250.XX, HCCs 15-19), congestive heart failure (428.0, HCC 80), atrial fibrillation (427.31,
HCC 92), chronic obstructive and pulmonary disease (496, HCC 108). These diseases are generally
managed by ongoing medication and have the potential for acute exacerbations if not treated
properly, particularly if the patient is experiencing other acute conditions. It is likely that these
diagnoses would be part of a general overview of the patient’s health when treating co-existing
conditions for all but the most minor of medical encounters.

Co-existing conditions also include ongoing conditions such as multiple sclerosis (340, HCC 72),
hemiplegia (342.9X, HCC 100), rheumatoid arthritis (714.0, HCC 38) and Parkinson’s disease
(332.0, HCC 73). Although they may not impact every minor healthcare episode, it is likely that
patients having these conditions would have their general health status evaluated within a data
reporting period, and these diagnoses would be documented and reportable at that time.

56. RADV/IVA audit submissions typically require:

I. Provider printed name
II. Two patient identifiers
III. Provider's signature
IV. Must include specialist consultations
V. Must include coordination of care documentation by clinical staff
A. II and III
B. I, II and IV
C. I, III, IV, and V
D. I, II, III, IV, and V

RADV/IVA audits require the provider signature, credentials, and two patient ID’s such as patient
name and DOB. The printed provider name is only necessary when the signature is illegible and
there is a need to identify the provider.
 CRC Assessment - Mock I
57. Which statements are TRUE regarding retrospective audits?
I. Can be performed by internal employees
II. Can be performed by external consultants who sign a business agreement
III. Performed prior to data being submitted
IV. Performed after data was submitted

A. I and III
B. I and IV
C. I, II, and IV
D. III and IV

Both internal and external, onshore and offshore resources can perform retrospective chart
audits as long as a Business Agreement is signed by the external vendor. Retrospective audits are
performed following data submission to validate correct information was submitted and correct
any errors in data submitted.

58. If a medical record has conflicting information documented, how is it resolved?

A. The conflicting information is deleted, and new documentation is created.
B. The conflicting information is only corrected if the revision will result in a higher RAF.
C. The provider is queried and if you do not receive a response, delete the conflicting
information.
D. The provider is queried and an addendum/late entry is created to address the conflicting
information.

Whenever conflicting information is found in a record, the provider should be queried to

confirm the accurate information. The provider must document an addendum or late entry to
correct the information that was added to the record in error. You cannot delete information
from the medical record once the provider has authenticated the note.

59. Which statement(s) is/are TRUE?

I. If in the assessment section of an EMR record states "Diabetes- E11.29" then E11.29
should be coded on the claim.

II. If in the assessment section of an EMR record states "Diabetes with Diabetic Renal
Manifestations E11.29" then E11.29 should be coded on the claim.
III. If in the assessment section of an EMR record states "HTN I10 and DM E11.9" then
I10 and E11.9 should be coded on the claim.
IV. If in the assessment section of an EMR record states "COPD J44.9," "HTN I10," "GERD
K21.9," then J44.9, I10, and K21.9 should be coded on the claim.
 CRC Assessment - Mock I
A. I
B. I and II
C. I, II, and III
D. II, III, and IV

Coders should only report codes for the diagnoses that are written out.

60. A 45-year-old female patient presents to her primary care office complaining of crying and
overall unhappiness and sadness. The physician has seen this patient before for the same
condition and has diagnosed the patient with Major Depressive Disorder, Recurrent. Which of
the following ICD-10-CM codes is for Major Depressive Disorder, Recurrent?

A. F32.1
B. F33.9
C. F43.21
D. F32.9

ICD-10-CM Code F33.9, Major Depressive Disorder, Recurrent, unspecified is the correct answer.

61. Patient has chronic thrombosis and is on blood thinners to combat this. What ICD-10-CM code is
reported?
A. I82.409
B. Z86.718
C. I82.509
D. I82.91

Chronic thrombosis stated may be coded as current. Look in the ICD-10-CM Alphabetic Index for
Thrombosis/chronic referring you to I82.91.

62. Patient diagnosed with severe protein calorie malnutrition. What is the appropriate diagnosis
coding?
A. E41
B. E43
C. E46
D. E43, F50.00

E43 is the appropriate code as the severe malnutrition is designated as protein calorie.

63. A patient has the diagnosis of diabetes and gangrene and osteomyelitis; which of the following is
most TRUE?
 CRC Assessment - Mock I
A. Conditions listed with a diagnosis of diabetes or in a diabetic patient are usually
complications of the diabetes.
B. Diabetes can have a causal relationship to these conditions.
C. There is an assumption that the gangrene and osteomyelitis are due to secondary diabetes.
D. Gangrene is usually associated with type 1 diabetes.

According to the ICD-10-CM guideline: The word “with” should be interpreted to mean
“associated with” or “due to” when it appears in a code title, the Alphabetic Index, or an
instructional note in the Tabular List. The classification presumes a causal relationship between
the two conditions linked by these terms in the Alphabetic Index or Tabular List. These conditions
should be coded as related even in the absence of provider documentation explicitly linking
them, unless the documentation clearly states the conditions are unrelated. For conditions not
specifically linked by these relational terms in the classification, provider documentation must
link the conditions in order to code them as related.
The word “with” in the Alphabetic Index is sequenced immediately following the main term, not
in alphabetical order.

64. Which ICD-10-CM code(s) is/are reported when the provider diagnoses the patient with adult
attention deficit disorder (ADD)?
A. I25.10, F90.1
B. F81.0
C. F80.2
D. F90.9

From the ICD-10-CM Alphabetic Index look for Disorder/attention-deficit hyperactivity

(adolescent) (adult) F90.9. Verify code selection in the Tabular List.

65. Patient is being seen in the Outpatient clinic today for liver cancer of a transplanted liver. Select
the correct code(s).

A. C22.8
B. C22.8, Z94.4
C. T86.49, C80.2, C22.8
D. Z94.4, T86.49, C80.2, C22.8

According to the ICD-10-CM guideline, code complication of transplanted organ T86.4-, followed
by C80.2 then additional code for specific malignancy. Z94.4 is not coded as it is described in
T86.49.
 CRC Assessment - Mock I
66. What is the proper way to code coronary artery disease with no history of prior coronary artery
bypass?
A. I25.110
B. I25.10
C. I25.810
D. None of the above

If the medical record documentation shows no history of prior coronary artery bypass, select the
code for the native artery for CAD. If the documentation is unclear concerning prior bypass
surgery, query the physician

67. A patient is diagnosed with VAP. Select the diagnosis code(s).

A. J18.9, J95.851
B. J18.9, J95.850
C. J95.851
D. J95.850

In the Alphabetic Index, look for Pneumonia, ventilator associated. Verify code selection in the
Tabular List.

68. A 69-year-old male presents for follow up wound care for his bilateral pressure ulcers. Her right
heel shows a stage one ulcer and left heel shows a stage two ulcer with dark scabbing. The
provider orders Betadine painting for both ulcers. Assign the correct ICD-10-CM code(s) for this
visit.
A. L89.622
B. L89.899
C. L89.622, L89.611
D. L97.409

In ICD-10-CM pressure ulcers have been made into combination codes that include the location,
stage and laterality. As this patient had an ulcer on each foot both of the ulcers would be coded
using combination codes.

69. 89-year-old female with history of PE on Coumadin presents to cardiology for follow up. Two
years ago the patient had chest pain and a small pulmonary embolus in the right lower lobe was
found. The patient reports no symptoms and daughter says she is at baseline. The provider
documents “chronic pulmonary embolism, continue with Coumadin”. Select the diagnosis
code(s).
A. I26.09
B. I26.90
 CRC Assessment - Mock I
C. I27.1
D. I27.82, Z79.01

In the ICD-10-CM Alphabetic Index look for Embolism/pulmonary/chronic leads us to code

I27.82. Below I27.82 is a note saying to use additional code, if applicable for associated long term
(current) use of anticoagulants (Z79.01).

70. Patient is seen today for follow up of cirrhosis of the lung found on a thoracic CT.
A. R91.8
B. J84.10
C. J98.4
D. K74.69

In the ICD-10-CM Alphabetic Index, look for Cirrhosis/ lung.

71. Which of the following sentences below, best describes the attributes of an Absence seizure
(petit mal)?
A. Causes stiffening of the muscles and may cause the patient to fall to the ground.
B. Characterized by blank staring and subtle body movements that begin and end abruptly. It
may cause a brief loss of consciousness.
C. Associated with sudden brief jerks or twitches on both sides of the body.
D. Characterized by rhythmic, jerking muscle contractions that affect both sides of the body at
the same time.

Absence seizures (petit mal): characterized by blank staring and subtle body movements that
begin and end abruptly. It may cause a brief loss of consciousness.

72. A 67 year-old male is brought in by his daughter for evaluation of two wounds on the legs. The
provider exams the skin and finds two skin ulcers. One ulcer is on the right calf and the second
ulcer is on the left ankle. The provider orders the nurse to clean both ulcers and for the patient
to return in one week. Assign the correct ICD-10-CM code(s) for this visit.

