AAPC-CRC Certified Risk Adjustment Coder - Set 1 - Part 1

Correct Answer: Centralized arrangements tracking system

OIG guidance describes an effective, robust centralized arrangements tracking system, audited regularly, as a compliance measure that prevents violations and mitigates potential liability under the Federal fraud and abuse laws, including the anti-kickback statute. Option a is incorrect because a payment methodology that, per OIG guidance, carries risks such as stinting on care; it is a source of risk, not a monitoring measure. Option b is incorrect because counsel may structure and draft agreements at the outset, yet the guidance calls ongoing monitoring of the terms equally important, so drafting alone falls short. Option c is incorrect because this is a risk adjustment monitoring technique for spotting outlier providers and prevalence rates, and it does not track contracts between referral sources and recipients.

Correct Answer: Criminal health care fraud statute

The criminal health care fraud statute requires the Government to prove beyond a reasonable doubt that the defendant acted with intent to defraud, but specific intent to violate the statute itself is not required for conviction. Option b is incorrect because it addresses offering or receiving gifts and other remuneration to reward past or future referrals, which is a different offense from executing a scheme to defraud a benefit program. Option c is incorrect because it is a strict-liability statute, so proof of intent to violate the law is not required at all, unlike the intent-to-defraud standard here. Option d is incorrect because it governs use and disclosure of protected health information by covered entities and is administered by OCR; it is not a fraud offense with an intent standard.

Correct Answer: Negotiating payer reimbursement rates

OIG guidance directs the Compliance Committee's quality program to audit incidents, conduct root-cause analyses, design or approve corrective action plans, and track their implementation and effectiveness. Negotiating payer reimbursement rates is not among these activities. Option a is incorrect because root-cause analysis is a named element of the committee's quality program, used to find why an incident occurred before corrective steps are designed. Option b is incorrect because the guidance lists auditing and reviewing quality and patient safety incidents as the first activity of the Compliance Committee's quality audit and review program. Option d is incorrect because the guidance expects the committee to follow implementation and effectiveness of corrective action plans, so this is part of the program rather than outside it.

Correct Answer: bill separately

The regulation requires risk adjustment data to account separately for each provider, supplier, physician, or other practitioner that would be permitted to bill separately under original Medicare, even when they participate jointly in the same service. Option a is incorrect because the regulation does not tie separate accounting to enrollment; it ties it to who could bill, even when they take part in the same service. Option b is incorrect because the regulation describes MA organizations contracting with providers for data submission; direct contracting with CMS is not the test for separate accounting. Option c is incorrect because electronic submission is a separate data requirement that applies to how the data reach the CMS contractor, not to which practitioners are counted separately.

Correct Answer: Provider contracts must impose financial penalties for incomplete data.

The regulation says MA organizations may include contract provisions requiring complete and accurate data, and these may include financial penalties. Penalties are permitted, not required, so this statement is not a requirement. Option b is incorrect because the sources-and-extent rule requires separate accounting for each practitioner who could bill separately under original Medicare, even when they take part jointly in one service. Option c is incorrect because the regulation states this directly under other data requirements, so electronic submission to the appropriate CMS contractor is a genuine requirement, not the exception. Option d is incorrect because the regulation tells MA organizations to get required data from the provider, supplier, physician, or other practitioner that furnished the item or service, which makes this a real requirement.

Correct Answer: Hospital inpatient, hospital outpatient and physician sources

CMS guidance states that the only acceptable data sources are hospital inpatient facilities, hospital outpatient facilities and physicians. Plan sponsors must implement procedures to ensure submitted diagnoses come from these sources. Option a is incorrect because equipment suppliers are not an acceptable source; CMS guidance restricts diagnoses to hospitals and physicians, so this mix fails despite two valid members. Option b is incorrect because skilled nursing facilities do not appear among the acceptable data sources, which name only hospital inpatient facilities, hospital outpatient facilities and physicians. Option c is incorrect because home health and laboratory data fall outside the list, which allows only hospital inpatient, hospital outpatient and physician sources for submitted diagnoses.

Correct Answer: CMS determines there is a reasonable possibility of fraud or similar fault

When CMS determines there is a reasonable possibility of fraud or similar fault, the audit-rights provision allows CMS to inspect, evaluate, and audit the MA organization at any time, beyond the normal retention window. Option b is incorrect because contract end starts the normal inspection period, which runs from that point or audit completion, whichever is later, so it does not create unlimited access. Option c is incorrect because these events extend the retention period until a set time after final resolution, which still leaves a defined window rather than access at any time. Option d is incorrect because it only lets CMS require longer retention of certain records, provided the MA organization is notified before the normal disposition date; it does not open unlimited access.