A. L89.509, L89.899
B. L89.529, L89.899
C. L97.219, L97.329
D. L97.209, L97.309

The provider documented skin ulcers and not pressure ulcers so a code from category L97.219
and L97.329 are correct to report the skin ulcers of calf and ankle.
 CRC Assessment - Mock I
73. Under ICD-10-CM guidelines, a condition exists only when it is stated. Amputation Status are
codes that are frequently overlooked by providers. Which of the following Z code series is used
to indicate a lower limb amputation status?
A. Z99.-
B. Z89.-
C. Z21
D. Z93.-

Remember to document permanent diagnoses as often as they are assessed or treated, or when
they are a consideration in the patient’s care at a minimum, they must be documented annually
in order for CMS to consider them as an active condition.
Patients undergoing dialysis (Z99.2)

Lower limb amputation status (Z89.-)

Asymptomatic HIV status (Z21)

Ostomy (specify SITE) (Z93.-)
74. A 62-year-old female with a long-standing history of endocrine disease has noticed numbness in
her hands and feet. She sees her physician and after examination, her provider documents the
following:
A/P: Polyneuropathy, due to endocrine disease. Will get new labs and have patient return in four
weeks.
Assign the correct ICD-10-CM code(s) for this encounter.
A. E34.9
B. G63
C. G63, E34.9
D. E34.9, G63

Manifestations of endocrine disease are reported as additional diagnosis. See the instruction
note in the Tabular List under code G63 indicates to: Code first underlying disease, such as:
endocrine disease, except diabetes (E00-E07, E15-E16, E20-E34). In the ICD-10-CM Alphabetic
Index look for Polyneuropathy/ in (due to)/endocrine disease NEC E34.9 [G63]. Brackets used in
the Alphabetic Index identify manifestation codes. Refer to ICD-10-CM guideline I.A.7.

Nurse Note: Patient here today for a Check-up. Patient is still coughing, might still have fluid in
lungs. Patient’s daughter thinks patient has depression. Patient is having trouble sleeping.

75. SUBJECTIVE
 CRC Assessment - Mock I
CC: Issues as above. Wakes after few hours, some daytime naps. Sometimes gets up at night and
sits at table and falls asleep.

HPI: Gets frustrated with limitations by poor health and that depresses her.
ROS:
Constitutional: Denies chills, fatigue, fever and weight change. General health stated as fair.
Eyes: Some squinting so going for re exam.
CV: Denies chest pain and palpitations.
Respiratory: Denies dyspnea and wheezing. Some cough can't get phlegm up.
Gastrointestinal: Denies constipation, diarrhea, dyspepsia, dysphagia, hematochezia, melena,
nausea and vomiting.
Genitourinary: Urinary: denies dysuria, frequency, hematuria, incontinence, nocturia and
urgency.
Musculoskeletal: Denies arthralgia and myalgia.
Skin: Denies rashes.
Neuro: Denies neurologic symptoms.
Psych: Denies symptoms other than depression stated above.

Current Meds: Indomethacin 50 mg. Lanoxin 0.125 mg. Iron 325 mg. Lasix 40 ma Glyburide 2.5
mg, Xalatan 0.005 %. Synthroid 125 meg, Lisinopril 40 mg, Mag-Tab SR 84 mg. Ditropan 5 mg,
Vitamin B-6 50 mg.

Allergies: NKDA

PMH:
Medical Problems:
Hypertension, Atrial Fibrillation, Non-insulin Dependent Diabetes

SH: Marital status: widowed. Patient lives alone. There are no pets in the home. Advance
directive includes living will. Pt feels safe at home.
Personal Habits: Cigarette Use: Never Smoked Cigarettes. Alcohol: Rare consumes alcohol. Drug
Use: Denies Drug Use. Daily Caffeine: Consumes on average four cups of coffee per day.
Reviewed and updated.

Objective

BP: 142/70. Pulse: 72. T: 98.5. HT: 63" 5'3." WT: 134lb.

Exam:
 CRC Assessment - Mock I
Constitutional: Appears well. No signs of apparent distress present. Elderly, wrinkled w/o bruises.
Alert and converses. Slightly HOH.

ENMT: Auditory canals normal. Tympanic membranes are intact. Nasal mucosa is pink and moist.
Dentition is in good repair. Posterior pharynx shows no exudate, irritation or redness.
Neck: Palpation reveals no lymphadenopathy. No masses appreciated. Thyroid exhibits no
thyromegaly. No JVD.
Respiratory: Respiration rate is normal. No wheezing. Auscultate good airflow. Lungs are clear
bilaterally.
CV: Rhythm is irregularly irregular. Heart Murmur is still 3/6.
Extremities: No clubbing, cyanosis or edema.
Abdomen: Bowel sounds are normoactive. Palpation of the abdomen reveals no CVA tenderness,
muscle guarding, rebound tenderness or tenderness. No abdominal masses.
Musculoskeletal: Uses a cane to ambulate.
Skin: Skin is warm and dry.

Assessment #1: Atrial Fibrillation

Comments: On digoxin. Not on COUMADIN due to falls.

Plan for #1: Med Current: Lanoxin 0.125 mg 1 po q d

Assessment #2: Arthritis Climacteric Multiple Sites

Plan for #2: Med Current: Indomethacin 50 mg take as needed

Assessment #3: Congestive Heart Failure Unspecified

Comments: digoxin, no edema

Assessment #4: Insomnia

Assessment #5: Adjustment Disorder With Depression

Comments: situational, with sleep issues.

Med Current: Remeron 15 mg 1 po hs

Med New: Remeron 15 mg 1 po hs

 CRC Assessment - Mock I
Assessment #8: Cough

Comments: Has infiltrates vs CHF on CXR’s. CXR next week

Plan for #8: X-ray: Chest, 2 Views

A. I48.91, M13.89, I11.0, I50.9, G47.00, F43.21, R05, E11.9, Z79.84
B. I48.91, M12.9, I50.9, G47.00, F32.9, E11.9, Z79.4, R05
C. I48.91, I50.9, F43.21, G47.00, E11.9, Z79.84
D. I48.91, M12.9, I10, I50.9, G47.00

All current conditions are reported. To locate the codes, in the ICD-10-CM Alphabetic Index look
for Fibrillation/atrial; Arthritis/climacteric which states to see Arthritis/specified form/multiple
sites; Hypertension/heart/with heart failure (congestive); Failure/heart/congestive; Insomnia;
Disorder/adjustment/depressed mood; Cough; Diabetes/Type 2; Long-term (current) use
of/oral/antidiabetic. On the CRC exam, for each case code all current conditions unless
specifically asked to only report diagnoses under the HCC model. Verify all code selection in the
Tabular List.

76. 05/01/XX
EMERGENCY DEPARTMENT VISIT NOTE

Mode of arrival: The patient arrived via ambulance. The patient’s condition upon arrival was fair.

Time seen by clinician: 1558

CC. GI bleed

HPI: The patient is a 79 year-old female with COPD, CHF, dementia and malnutrition who was
transferred from a local nursing home for evaluation of GI bleed. The patient is a poor historian
and not able to provide any history. EMS and nursing home staff reported that the patient
started with diarrhea today, after having a "explosive" episode of diarrhea had a large amount of
bright red blood per rectum. This occurred twice prior to arrival. On arrival to emergency
department the patient was noted to have a bleeding external hemorrhoid A Rhino rocket was
used to apply pressure to this hemorrhoid and gauze packing with hemostasis. Approximately
one hour after initial evaluation the patient then had a more significant approximately 800 cc
bowel movement with dark blood and clots. After this large bloody bowel movement, the patient
did have transient hypotension which was responsive to IV fluid hydration. Once patient's family
arrived they report that the patient has had a prior history of similar GI bleed. Patient's findings
were reviewed with her family and her niece who is her designated medical proxy stated the
patient should not have any aggressive measurements, GI can be consulted urgently. No
 CRC Assessment - Mock I
emergent endoscopy. The patient appears to agree with this plan. The patient is on no current
NSAIDs or anticoagulation.

ROS: ALL OTHER SYSTEMS NEGATIVE

PMH: As noted, admitted here with aspiration pneumonia and pleural effusion in April.
ALLERGIES: NKDA
MEDICATIONS' Reviewed, see medication list.
SOCIAL HX: Remote history of smoking.
FAMILY HX Noncontributory
PE

VITAL SIGNS: NURSING RECORDS AND DEMOGRAPHICS REVIEWED

No respiratory distress.
HEENT' PERRLA, EOMI, TMs and Oropharynx within normal limits Airway patent.
NECK: Supple, non-tender, no lymphadenopathy. No JVD or carotid bruits.
LUNGS: Scattered rhonchi bilaterally, decreased sounds in the bases No rales
HEART: RRR, 2/6 diastolic murmur.
ABDOMEN: soft, non-tender, hypoactive bowel sounds, moderate distention. Rectal as
described.
EXTREMITIES No edema or cyanosis noted
NEUROLOGICAL: A0x2, CNs intact, motor functions within normal limits No focal deficits.
SKIN: No rash.
INTERVENTIONS: The patient was given gentle fluid hydration, IV Protonix’

Labs: The patient's CBC shows a normal white count of 8000, H&H is 11 and 34. Normal platelet
count of 257. Electrolytes show an elevated BUN of 72 and creatinine of 1 9, potassium 5 9"- C02
is 30. Anion gap of five. LFTs are unremarkable. Urinalysis negative

EKG: Normal sinus rhythm, LAFB and right bundle-branch block, no change when compared to
EKG from 04/20/2008. No acute Ischemia, interpretation by EDMD.

CXR: COPD, no acute infiltrate or free air.

19 00- pts care and results reviewed with family, will start blood transfusion when available
given significant GI bleed and intermittent hypotension. he is to remain DNR status. BP
responsive to fluids/blood products Rectal tube to monitor output/bleeding. Awaiting bleeding
scan
 CRC Assessment - Mock I
CONSULTS The patient's findings were reviewed with GI. Patient to have emergent endoscopy
otherwise will consult the morning Agrees with bleeding scan. Reviewed with PCP on call at
20:20

CRITICAL CARE TIME: 120 minutes

DIAGNOSES:

1 Lower GI bleed
2. Transient Hypotension
3. Bleeding external hemorrhoid.
DISPOSITION. The patient was admitted in guarded condition.

Select all current diagnosis codes.

A. K92.2, I95.9, K64.4
B. K92.2, R03.1, K64.4
C. K92.2, R03.1, K64.4, J44.9, I50.9, F03.90, E46
D. K92.2, I95.9, J44.9, I50.9, F03.91, E46, J91.8

All the current conditions are reported. To locate codes in the ICD-10-CM Alphabetic Index look
for Bleeding/gastrointestinal; Transient hypotension is not reported with I95.9. Look for
Low/blood pressure/reading referring you to R03.1; Hemorrhoid/external;
Disease/pulmonary/chronic; Failure/heart,/congestive; Dementia; Malnutrition. The pulmonary
effusion is not reported because it was treated during a previous admission. Verify all code
selections in the Tabular List.

Admission:
77. The patient is a 68 year-old white female patient. She is a known insulin dependent diabetic who
has had a history of having complications of diabetes including ulcers of both feet, eventually
resulting in amputation of left leg below the knee. Patient presents with infection on the bottom
of her right foot. This had become secondarily infected. She reported the pain as sharp and
jabbing and 7/10. She presented to the hospital essentially with cellulitis of her right ankle. Her
diabetes is out of control secondary to the infection with a level of 500 on admission. She was
placed in the hospital.

Social history is negative for tobacco and drugs. She does admit to occasional alcohol. Father
had diabetes. Mother had a brain tumor.
The patient admits to fevers and chills. She denies headaches, nausea, vomiting, diarrhea, or
urinary difficulty. She denies shortness of breath or chest pain. She has had no problems with
her eyesight and no problems with hearing. She denies any swelling in her axilla or groin.
 CRC Assessment - Mock I
BP is 150/84, P 84, RR 16, and T 98. Eyes, PERLA. TMs are clear. Heart is regular rate and
rhythm. Lungs are clear. Abdomen is soft and obese, with no tenderness. She has swelling in
the right foot secondary to osteomyelitis. The patient is oriented to person, place, and time.
Cranial nerves 2 thru 12 are intact.

Impression: Cellulitis of right ankle, Osteomyelitis of right foot, Insulin-dependent Type 2

diabetes mellitus.

Plan: Flagyl 500mg IV q 6 hours, insulin q 6 hours on a sliding scale, Percocet q 4 hours prn pain.
Bone scan ordered.

Select all current diagnosis codes.

A. L03.115, E10.9, M86.9
B. L03.115, E11.69, M86.9, Z89.512, Z79.4
C. L03.119, E11.9, M86.9
D. L03.119, E11.69, M90.871, Z89.512, Z79.4

Code all current conditions. Cellulitis of the right ankle is reported with L03.115. There is a causal
relationship between diabetes and osteomyelitis. Look in the ICD-10-CM Alphabetic Index for
Diabetes, diabetic/with/osteomyelitis referring you to E11.69. Report the osteomyelitis code
M86.9 according to the instructional note in the Tabular List under code E11.69. Report a code
for the amputation status. The patient is insulin dependent.

78. OPERATIVE REPORT

PREOPERATIVE DIAGNOSIS: Stage Duke’s D colon cancer
POSTOPERATIVE DIAGNOSIS: Stage Duke’s D colon cancer

PROCEDURE: Insertion of an Infusaport

ANESTHESIA: Local with IV sedation

PROCEDURE: The patient was brought to the operative suite and placed in a supine position.
Following IV sedation, she was sterilely prepped and draped in the usual fashion. 1% Xylocaine
was used for local anesthesia. A transverse skin incision was made over the left deltoid
pectoralis groove and electrocautery used for hemostasis. The incision was then deepened in an
attempt to isolate the cephalic vein. The cephalic vein was unable to be identified.

Attention was then directed to the left infraumbilical region. The left subclavian vein was then
cannulated with 14-gauge needle and guide wire inserted through the needle into the subclavian
 CRC Assessment - Mock I
and advanced into the central venous system. The needle was removed, leaving the guide wire
in place. Fluoroscopic visualization was utilized. The guide wire was then delivered
subcutaneously to the incision. A subfascial pocket was then created with blunt dissection.
Appropriate length of Infusaport catheter was selected.

Introducer was inserted over the guide wire and advanced into the left subclavian vein. The
introducer and guide wire were removed, leaving the sleeve in place. The Infusaport catheter
was inserted through the sleeve into the left subclavian vein and advanced to the superior vena
cava. The sleeve was removed, leaving the catheter in place. The Infusaport was then secured
to the pectoralis muscle with 3-0 Prolene in the usual fashion.

The fascial margins were approximated with 3-0 Vicryl in simple interrupted fashion. The skin
margins were approximated with 4-0 Vicryl in simple running intradermal fashion. The system
was accessed, aspirated, and flushed with heparinized saline. The system was then clamped and
sealed with an op site dressing. The procedure was completed without incident. The patient
tolerated the procedure well. All needle and sponge counts were correct and the patient was
transported to the recovery room in satisfactory condition with stable vital signs.

PATHOLOGY: Preoperatively this 61-year-old patient was evaluated and found to have Duke’s D
adenocarcinoma of the colon with spread to the abdomen. She wishes to proceed with
chemotherapy. At the time of surgery, an Infusaport was inserted through the left subclavian
vein as described above. Postprocedure chest X-ray was ordered and will be reviewed. No other
pathology at the time of surgery.
Select all current diagnosis code(s).

A. C18.9
B. C18.9, C76.2
C. C18.9, C79.89
D. C78.5, C79.89

The patient is having a port placed to begin chemotherapy. The patient has colon cancer which
has spread to the abdomen. In the Table of Neoplasms look for Neoplasm,
neoplastic/colon/Malignant Primary column. Next look for Neoplasm,
neoplastic/abdomen/Malignant Secondary column C79.8-. In the Tabular List complete code is
C79.89.

79. Which of the following statements are TRUE regarding problem lists?
I. In some EHRs the problem list can be carried over from a previous visit without
updating the information
II. Problem lists include chronic conditions
 CRC Assessment - Mock I
III. Problem lists can include previously treated conditions.
IV. In some EHRs the problem list can include conditions from previous years
A. I and II
B. I and III
C. II, III and IV
D. I, II, III, and IV

All statements regarding problem lists are true.

80. Coders review medical records in their entirety to capture the current diagnosis codes. In which
of the following components of the record should the coder NOT capture diagnosis codes?
A. Exam
B. History
C. Nurse notes
D. Consultation

Diagnosis must be documented by the treating provider. The nurse's notes can not be used for
documentation to support diagnosis codes.

81. The patient is seen by her primary care provider. The provider documents the patient has
diabetes, CKD stage II and CKD stage III. What should the coder do?

A. Report E11.22, N18.2, N18.3

B. Report E11.22, N18.3
C. Query the provider to determine if the diabetes in out of control
D. Query the provider to determine the appropriate stage of CKD

Because two different stages of CKD are documented, query the provider to confirm. If this
documentation was during the course of the admission it is possible for a patient to progress
from one stage to another but not during the course of an office visit.

82. What can result from the improper use of cut and paste functions in an EHR to pull in elements
of a previous encounter?
A. The patient could end up with duplicate claims for the same date of service
B. The provider may include diagnoses that are not relevant for the date of service
C. The nurse might provide medical care to the wrong patient
D. The coder might overlook chronic illnesses that are currently being treated
 CRC Assessment - Mock I
The use of cut and paste functions in EHR are discouraged because there is a high error rate in
proper use. It allows the provider to bring information forward from a previous encounter that
may not be addressed in the current visit.

83. Which of the following is TRUE regarding the past, family, and social histories?
I. PFSH contains information regarding a patient's chronic conditions
II. PFSH includes information regarding the patient's history that may put him/her at
risk for certain conditions
III. PFSH should not be used for supporting documentation for diagnosis codes
A. I
B. I and II
C. II
D. III

PFSH can include pertinent information for risk adjustment coding such as tobacco use, chronic
conditions the patient is treated for and family histories that put the patient at risk.

84. When providing physician education for documentation, the coder should:
A. Focus only on the conditions that have a risk adjustment score
B. Instruct the provider to document all diagnoses managed, treated, and
monitored
C. Instruct the provider to always code using the diabetic manifestation codes
D. Focus on the conditions that have been on the list for audit targets

It is important to remember that documentation is used for more than coding. It is a legal
document that supports the services provided and continuity of care. To train providers to
document with only coding requirements in mind will cause other compliance issues.

85. What does the abbreviation MI stand for?

A. Missed Intervention
B. Minimally Invasive
C. Myocardial Infarction
D. Mandatory Intervention

View Rationale
MI is the medical abbreviation for myocardial infarction.

86. What is the function of the spinal cavity?

A. Protects the vertebrae
B. Enfolds and protects the spinal cord
 CRC Assessment - Mock I
C. Protects the kidneys
D. Protects the pleura

View Rationale
The spinal cavity enfolds and protects the spinal cord.

87. Use the table provided below to answer the question.

If the patient is diagnosed with colon cancer and acute leukemia, which HCC is used in the risk
calculation?

A. HCC 8
B. HCC 11
C. HCC 12
D. HCC 8 and HCC 11
View Rationale
Payment will always be associated with the HCC in column 1, if a HCC in column 3 also occurs
during the same collection period.