Correct Answer: Accuracy, completeness and truthfulness

Under 42 CFR 422.504(l), the CEO, CFO or a delegated individual certifies, based on best knowledge, information, and belief, the accuracy, completeness, and truthfulness of the relevant data CMS requests for payment. Option a is incorrect because timeliness and consistency are not the qualities the regulation names; the certification covers accuracy, completeness and truthfulness of the data CMS requests. Option b is incorrect because these terms do not appear in the certification requirement, which uses different wording for the qualities of data that determine payment. Option d is incorrect because only completeness overlaps with the regulation; legibility and authenticity are not named among the certified qualities of payment data.

Correct Answer: A termination, dispute, or allegation of fraud

The regulation allows retention to extend to 6 years from the date of any resulting final resolution when there has been a termination, dispute, or allegation of fraud or similar fault by the MA organization. Option a is incorrect because a CMS-determined special need lets CMS require longer retention of particular records with 30 days' notice, but it carries no 6-year extension from final resolution. Option b is incorrect because this lets CMS inspect, evaluate, and audit the MA organization at any time, which concerns audit timing rather than a 6-year retention extension. Option c is incorrect because the guidance lists no officer turnover among the exceptions; the exceptions concern a CMS-determined special need, a termination, dispute or fraud allegation, or a reasonable possibility of fraud.

Correct Answer: I, II, and III

OIG guidance bases the audit schedule on the annual risk assessment, requires capacity for additional audits during the year, and allows internal or external auditors. Claims audits should include clinical medical necessity review, so statement IV is wrong. Option b is incorrect because it leaves out statement III, yet OIG guidance says audits may be conducted by internal or external auditors with the required expertise. Option c is incorrect because it includes statement IV, but the guidance says claims reviews and audits should include medical necessity review by an appropriately credentialed clinician. Option d is incorrect because statement IV contradicts the guidance on clinical review, and this choice also drops statement II, which describes the capacity for audits prompted by risks arising mid-year.

Correct Answer: Report and return the overpayment

OIG guidance on auditing and monitoring states that when monitoring and auditing of provider claims identify an overpayment, MAOs are obligated to report and return it. This supports accurate data submitted to CMS. Option a is incorrect because provider education is listed as an additional oversight step for risk adjustment, not as the obligation that follows identification of an overpayment. Option b is incorrect because expanding audit scope is one response to detected risk adjustment problems, but it does not satisfy the stated duty tied to an identified overpayment. Option c is incorrect because SIUs detect and investigate potential fraud, waste, or abuse; guidance does not make an SIU referral the required step for an identified overpayment.

Correct Answer: Auditing diagnosis data only after submission

OIG guidance says MAOs should audit diagnoses data both before and after submission to CMS. Restricting audits to the post-submission stage conflicts with that guidance, so it is not a suggested oversight step. Option a is incorrect because the guidance names review of software or systems, including vendor-created tools and those used by providers, as a recognized oversight step. Option b is incorrect because provider education, covering both employed and contracted providers, appears in the guidance as one of the additional oversight steps MAOs may take. Option d is incorrect because OIG guidance lists data filtering logic among the additional oversight steps, intended to flag anomalies, outliers, or other potentially inaccurate diagnosis data.

Correct Answer: miscoded

OIG guidance tells MAOs to scrutinize particularly high-risk diagnosis codes, defined as those at greater risk of being miscoded. This scrutiny is part of additional oversight, including audits of diagnoses data before and after submission to CMS. Option b is incorrect because the guidance does not describe high-risk diagnosis codes as codes at risk of removal; the concern is accuracy of how they are reported. Option c is incorrect because resubmission is a possible response to detected problems, such as sending data to CMS for payment adjustments, not the reason a code is labeled high-risk. Option d is incorrect because payment outcomes are a downstream consequence; the guidance defines high-risk codes by the likelihood of coding errors, not by payment status.