88. Using the information provided. If the patient's diagnoses included K76.6, K74.60, and B18.2,
which HCC is used in the risk calculation?
Diagnosis CodeDescription CMS-HCC
Model Category V22
Diagnosi Description CMS-HCC
s Code Model Category V22

B18.0 Chronic viral hepatitis B with delta- 29

agent
B18.1 Chronic viral hepatitis B without 29
delta-agent
B18.2 Chronic viral hepatitis C 29
B18.8 Other chronic viral hepatitis 29
B18.9 Chronic viral hepatitis, unspecified 29
 CRC Assessment - Mock I
K74.3 Primary biliary cirrhosis 28
K74.4 Secondary biliary cirrhosis 28
K74.5 Biliary cirrhosis, unspecified 28
K74.60 Unspecified cirrhosis of liver 28
K74.69 Other cirrhosis of liver 28
K76.6 Portal hypertension 27
K76.7 Hepatorenal syndrome 27
K76.81 Hepatopulmonary syndrome 27

Hierarchica
l Condition Then drop the HCC(s)
If the HCC Label is listed in this column…
Category listed in this column
(HCC)
27 Portal Hypertension 28, 29, 30
28 Cirrhosis of Liver 29
29 Chronic Hepatitis

A. HCC 27
B. HCC 28
C. HCC 29
D. HCC 27, HCC 28, HCC 29
View Rationale
Payment will always be associated with the HCC in column 1, if a HCC in column 3 also occurs
during the same collection period.

89. If you were using a predictive model and the results were:
 The member had an Rx Claim for a beta blocker.
 The member had a medical claim which included comprehensive lab panel.
Which diagnosis would you predict this member has?
A. DM
B. Hypertension
C. CKD
D. Asthma

View Rationale
Beta blockers, also known as beta-adrenergic blocking agents, are medications that reduce your
blood pressure.

90. Which risk adjustment model is most commonly used by Medicare?

A. HCC
 CRC Assessment - Mock I
B. CDPS
C. Blended
D. Fee for service

View Rationale
The Medicare Hierarchal Condition Categories (HCC) model is used by Medicare Advantage plans
(Medicare HMOs).

91. Are NDC codes helpful in data mining?

A. No, NDC codes are not reported.
B. No, NDC codes are only evaluated if it is a fee for service plan.
C. Yes, the codes indicate medications prescribed which is an indication of the
conditions being treated.
D. Yes, the codes generate a higher rate of reimbursement.

View Rationale
The NDC codes help identify the medications the patient is taking. This provides information
regarding the condition and severity of the condition.

92. Which payer type uses HEDIS measures?

A. Medicare
B. Medicaid
C. Private payers
D. A variety of payer types

View Rationale

There are some HEDIS measures captured by Medicare, Medicaid and private payers. HEDIS
makes it possible to compare the performance of health plans.

93. What is the highest Star Rating that can be achieved?

A. 4
B. 5
C. 10
D. 15

View Rationale
CMS defines the star ratings in the following manner:
5 Stars = Excellent Performance
4 Stars = Above Average Performance
 CRC Assessment - Mock I
3 Stars = Average Performance
2 Stars = Below Average Performance
1 Star = Poor Performance

94. What does the abbreviation RADV indicate?

A. Risk adjustment diagnosis values
B. Risk adjustment diagnosis voucher
C. Risk adjustment data validation
D. Reporting adjusted diagnosis values

View Rationale
RADV indicates Risk Adjustment Data Validation

95. Which of the following statements is TRUE regarding rule out diagnoses?
A. A code for a rule out diagnosis can be coded when coding for HCC
B. A code for a rule out diagnosis can be coded in the outpatient setting only
C. The provider can document the rule out diagnosis, but a code is not selected to
report it
D. The provider can document the rule out diagnosis and select a secondary code
to report it

View Rationale
A rule out diagnosis cannot be reported for outpatient services. The provider documents the rule
out diagnoses in the patient chart to capture the medical decision making but a diagnosis code is
not reported.

96. How are HCCs categorized?

A. Type of complication
B. Diagnosis groups
C. Organ systems
D. Age group

View Rationale
The model takes ICD codes and filters them into Diagnosis Groups (DxGs), then into Condition
Categories (CCs), where hierarchies or “families” of conditions are placed to gain an HCC numeric
code, which translates to a risk adjustment factor (RAF) value.

97. Subjective: Tile patient is a 67-year-old diabetic female who presents today for evaluation and
treatment of her painful ingrown toenails. Past treatment has consisted of self-palliative care.
The patient is consulting me today for ongoing palliative treatment of these toenails.
 CRC Assessment - Mock I
Examination:
Vascular: The pedal pulses are rated as ¼ in both feet. The digital capillary filling time is rated as
3+ seconds.
Dermatological: The skin texture, temperature and turgor are normal for the patient’s stated
age. Closer evaluation of the patient’s feet demonstrates onychocryptosis involving all digits of
both feet.
Neurological: The patient’s tactile sensations are grossly intact for the patient’s stated age.
Assessment: A risk patient with a history of diabetes. The patient requires long-term palliative
debridement of her toe nails to prevent possible pedal infection.
Treatment: The patient’s toenails were debrided manually today with the use of a bone cutter
and all dystrophic nail plate thickness was reduced to normal nail plate thickness with the use of
an electric rotary nail bur. The patient was rescheduled for follow up evaluation and palliative
treatment in 2 months.
Signed by: X, DPM 03/01/XX
Which codes are recommended to be reported that will affect the HCC risk adjustment value?

I. E11.9
II. E11.65
III. L60.0
IV. R52
A. I
B. II
C. I, III, and IV
D. II, III, and IV

View Rationale
The diabetes is the only condition that has an HCC assignment. The diabetes is not documented
as uncontrolled. An ingrown toenail is an acute problem. Pain is not assigned an RAF.

Terify diagnosis codes that have an HCC risk factor go to https://www.cms.gov/Medicare/Health-

Plans/MedicareAdvtgSpecRateStats/Risk-Adjustors.html.

98. PATIENT: DT
PAIENT ID: 4321
DOB: 05/05/XXXX
DOS: 02/02/XX

CHIEF COMPLAINT: Cyst on the right upper eyelid.

SECOND COMPLAINT: Hypertension. Denies chest pain, shortness of breath, or extremity

 CRC Assessment - Mock I
swelling. Tolerating meds. He is due for labs and refills. THIRD COMPLAINT: Rash on his scalp and
forehead.
OBJECTIVE: A 72 year-old in no acute distress. Weight and vitals documented. He has a 2- to 3-
mm cystic area on the right upper lid laterally. He has some scaliness to the temporal areas and
to the scalp. CV: Regular. Lungs are clear. Extremities without significant edema.

ASSESSMENT/PLAN
Chalazion, right upper eyelid. Refer to Ophthalmology. Follow up here in six months.
Hypertension with congestive heart failure, well controlled.
Seborrhea. Nystatin and triamcinolone cream as needed.

Which codes are recommended to be reported that will affect the HCC risk adjustment value?
I. H00.11
II. I11.0
III. L21.0
A. I
B. II
C. I and III
D. I, II, and III
View Rationale

Hypertension with congestive heart failure is the only condition that has an HCC assignment. The
cyst and seborrhea are acute conditions that do not have an HCC assigned.
To verify diagnosis codes that have an HCC risk factor go to
https://www.cms.gov/Medicare/Health-Plans/MedicareAdvtgSpecRateStats/Risk-Adjustors.html.

99. Can a request for recalculation from the plan be requested when inaccurate diagnosis codes are
identified after the final risk score is determined?
A. Yes, plans can request a recalculation if an inaccurate diagnosis will impact the
final payment
B. Yes, plans can request a recalculation if found within ten days
C. No, plans cannot request a recalculation once a final risk score is calculated
D. No, plans request for a recalculation can only occur when notified by CMS
View Rationale
Once CMS calculates the final risk scores for a payment year, plan sponsors may request a
recalculation of payment upon discovering the submission of inaccurate diagnosis codes that
CMS used to calculate a final risk score for a previous payment year and that had an impact on
the final payment. Plan sponsors must inform CMS immediately upon such a finding. Medicare
Managed Care Manual, Chapter 7 – Risk Adjustment
 CRC Assessment - Mock I
100. Which provider types are unacceptable data sources under the HCC model?

I. Excluded providers
II. Children hospitals
III. Rural health clinics
IV. Independent laboratories

A. I
B. I and II
C. I and IV
D. I, II, III, and IV

Medicare will not pay for items or services rendered to beneficiaries and recipients by an
excluded provider or by entities owned or managed by an excluded provider. Therefore, MA
organizations should not submit risk adjustment data if it was submitted by an excluded
provider. Laboratory services are not submitted to support HCC score. Medicare Managed Care
Manual, Chapter 7 – Risk Adjustment

101. Do the HCC category hierarchies play a role in which medical record to submit for a
RADV?

I. No, there are no benefits in taking hierarchies into consideration

II. No, CMS will treat all diagnosis with the same financial weight
III. Yes, CMS will accept a lower or higher HCC to validate an HCC within the same
category
IV. Yes, there can be a financial gain by submitting a higher hierarchy HCC
A. I
B. II
C. III
D. III and IV

View Rationale
CMS states for HCCs in a Hierarchy category can be submitted; either of lower risk score or
higher risk score.

102. Retrospective audits provide insurance companies with ability to scrub/correct their data
which accomplishes which of the following?

I. Provides opportunities to increase revenue by submitting additional codes

 CRC Assessment - Mock I
II. Provides opportunities to compare claims data to the documentation and submit
deletions if the documentation does not support what was on the claim
III. Provides opportunities to correct coding errors prior to data being submitted
A. I and II
B. I
C. II
D. II and III

View Rationale
Retrospective chart audits have been commonly used to increase revenue, but for companies
that want to do the "right" thing and to decrease the financial risk during RADV audits,
comparing the claims to the documentation and where there are discrepancies submit deletes
(remove ICD-10-CM code from CMS data base) and to submit additional codes is the best use of
the retrospective chart audits.

103. Which of the following is an example of fraud?

A. Reporting a diabetic manifestation to increase the risk score.
B. Submitting a record for a RADV audit which includes diagnoses that were not
previously reported.
C. Training physicians to document causal relationships for manifestations for
chronic illnesses when present.
D. Setting a policy to report all patient's with DM and CKD as a diabetic
manifestation.

View Rationale
Intentionally reporting a diagnosis that is not supported by the documentation in order to raise a
risk score is fraud.

104. Risk Adjustment is a:

A. Prospective payment system

B. Retrospective payment system
C. Fee-for-service payment system
D. Case rate payment system

View Rationale
Risk adjustment is a prospective payment model. It uses diagnostic information from a base year
to predict Medicare benefit costs for the following year.
 CRC Assessment - Mock I
105. Choose the best medical record for a RADV audit to include all the diagnoses in this
scenario:
• CMS is requesting diabetes mellitus with neuropathy to be validated
• Assume all the notes are signed by the provider and the diagnoses are
supported by the documentation
i. Chart #1: DOS 1/1/20XX—Diagnoses: DM, PVD
ii. Chart #2: DOS 4/2/20XX—Diagnoses: DM with neurologic manifestations,
polyneuropathy, CKD
iii. Chart # 3: DOS 7/7/20XX—Diagnoses: DM with neurologic manifestations
iv. Chart # 4: DOS 9/9/20XX—Diagnosis: DM, HTN

View Rationale
When a diabetic manifestation is reported a combination code is used to include the type of
diabetes and the manifestation. The record that supports the condition in question is chart #2.

106. Which statement is TRUE regarding RADV audits?

A. A cover page is not necessary
B. The purpose is to validate submitted HCC data
C. Conducted randomly throughout the year
D. CMS creates a special cover page for each patient being audited

View Rationale
The purpose is to ensure risk adjusted payment integrity and accuracy by verifying the HCC
submitted is supported in the medical record. CMS requires that their cover letter be used, and
stress that organizations may not create their own cover page.

107. During a retrospective chart audit for a XYZ Medicare Advantage Company, it is
determined a diagnosis submitted is not supported by medical record. There is no additional
information to validate the diagnosis. The member is part of a health plan that has 1,500
members and the insurance company received $350 for this diagnosis. This HCC is chosen for a
RADV audit. Using the CMS extrapolation methodology, how much could the company have
saved if it deleted this code during the retrospective chart audit process?
A. $1,500
B. $350

C. $525,000
D. There is not a financial penalty

View Rationale
 CRC Assessment - Mock I
The value of invalidated HCCs is extrapolated across the entire plan population ($350 x 1,500)

108. In order for a MA Plan to improve their revenue, which of the following statements
describes the correct approach a plan should take to accomplish this?
A. Code all diagnoses listed in the patient's problem list
B. Develop a prospective and retrospective review to capture all accurate
diagnoses
C. Target diagnosis code selection for the most high risk diagnoses which yield
more reimbursement
D. Transfer healthy patients out of the network and focus on treating patients
with chronic conditions

View Rationale
For a plan to increase revenue, it should develop an HCC capture strategy from a prospective
approach versus a retrospective approach. When an MA plan focuses HCC capture solely from a
retrospective approach, the plan risks being exhausted by the tedious nature and high cost of
using an outside vendor for large numbers of medical charts. When the provider sees the
member one to two times a year, the provider can review the problem list and accurately report
all existing chronic disease processes to the MA plan. This prospective approach improves the
MA plan’s ability to capture more HCC codes for better reimbursement and eliminates the need
for expensive retrospective chart reviews in the future.

109. When is it appropriate to use history of malignancy, from category Z85?

A. Once the malignancy is removed from that site
B. When the patient cancels treatment for that site
C. It has been excised and no further treatment directed to the site
D. When the patient has a lapse in treatment

View Rationale
Per ICD-10-CM guideline I.C.2.d, when a primary malignancy has been excised or eradicated from
its site and there is no further treatment directed to that site and there is no evidence of any
existing primary malignancy, a code from category Z85, Personal history of malignant neoplasm,
should be used to indicate the former site of the malignancy.

110. Patient is admitted to the hospital with streptococcal sepsis which has caused
pneumonia. What codes are assigned?
A. A49.1, T91.4XXA
B. A40.9, J16.8
C. A40.9
D. A49.1, J18.9
 CRC Assessment - Mock I
View Rationale
Per ICD-10-CM guideline I.C.1.b.4: A localized infection, such as pneumonia or cellulitis, a code
for the systemic infection (A40.-) should be assigned first and the code for the localized infection
should be assigned as a secondary code. To find the codes look in the ICD-10-CM Alphabetic
Index for Sepsis/Streptococcus, streptococcal. Then code the pneumonia found in the ICD-10-CM
Alphabetic Index under Pneumonia/specified/organism J16.8. Verify all codes in the Tabular List.

111. 70 year-old with COPD is admitted to the hospital for acute exacerbation of chronic
bronchial asthma. What diagnosis code(s) should be reported?
A. J44.1
B. J45.901, J44.9
C. J45.901
D. J44.1, J45.901

View Rationale
In the ICD-10-CM Alphabetic Index look for Asthma/with chronic obstructive pulmonary disease
(COPD)/with/exacerbation (acute) leads MDDyou to code J44.1. In the Tabular List category code
J44 has an includes note that indicates asthma with COPD; however, there is also an instructional
note that indicates to code also type of asthma, if applicable. Code J45.901 is also reported.

112. Patient with coronary arteriosclerosis disease (CAD) sees his cardiologist to discuss a
coronary artery bypass graft (CABG). This would be the patient’s first CABG. What ICD-10-CM
code should be reported?
A. I25.110
B. I25.810
C. I25.790
D. I25.10

View Rationale
A patient with CAD and no history of a previous CABG indicates it would be the patient’s native
coronary artery (it has not been replaced or bypassed). In the ICD-10-CM Alphabetic Index look
for Arteriosclerosis/coronary/artery guiding you to code I25.10. Verify code selection in the
Tabular List.

113. A patient is being treated for diabetes with hypoglycemia and coma due to malignant
neoplasm of pancreas. The patient uses insulin routinely but is not dependent. What ICD-10-CM
codes should be reported?
A. E11.641, C25.9
B. C25.9, E10.641, Z79.4
 CRC Assessment - Mock I
C. C25.9, E08.641, Z79.4
D. E08.641, C25.9

View Rationale
The patient’s diabetes is due to the pancreatic cancer and is reported as secondary diabetes.
When diabetes is caused by another disease or illness, it is considered secondary diabetes. In the
ICD-10-CM Alphabetic Index, look for Diabetes/due to underlying
condition/with/hypoglycemia/with coma E08.641. Next go to the Table of Neoplasms look for
Neoplasm, neoplastic/pancreas/Malignant Primary column C25.9. In the Tabular List there is an
instructional note under category code E08 that indicates to Code first the underlying condition.
The neoplasm code is reported first. For patients who routinely use insulin, use code Z79.4 (ICD-
10-CM guideline I.C.4.a.6.a.) which is found in the Alphabetic Index under Long-term (current)
(prophylactic) drug therapy (use of)/insulin Z79.4. Verify code selection in the Tabular List.

114. A patient is admitted after being found unresponsive at home. The patient had right-
sided hemiplegia and aphasia from a previous CVA. The physician documents a current CVA as
the final diagnosis and the patient is transferred for rehabilitation. What ICD-10-CM code(s)
should be reported?
A. I63.5
B. I67.89, I62.9, R47.01
C. I63.9, I69.351, I69.320
D. I67.89, I69.851, I69.920

View Rationale
Per ICD-10-CM guideline I.C.7.d.2, tells us codes from category I69 may be assigned on a health
care record with codes from I60-I67, if the patient has a current CVA and deficits from an old
CVA. Look in the ICD-10-CM Alphabetic Index for Accident/cerebrovascular (current) I63.9. Also
look for Sequela (of)/stroke NOS/hemiplegia I69.35-. ICD-10-CM guideline I.C.6.a indicates:
Should the affected side be documented, but not specified as dominant or non-dominant, and
the classification system does not indicate a default, code selection is as follows: For
ambidextrous patients, the default should be dominant; If the left side is affected, the default is
non-dominant; if the right side is affected, the default is dominant. Then, look for Sequela
(of)/stroke NOS/aphasia I69.320. Verify code selection in the Tabular List.

115. A patient is coming in for follow up of his essential hypertension and cardiomegaly. Both
conditions are stable, and he is told to continue with his medications. What ICD-10-CM code(s)
should be reported?
A. I11.0, I51.7
B. I10, I51.7
 CRC Assessment - Mock I
C. I11.9
D. I10, I51.9

View Rationale
Per ICD-10-CM guideline I.C.9.a. indicates: The classification presumes a causal relationship
between hypertension and heart involvement, as two conditions are linked by the term "with" in
the Alphabetic Index. These conditions should be coded as related even in the absence of
provider documentation explicitly linking them, unless the documentation clearly states the
conditions are unrelated. Look in the Alphabetic Index for Hypertension/heart (disease)
(conditions in I51.4-I51.9 due to hypertension referring you to I11.9 Cardiomegaly code, I51.7, is
not reported. There is an Excludes1 note under category code I51 that indicates not to report
any condition in I51.4-I51.9 due to hypertension (I11.-).

116. 73 year-old visits his primary care physician to discuss lap band procedure for his morbid
obesity. His BMI is currently 45. What ICD-10-CM code(s) should be reported?