Correct Answer: Educating employees and FDRs on appropriate use of queries

OIG lists educating employees and, as appropriate, first tier, downstream, or related entities (FDRs), on the appropriate use of queries and other prompts, and overseeing their use, as an oversight step against unsupported diagnoses. Option a is incorrect because OIG guidance calls for evaluating and overseeing in-home HRA programs, not eliminating them, and HRAs are separate from query prompts. Option b is incorrect because payment adjustment submissions are a response to detected problems, so sending every prompted diagnosis would not prevent unsupported data and contradicts the accuracy certification. Option d is incorrect because the guidance lists oversight of chart review programs that result in risk-adjusting diagnoses, and it does not describe restricting reviews to previously submitted diagnoses.

Correct Answer: Failing to remove unsupported diagnosis codes

Federal investigations found potentially fraudulent and abusive conduct when organizations fail to remove diagnosis codes previously submitted to CMS after chart reviews show those codes were unsupported or otherwise invalid. The scenario matches that conduct. Option a is incorrect because this refers to electronic medical record queries or prompts pushing physicians to add diagnoses the patient did not have, and nothing here involved a query. Option c is incorrect because OIG ties this conduct to in-home HRAs that generate diagnoses outside the enrollee's care, and no HRA appears in the situation. Option d is incorrect because this conduct concerns chart reviews that identify additional diagnoses to raise risk scores, whereas here the review exposed an unsupported diagnosis that was already submitted.

Correct Answer: Other records showing enrollees received services

OIG examined MAOs reporting diagnoses based solely on chart reviews or HRAs while providing no other records in the encounter data that enrollees received services for those diagnoses. This raised concerns about payment appropriateness. Option a is incorrect because CMS calculates risk scores in part from submitted diagnoses, so scores existed; OIG's finding concerned missing evidence of care, not missing scores. Option b is incorrect because the MAOs did submit diagnosis codes; the concern was that nothing besides the chart review or HRA backed those reported diagnoses. Option d is incorrect because certification of accurate, complete and truthful data is a separate CMS regulatory requirement for MAOs, not the gap OIG described in the encounter data.

Correct Answer: Whistleblower provision

The False Claims Act contains a whistleblower provision that lets a private individual, including office staff, file a lawsuit on behalf of the United States and, if appropriate, receive a percentage of any recoveries. Option a is incorrect because it lets a court assess not less than 2 times damages when a violator promptly discloses and cooperates, so it concerns a defendant's penalty, not who may sue. Option b is incorrect because it makes a violator liable to the government for the costs of recovering penalties or damages; it does not authorize a private person to bring a case. Option c is incorrect because it is part of the definition of "knowing," which sets the state of mind needed for liability and says nothing about who may file suit.

Correct Answer: Knowingly presenting a false or fraudulent claim for payment

The False Claims Act imposes liability on any person who knowingly presents, or causes to be presented, a false or fraudulent claim for payment or approval. This is the first listed prohibited act in the liability section. Option b is incorrect because the statute reaches a person with custody of Government money or property who knowingly delivers less than all of it, not one who delivers everything. Option c is incorrect because the receipt provision targets an authorized person who, intending to defraud, makes or delivers a receipt without completely knowing the information is true; verification is the opposite. Option d is incorrect because liability attaches to a false record or statement material to a false or fraudulent claim, so a truthful record falls outside that provision.

Correct Answer: Identification of the overpayment

Under 42 CFR 422.326(d), an MA organization must report and return an overpayment no later than 60 days after the date on which it identified the overpayment, unless CMS directs otherwise. Option a is incorrect because the regulation measures the period from the date the organization identified the overpayment, which occurs on knowing receipt or retention, not from the payment arriving. Option b is incorrect because it is the annual final deadline for risk adjustment data submission and helps define what an overpayment is, not when the 60 days begin. Option d is incorrect because a CMS direction is only an exception that can change the standard deadline; it is not the event that starts the 60 days.

Correct Answer: Failing to report and return a known overpayment

OIG guidance lists failing to report and return a known overpayment among conduct that could lead to civil monetary penalty liability. Keeping funds after confirming they exceeded what was owed, without notifying anyone, fits that description. Option a is incorrect because OIG guidance ties this to hospital emergency department patients with an emergency medical condition or in labor, which has no connection to retaining payment. Option b is incorrect because OIG guidance describes this as arranging with a person known to be excluded from a Federal health care program, which involves a staffing relationship rather than keeping funds. Option c is incorrect because this conduct concerns billing a pattern of items or services known not to be medically necessary, whereas the manager submitted nothing new and simply kept money.