A. E66.9
B. E66.01, Z68.42
C. E66.1, Z68.42
D. Z68.42, E66.01

View Rationale
In the ICD-10-CM Alphabetic Index look for Obesity/morbid guiding you to code E66.01. In the
Tabular List you will see the code for morbid obesity E66.01 states “due to excess calories.” Even
though the documentation does not indicate due to excess calories the Alphabetic Index directs
you to report code E66.01 for morbid obesity. In the Tabular List, there is a note under
subcategory code E66.- to Use an additional code to identify the BMI (Z68.-). Look at the code
range for Z68 in the Tabular List. The second code is Z68.42 indicating a BMI of 45.0 - 49.9 adult.

117. Patient presents to her physician 10 weeks following a true posterior wall myocardial
infarction. The patient is still symptomatic and is receiving care related to the myocardial
infarction. What is the correct first-listed ICD-10-CM code for this condition?

A. Z51.89
B. I21.29
C. I22.8
D. I25.2

View Rationale
 CRC Assessment - Mock I
Because it is past four weeks and the patient is still symptomatic, according to ICD-10-CM
guidelines, Section 1.C.9.e.1, for encounters after the 4 week time frame and the patient is still
receiving care related to the myocardial infarction, the appropriate aftercare code should be
assigned, rather than a code from category I21.

118. Patient is seen in his physician’s office and diagnosed with benign hypertension and
Stage 3 chronic kidney disease. Select the diagnosis codes.
A. I12.9, N18.3
B. I10, N18.3
C. I12.9, N18.6
D. I10, N18.9

View Rationale
According to ICD-10-CM guideline I.C.9.a.2, a causal relationship is always assumed with
hypertension and chronic kidney disease. Look in the ICD-10-CM Alphabetic Index for
Hypertension/kidney/stage 1 through stage 4 chronic kidney disease. The instructional note
under code I12.9 indicates to report an additional code for the stage of chronic kidney disease.
This is stage 3; therefore, N18.3 is also reported.

119. A 65-year-old male presents to the office with history of ongoing diabetes which has
been controlled with insulin for follow-up exam with his family practice physician, during this
encounter the physician notes a chronic diabetic wound of his right greater toe and determines
gangrene has set in. After examination and testing the family practice physician recommends the
gentleman to be seen by a general surgeon for treatment of his gangrene of his right great toe.
What are the correct diagnoses to report for this encounter?
A. I96, E11.51, Z79.4
B. Z79.4, E10.52
C. E11.52, Z79.4
D. E11.51, I70.269, Z79.4

ViewRationale
When coding for a diabetic with gangrene, first select a code for the diabetes with gangrene
combination code. Look in the ICD-10-CM Alphabetic Index for Diabetes, diabetic (mellitus)
(sugar)/type 2/with/gangrene which directs you to E11.52. Next, the patient is treated with
insulin which is reported with Z79.4

120. What is the correct code assignment for a residual deficit of hemiplegia secondary to late
effect of a cerebrovascular accident?
 CRC Assessment - Mock I
A. I69.398, M62.81
B. G81.90, I63.9
C. I69.359, G81.90
D. I69.359

View Rationale
The hemiplegia is due to a CVA which is coded with a late effect or sequelae code. You will not
report code I63.9. In the Alphabetic Index look for Hemiplegia/following/cerebrovascular
disease/cerebral infarction referring you to I69.35-. Verification in the Tabular List indicates a
6th character is needed to complete the code. You are not given which side of the body is
affected; the complete code is I69.359. You will not report code G81.90 as an additional code
because code I69.359 is a combination code that covers both conditions in one code. Refer to
ICD-10-CM coding guideline I.B.9.

121. A 32 year-old patient suffered a crush and avulsion type injury which has now resulted in
loss of the fourth and fifth digits at the metacarpophalangeal joint levels, loss of the index and
long fingers through the proximal phalanx proximal aspect and soft tissue loss dorsally over the
left hand.
What is (are) the appropriate diagnosis code(s)?
A. S63.261A, S63.263A, S67.191A, S67.193A
B. M20.092
C. Z89.022, S63.261A, S63.263A
D. M20.092, S67.191A, S67.193A

View Rationale
Assign code M20.092 Other deformity of left finger(s), as the principal diagnosis. Code Z89.022,
Acquired absence of left finger(s), is not an acceptable principal diagnosis. Code Z89.022 should
not be reported as an additional diagnosis with code M20.092 because it is listed under the
Excludes1 note.

122. A 65 year-old male patient was admitted with ascending cellulitis and infection of a 2nd,
3rd, and 4th toes amputation site. What are the appropriate diagnosis codes for this?

A. E11.9, T87.40
B. T87.40, L03.039
C. L03.039, E11.9
D. Z89.429, T87.40

View Rationale
 CRC Assessment - Mock I
Assign code T87.40, Infection of amputation stump, unspecified extremity as the principal
diagnosis with an additional code of L03.039, Cellulitis of unspecified toe.

123. An AV fistula connects:

A. The aorta to a vein
B. An artery to a varicose vein
C. An artery to a vein

D. An artery to a ventricle

View Rationale
An AV (Arteriovenous) fistula is a connection between an artery and a vein.

124. Which of the following physician assessments support the correct coding of CKD stage 2,
code N18.2?
A. A/P: Mild CKD
B. Assessment and Plan: Moderate CKD
C. Assessment: Severe Chronic Kidney Disease
D. A/P: ESRD

View Rationale
ICD-10-CM guideline I.C.14.a.1 states the stages of chronic kidney disease. Mild CKD is reported
with N18.2.

125. Which of the following is appropriate to assign ICD-10-CM code N18.9?

I. Chronic Renal Disease

II. Chronic Renal Failure
III. Chronic Kidney Disease Unspecified
IV. Chronic Renal Insufficiency

A. I
B. I, II, and IV
C. III
D. I, II, III, and IV

View Rationale
Answer III is correct because it is included in the description of ICD-10-CM code N18.9. Answers I,
II, and IV are the listed under the Inclusion Terms under code N18.9 and therefore also correct.
 CRC Assessment - Mock I
126. Patient is admitted to the hospital for treatment of a Subarachnoid Hemorrhage. The
patient has hypertension and is being evaluated by Neurosurgery for possible surgical
intervention. Assign the correct ICD-10-CM code(s) for the admission.

A. I60.9, I10
B. I10, I60.9
C. I60.9
D. I61.9, I10

View Rationale
There is an instructional note under category I60-I69 in the Tabular List that indicates to use
additional code to identify presence of hypertension.

127. Chronic and acute conditions/diagnoses from the previous year that Risk Adjust are used
to establish reimbursement for patient care provided by the MA plan. Which of the following
statements is TRUE?
A. HCCs must be captured every 12 months for CMS to reimburse/ DM with a
manifestation (complication) requires that you document and code the
manifestation as well
B. Health Risk is re-determined every year/ Document all clinical findings in the
medical record
C. Health Risk is re-determined every year/ Document all clinical findings in the
medical record/HCCs must be captured every 12 months for CMS to reimburse
D. Document all clinical findings in the medical record (chart)/ the medical record
is used to support ICD-10-CM and HCC coding

View Rationale
Chronic and acute Conditions/Diagnoses from the previous year that Risk Adjust are used to
establish reimbursement for patient care provided by the MA plan. HCCs must be captured
every 12 months for CMS to reimburse. Health Risk is re-determined every year.

128. The provider sees a patient in the Emergency room for acute flank pain. The patient has
high blood pressure after serial BPs taken. The ultrasound shows acute pyelonephritis. The
provider documents acute pyelonephritis and secondary hypertension. Assign the correct ICD-
10-CM codes.
A. N10, I15.8
B. N11.0, I15.8
C. N11.0, I10
D. N10, I10
 CRC Assessment - Mock I
View Rationale
ICD-10-CM guideline I.C.9.a.6 indicates two codes are required for secondary hypertension: one
to identify the underlying etiology and one from category I15 to identify the hypertension.
Sequencing of codes is determined by the reason for the encounter. In this case the patient
presented for acute flank pain due to acute pyelonephritis.

129. This 75-year-old male with no prior cardiac history has had exertional dyspnea. A stress
test was markedly positive. He underwent cardiac catheterization today, he was found to have
normal left ventricular function. There was severe disease affecting the left anterior descending
and circumflex coronary arteries. There was no significant disease affecting the right coronary
artery. Dr.
Internal Medicine has asked me to see the patient for consideration of further intervention. The
patient is known to have hypertension. There is no history of diabetes or hyperlipidemia.
He is status post hemorrhoidectomy. Status post inguinal hernia repair. Status post
Esophagogastroduodenoscopy for an esophageal ulcer due to gastroesophageal reflux. He is
allergic to PENICILLIN (the patient believes he had a rash to penicillin, although it was so many
years ago that he cannot accurately recall).

Current Medications are:

Aspirin 325 mg p.o. qd., Atacand 16 mg p.o. qd., Aciphex 20mg p.o. bid.

The patient is married and was accompanied with his wife. He is a farmer and works as a
repairman for farm equipment. He does not smoke. A review of systems was reviewed and are
all-negative except for above.
These records are located in his inpatient record dated 03/05/20XX.

The patient is a healthy-appearing man who appeared younger than 75. He was afebrile. P 70
and electrocardiogram monitor showed that he was in normal sinus rhythm. B/P is 160/70, Ht
171cm, Wt 75 kg. Lungs were clear to auscultation. Heart tones normal. Examination of his
abdomen was negative. His extremities were normal with normal dorsalis pedis pulses
bilaterally. There was no cervical bruit audible.
There was no gross neurologic deficit.

Impression:
Severe multivessel coronary artery disease with exertional dyspnea.
The patient and his wife were fully informed regarding his problem and the recommended
management of further intervention. We discussed risks and benefit of further cardiovascular
intervention. The risks attendant with the operation were understood. I have discussed the plan
with Dr. Cardio surgeon and he has agreed to perform the procedure on his patient.
 CRC Assessment - Mock I
Based on the documentation provided, which diagnosis are reported for risk adjustment
purposes?
A. I25.10, I10
B. I25.10, R06.00
C. I25.10
D. I25.110
View Rationale
The patient is diagnosed with CAD. In the ICD-10-CM Alphabetic Index, look for
Arteriosclerosis/coronary. There is no indication the patient has angina. Code also for the
patient's chronic condition of hypertension.

130. A 72 year-old female returns today to the family practice clinic at the university hospital
for a scheduled appointment. She is returning after previous visit of 2 years ago, with history of
HTN, diabetes, CHF presents. She has shortness of breath and chest pain radiating to her right
arm. She was in her normal state of health until 2 hours prior to arrival. She also admits nausea,
diaphoresis, she denies any palpitations she admits shortness of breath and difficulty getting a
deep breath. She denies any abdominal pain. Denies any pain in the extremities, weakness,
numbness, tingling. She had no loss of consciousness or altered mental status. She has no other
complaints.

Allergies: Codeine

Medications: Potassium, Lasix, Correg, Gliburide, Aspirin, and Nitroglycerin, sublingual prn She
did not take any of her sublingual nitro with the onset of this chest pain.

Patient is a non-smoker, married for forty years Family history significant for Diabetes type II,
also Coronary disease/MI in mother and father before the age of 50.

Review of systems: Otherwise negative.

Temp: 98.2 P: 112 R: 18 somewhat labored BP: 184/98
Pulse ox is 92% on room air
Elderly female appears her stated age. She is a/o x3, Mild/moderate respiratory distress. She is
pale and diaphoretic, resting on the gurney.
PERRL, EOMI, conjunctivae clear TM’s clear, nasopharynx and oropharynx pink and moist. Neck:
soft, supple JVD is present. Heart: regular rhythm, no click, rub, murmur, gallop. Tachycardic at
120 bpm.
Lungs show fine crackles and wet rales throughout. Lung sounds present in all fields. Abdomen:
obese, soft, NDNT, no mass or hepatosplenomegaly, bowel sounds present time 4 with no bruits.
 CRC Assessment - Mock I
Musculoskeletal: ROM, Strength in upper and lower extremities are normal. Neurologic: Cranial
nerves III-XII grossly intact, no evidence of focal deficits. Sensation normal and equal in upper
and lower extremities, DTR’s 2+ at patella, Achilles, biceps, triceps brachioradialis. Pulses 2+
dorsalis pedis, radials, carotids. There are faint carotid bruits right sided.
Lab data obtained shows chemistry was normal except for potassium, which was high at 5.2. CBC
shows normal white count. H/H is normal as well as platelet count. EKG shows sinus tachycardia
at a rate of 122 bpm. LVH is noted no evidence of ischemia or infarct. Chest x-ray shows
pulmonary edema with widened cardiac silhouette. PT, PTT, CK, Troponin I, are all normal.
Patient was given an aspirin upon arrival to the clinic. She was given lasix 60 mg IV. She was also
placed on nitroglycerin and accupril was given. Patient had diuresis of about 1400cc of urine over
the next 45 minutes

Impression: Acute exacerbation of congestive heart failure

Hypertension
Coronary artery disease
DM Type II

Plan: Patient will be admitted to the floor under her cardiologist and followed by her primary
care physician as well.

Based on the documentation provided, which diagnosis codes are reported for risk adjustment
purposes?
A. I50.9, I11.0, I25.10, E11.65
B. I50.9, I11.0, I25.10, E11.9
C. I50.21, I11.0, I25.110, E11.65
D. I50.31, I11.0, I25.110, E11.9

View Rationale
The patient is diagnosed with an exacerbation of CHF, HTN, CAD and diabetes. All the conditions
documented are chronic conditions which are assigned an HCC risk score.

131. Subjective:
Patient presents to clinic today for multiple complaints. First, he is here for follow-up of his
hypertension. He has been doing well on his labetalol, is not having any difficulties. However,
over the last week he has had an upper respiratory infection and has been taking Sudafed-based
cold products without noting what is on these. He has not taken his blood pressure at home
since he has been sick. Next issue is that he is having some trouble with his knees. Anytime he
gets up to move, his knees are stiff in particular when he starts walking or going down stairs his
knees ache. The more steps he does, the better this becomes. It is more of an ache and stiffness
than actual pain. A while ago, his right knee was bothering him quite significantly in regards to
 CRC Assessment - Mock I
pain. This was injected with 80 mg of Depo-Medrol here in the office and this has helped with
the pain but still has stiffness and achy. This is particular in morning -when he gets up. He was
requesting a referral for a possible surgical intervention at this time. Other complaints today
include a rash or possible fungus of the feet. He has been having troubles with this for a while,
just thickening and callusing of his feet and some discoloration and would like this looked at.
Next issue is since he had been taking blood pressure medicines he has been having some
problem with erectile dysfunction mainly with getting and maintaining an erection. He was
wondering if he has the option of trying a Viagra or other similar medication.

2. He was given a letter stating that his blood sugar was elevated. He should come in to discuss
diabetes.

Next issue is he has a rash on his scalp that he has been doing shampoo in the past for. This has
helped somewhat but has never resolved completely. He would like this looked at also today.

Objective: Today, respirations 18. Pulse is 92. Blood pressure is 150/88. This is on Sudafed. Temp
is 99. Weight is 164. Height 568-1/2 inches. In general, this is a 60-year-old obese male, very
pleasant here with his wife who has slight nasal congestion in the office today. Skin is warm and
moist. General: Sclerae are white. Examination of the feet noted to have some thickening and
scaling with some calluses noted. Sensation is intact with good vascular supply. There is no
discoloration noted. This is mainly between the toes and the dorsum of the foot distally. Heart
was regular rate and rhythm. Lungs are clear to auscultation. No wheezes, rhonchi or rales.
Knees noted to have x-rays that were done in the beginning of the year that shows possible
arthritis in both knees. Examination of the scalp revealed multiple patches, scaliness and flaky
skin that are in circular areas more prominent on the edge of the circle with some central
clearing. A Wood's lamp was used and noted that these areas fluoresced.

Assessment/Plan:

Hypertension slightly elevated today but patient has been taking Sudafed. Patient was instructed
to avoid all pseudoephedrine and we will recheck this in a month.

Diabetes mellitus. This is a new diagnosis for him. We will send him to diabetic management and
we will start him on Glucophage 500 mg twice a day. We will also get a hemoglobin A1c and
microalbumin to creatinine ratio, basic metabolic and CBC today.

Eczema of the feet. Were given some Lac-Hydrin to be used. He is instructed on good diabetic
foot care.
 CRC Assessment - Mock I
Bilateral knee pain consistent with osteoarthritis of his knees.

Tinea capitis. We will give him some Diflucan for 4 weeks to see if this clears it up. If this
continues to be a problem, may need to do scraping or a biopsy.

Erectile dysfunction. Patient will be given some samples of Viagra to see if this helps. Patient is to
return to the clinic in a month for continued care.

The diagnoses reported include: I10, E11.9, L25.9, M17.9, B35.0, N52.9

What diagnosis code would NOT be reported?

A. I10
B. E11.9
C. M17.9
D. B35.0

View Rationale
Diagnoses documented as consistent with are considered uncertain. A code for knee pain is
appropriate for this documentation, not OA.

132. A 77 year-old male presents for follow up with his primary care provider. The provider
documents a healed pressure ulcer of the right heel and hypertension. The Assessment and Plan
is: A/P healed pressure ulcer of right heel, no further treatment and hypertension.
Assign the correct ICD-10-CM code(s) for this visit.
A. L89.619, I10
B. I10, L89.619
C. L89.610, I10
D. I10

View Rationale
ICD-10-CM guideline I.C.12.a.4 indicates that no code is assigned if the documentation states the
pressure ulcer is healed.

133. Which of the following codes should be coded as a history code once the patient has
been discharged from the hospital?

A. Diabetes type 2 controlled

B. Breast cancer
C. Acute Respiratory Failure
 CRC Assessment - Mock I
D. CKD Stage 4

View Rationale
Once the patient has been discharged from the hospital, these conditions should no longer be
coded. In some cases, it’s appropriate to code the “history of” code, or the underlying condition.
But coding these conditions in the office setting is only appropriate if the patient presents in the
office and is (generally) transported by ambulance to the hospital.

•CVA
•Sepsis
•Acute MI (except in 1st 8 weeks)
•Acute Coronary Syndrome
•Non-ST Elevation MI (NSTEMI)
•Unstable Angina
•Acute Respiratory Failure

134. In order for a coder to properly code for a vascular ulcer, which of the following must be
included by the treating provider in the documentation?
A. Location and type of ulcer must be described for vascular ulcers

B. Size and location of ulcer must be described for vascular ulcers

C. Size and type of ulcer must be described for vascular ulcers
D. Only the location of the ulcer must be described for vascular ulcers

View Rationale
The treating provider must call it an ulcer and must include a description of the location and type
of ulcer in order to code a vascular ulcer.

135. What is the function of the thyroid gland?

A. It secretes hormones regulating body metabolism and blood calcium
B. It secretes hormones regulating the secretion of insulin and hemoglobin
C. It secretes hormones regulating mood and growth hormones
D. It secretes hormones regulating the immune system and blood calcium

View Rationale
It secretes hormones regulating body metabolism and blood calcium.

136. Which cells produce hormones to regulate blood sugar?

A. Eosinophils
B. Pancreatic islets
 CRC Assessment - Mock I
C. Hemoglobin
D. Target cells

View Rationale
Pancreatic islets

137. Excessive potassium in the blood is referred to as:

A. Hematuria
B. Hyperkalemia
C. Hypoproteinemia
D. Hypernatremia

View Rationale
Hyperkalemia

138. Using the information provided, what is the correct HCC for a patient with esophagus
cancer and larynx cancer?
Diagnosi Description CMS-
s Code HCC
Model
Category
V22

C15.3 Malignant neoplasm of upper third of esophagus 9

C15.4 Malignant neoplasm of middle third of esophagus 9

C15.5 Malignant neoplasm of lower third of esophagus 9

C15.8 Malignant neoplasm of overlapping sites of 9

esophagus

C15.9 Malignant neoplasm of esophagus, unspecified 9

C32.0 Malignant neoplasm of glottis 11

C32.1 Malignant neoplasm of supraglottis 11

C32.2 Malignant neoplasm of subglottis 11

C32.3 Malignant neoplasm of laryngeal cartilage 11

C32.8 Malignant neoplasm of overlapping sites of larynx 11

C32.9 Malignant neoplasm of larynx, unspecified 11

 CRC Assessment - Mock I
Hierarchical
If the HCC Label is listed in this …Then drop the HCC(s)
Condition
column… listed in this column
Category (HCC)
Metastatic Cancer and Acute
8 9,10,11,12
Leukemia
9 Lung and Other Severe Cancers 10,11,12
10 Lymphoma and Other Cancers 11,12
Colorectal, Bladder, and Other
11 12
Cancers

A. 9
B. 10
C. 11
D. 12

View Rationale
Esophagus cancers are reported from ICD-10-CM Category C15 which maps to HCC 9. Larynx
cancers are reported from ICD-10-CM category C32 which maps to HCC 11. In looking at the HCC
conditions, if HCC is reported, then HCC 11 is dropped. HCC 9 is the correct answer.

139. Predictive Modeling can use many data elements. Which are beneficial for identifying a
person with COPD?
I. DME claims
II. Rx claims
III. Therapy claims
A. I
B. II and III
C. I, II, and III
D. None of the above

View Rationale

Patients with COPD can require oxygen provided by DME providers, medications, and pulmonary
rehab which is considered a therapy service.

140. What is predictive modeling?

A. Analysis of data to determine a hypothesis related to the future health care
needs of patients
B. Cost comparison of health care costs generated locally versus nationally
 CRC Assessment - Mock I
C. Comparison of money saved with risk adjustment models compared to fee-for-
service models
D. Chronic disease management education to prevent high health care costs

View Rationale
Predictive modeling is an analytical review of known data elements to establish a hypothesis—or
educated guess—related to the future health of patients or suspected current diagnoses felt to
be present with varying certainty. Predictive modeling is often used by health plans and other
health specialists as a way to anticipate potential future diagnoses for an individual patient, as
well as groups of individuals to prepare for those medical needs.

141. Which statement is TRUE regarding risk adjustment models?

A. Additional reimbursement is allotted for acute care
B. Risk scores are used to adjust payments for each beneficiary’s expected
expenditures
C. Risk scores are used to monitor health care outcomes and response to
treatment for each patient
D. Determination of payment is made based on the first assessment of the patient
during a calendar year

View Rationale

Risk adjustment allows CMS to pay plans for the risk of the beneficiaries they enroll, instead of
an average amount for Medicare beneficiaries. By risk adjusting plan payments, CMS is able to
make appropriate and accurate payments for enrollees with differences in expected costs. Risk
adjustment is used to adjust bidding and payment based on the health status and demographic
characteristics of an enrollee. Risk scores measure individual beneficiaries’ relative risk and risk
scores are used to adjust payments for each beneficiary’s expected expenditures.

142. Which of the following can effect RAF score?

I. Reporting the manifestation of a chronic illness
II. Disease interactions
III. Patient age
IV. Reporting acute illnesses (eg, URI and UTI)
A. I and II
B. I and IV
C. I, II, and III
D. I, II, III, and IV

View Rationale
 CRC Assessment - Mock I
RAF scores are determined based on patient demographics and condition categories. Certain
combinations of coexisting diagnoses for an individual can increase medical costs more than the
additive nature of the CMS-HCC model reflects. The CMS-HCC model recognizes these higher
costs by incorporating disease interactions in the model. Acute illnesses such as URI and UTI are
not assigned a risk value.

143. Which of the following regarding HEDIS is NOT true?

A. It is the acronym for Healthcare Effectiveness Data and Information Set

B. It’s developer and sponsor is the National Committee for Quality Assurance
(NCQA), a not-for-profit, non-government organization
C. It is a set of standardized performance measures designed to assess the quality
of health care and services provided by managed care plans
D. It is a division of the Centers for Medicare and Medicaid Services

View Rationale
It is a division of the Centers for Medicare and Medicaid Services

144. What does the abbreviation RAPS indicate?

A. Risk Adjustment Provider Service
B. Risk Adjustment Processing System
C. Risk Auditing Process System
D. Risk Auditing Provider System

View Rationale
Risk Adjustment Processing System

145. In order for a code to be counted as part of the current CMS HCC model, what is the
criteria a diagnosis code must meet?
A. The diagnosis is included in the CMS-Hierarchical Condition Category (CMS-
HCC)
B. The diagnosis is a history code
C. The diagnosis has never been reported
D. The diagnosis is an acute condition

View Rationale
A current model diagnosis code must meet the following criteria:
The diagnosis is included in the CMS-Hierarchical Condition Category (CMS-HCC), Prescription
Drug (CMS-RxHCC) or End Stage Renal Disease (CMS-HCC ESRD) risk adjustment models.
 CRC Assessment - Mock I
The diagnosis must be received from one of the three provider types (hospital inpatient, hospital
outpatient, and physician) covered by the risk adjustment requirements.
The diagnosis must be collected according to the risk adjustment data collection instructions.

146. In order to avoid risk adjustment coding errors, a coder must be aware of Disease
Hierarchies within the HCC categories. Which of the following sentences best describes what a
Disease Hierarchy is?

A. Core information submitted by MA organizations for each diagnoses submitted

B. CMS risk adjusts payments for a beneficiary using the CMS-HCC dialysis model
C. A disease hierarchy is combined of multiple ICD-9-CM/ICD-10-CM diagnosis
codes that address multiple levels of severity for a disease with varying levels of
associated medical costs
D. Three to five-digit codes used to describe the clinical reason for a patient’s
treatment

View Rationale
A Disease Hierarchy is combined of multiple ICD-9-CM/ICD-10-CM diagnosis codes that address
multiple levels of severity for a disease with varying levels of associated medical costs, which
allow an MA Plan to factor a members costs accurately with proper diagnosis code selection that
equates to a corresponding HCC code.

147. Which of the following is NOT considered part of the HCC coding process?
A. Assessments, plans, all active chronic conditions, and diagnosis codes
documented in charts annually.
B. Coding precision and specificity: Coders have the ability to conduct prospective
chart reviews to capture missed chronic conditions that have been
documented, but not submitted, by the provider or group.
C. HCC codes should be submitted without validation from the medical record in
order to meet the CMS calendar deadline
D. The plan sends to risk adjustment processing system (RAPS) diagnosis codes
that are converted to HCC codes.

View Rationale
The HCC coding process includes a wide variety of elements to achieve compliance and accuracy,
the following list illustrates those processes:

HCC coding processes include:

 CRC Assessment - Mock I
•Assessments, plans, all active chronic conditions, and diagnosis codes documented in charts
annually.
•Coding precision and specificity: Coders have the ability to conduct prospective chart reviews to
capture missed chronic conditions that have been documented, but not submitted, by the
provider or group.
•The provider’s ability to submit at least 12 diagnosis codes to maximize HCC reporting to plans
(CMS has accepted 12 diagnosis codes since 2012). You may claim 99080 Special reports such as
insurance forms, more than the information conveyed in the usual medical communications or
standard reporting form for providers who submit to Medicare Advantage plans to report
additional diagnosis codes for chronic conditions. Some providers who use an electronic health
record (EHR) may not have the ability within the EHR to submit more than four diagnosis codes
to a plan. Code 99080 has no relative value units (RVUs), and may be used as an adjunct to the
evaluation and management (E/M) code to capture additional diagnosis codes without skewing
the provider’s accounts receivable (A/R) report.
•The plan sends to risk adjustment processing system (RAPS) diagnosis codes that are converted
to HCC codes.
•CMS factors the plan’s risk adjustment.
•Allows Plan & Providers To Deliver Better Benefits/Care

148. Which risk adjustment model incorporates high, medium, and low risk in the numeric
value?
A. HCC
B. CDPS
C. ACA-HHS
D. Medicare Advantage
View Rationale
CDPS diagnoses also carry a numeric value for risk, they are also rated as “high,” “medium,” and
“low” risk overall. This rating is used in hierarchal value setting.

149. Which statement is TRUE regarding the HCC blended model?

A. Eases the transition from one year's model to the next because of potential lost
values
B. Requires additional resources to code records working under two different
models
C. Allows for fee-for-service model incorporation into the risk adjustment factor
score
D. Results in loss of revenue in the first year which can be recouped the following
year
View Rationale
 CRC Assessment - Mock I
The blended methodology was chosen to ensure ease of transition from one model to the next
because of their vast differences and potential lost values.

150. Which of the following signatures is acceptable?

I. Signed but not read

II. Electronically produced: John Smith
III. Dictated but not read
IV. Electronically signed and authenticated by John Smith, MD
V. Signature stamp: John Smith, MD
A. II, III, and V
B. IV
C. II and IV
D. I, II, III, IV, and V