July 15, 2024

AAPC CRC Exam Tips

AAPC | Certification | Education | HCC Internship | Medical Coding Grants | Medical Coding Scholarships | Online Medical Coding Training | scholarships for medical coding | Training | Uncategorized | WIOA | Work From Home
By Janine Mothershed

Mastering Medical Coding and Risk Adjustment: Tips for the AAPC CRC Exam

Medical coding in the realm of risk adjustment plays a crucial role in healthcare finance and patient care management. As you prepare for the AAPC Certified Risk Adjustment Coder (CRC) exam, here are essential tips to help you excel:

BREAKDOWN OF THE 100-QUESTION CRC EXAM

Passing the CRC exam requires you to correctly answer a minimum of 70 questions from the domains below.
The exam will rely on a level of understanding that enables you to identify the domain.
Compliance (15 questions)
These questions will assess your knowledge of the process for prospective audits, RADV audits, and retrospective audits, and your ability to identify common coding errors identified in RADV audits.
Protecting our programs’ sustainability for future generations by serving as a responsible steward of public funds is a CMS Strategic pillar. The Medicare Advantage Risk Adjustment Data Validation (RADV) program is CMS’ primary way to address improper overpayments to Medicare Advantage Organizations (MAOs). During a RADV audit, CMS confirms that any diagnoses submitted by an MAO for risk adjustment are supported in the enrollee’s medical record.

RADV audits occur after the final risk adjustment data submission deadline for the MA contract year and after CMS recalculates the risk factors for affected individuals to determine if payment adjustments are necessary.

Risk adjustment discrepancies are identified when an enrollee’s HCCs used for payment, which are based on MAO self-reported data, differ from the HCCs assigned based on the medical record review performed by CMS through the RADV audit process. Risk adjustment discrepancies can be aggregated to determine an overall level of payment error.

Diagnosis coding (30 questions)
These questions will assess your ability to apply Coding Clinic guidance to coding scenarios and identify common coding errors in risk adjustment as well as the diagnosis codes that risk adjust.
Additionally, you must demonstrate the ability to code properly:
  • Amputations Z89 Acquired absence of limb
  • Artificial openings Z93 Artificial opening status
  • Atherosclerosis I70.90 Unspecified atherosclerosis
  • AV fistulas I77.0 Arteriovenous fistula, acquired
  • CHF I50 Heart failure
  • CKD N18 Chronic kidney disease (stage)
  • Complications of devices T85.6 Mechanical complication of other specified internal and external prosthetic devices, implants and grafts
  • COPD J44.9 Chronic obstructive pulmonary disease, unspecified
  • CVA/Stroke I63 Cerebral infarction
  • Dementia F03.9 Unspecified dementia, unspecified severityDepression F32 Depressive episodeDiabetes E08 Diabetes mellitus due to underlying condition E09 Drug or chemical induced diabetes mellitus E10 Type 1 diabetes mellitus E11 Type 2 diabetes mellitus E13
  • Other specified diabetes mellitus
  • DVT I82.40 Acute embolism and thrombosis of unspecified deep veins of lower extremityHIV/AIDS B20 Human immunodeficiency virus disease
  • Hypertension I10 Essential (primary) hypertension
  • Malnutrition E46 Unspecified protein-calorie malnutrition
  • Manifestations of diseases (e.g., DM, stroke, COPD)
  • Mental disorders F99 Mental disorder, not otherwise specified
  • Neoplasms C00-D49 code range for neoplasms Use Neoplasm Table in the ICD-10
  • Pneumonia J18.9 Pneumonia, unspecified organism
  • Pressure ulcers L89.90 Pressure ulcer of unspecified site unspecified stagePulmonary embolism I26 Pulmonary embolism
  • Pulmonary fibrosis J84.10 Pulmonary fibrosis, unspecified
  • Seizures G40.89 Other seizures
  • Skin ulcers L98.499 Non-pressure chronic ulcer of skin of other sites with unspecified severity
Note: Not an all-inclusive list and remember to add all digits to include the specificity needed to complete the code.
Documentation improvement (12 questions)
This section will test your knowledge of communicating documentation discrepancies with providers and your ability to identify documentation discrepancies.
Common causes of medical coding discrepancies include Inconsistent documentation practices, Lack of standardized templates, Communication gaps between clinicians and coders, and Insufficient training on proper documentation.

Coding errors 

Unbundling codes 

Unbundling involves submitting multiple codes for the different parts of a procedure that should be billed under a single code. This can artificially inflate the reimbursement amount and is generally not allowed. 

Overcoding/Undercoding 

Overcoding occurs when a healthcare provider submits a code suggesting a more severe illness or procedure than was genuinely carried out. 

Undercoding occurs when a provider employs a code that doesn’t aptly capture the intricacy or intensity of the services rendered, resulting in lower reimbursements. 

Inaccurate Coding 

With the extensive collection of ICD-10 codes numbering over 78,000 and the frequent incorporation of new codes by CMS, it has become increasingly imperative for both seasoned and novice coders to undergo ongoing training to maintain their current proficiency. 

Neglecting NCCI Edits for Multiple Codes 

NCCI edits are sets of rules that identify code pairs or groups that typically should not be billed together for the same patient on the same day by the same provider. 

Duplicate Billing 

When the same medical service or procedure is billed more than once for a single patient during the same visit or treatment period. 

When the same medical service or procedure is billed more than once for a single patient during the same visit or treatment period. 

Inappropriate Modifier Application with Inadequate Documentation 

Please see the Coding Clarified CPT modifier blog. 

https://codingclarified.com/cpt-medical-modifiers/ 

Improper Code Usage 

  • Incorrect procedure code 

Using the wrong procedure code based on incomplete medical records can lead to the wrong procedure being performed, which could be risky for the patient. 

  • Incorrect diagnosis 

Entering the wrong diagnosis can be risky for the patient. 

Using Unlisted Codes without Proper Documentation 

Unlisted codes are typically used when no specific existing code precisely represents the provided service. 

Pathophysiology/medical terminology/anatomy (5 questions)
This section will assess your ability to identify common acronyms for industry and medical terminology and identify anatomic structures, locations, and functions. You also will be asked to define common medical terms and explain disease processes and interactions for common chronic conditions.
Quality of care (3 questions)
This area will test your ability to explain the purpose of HEDIS and STAR ratings, as well as their alignment with risk adjustment.
The Healthcare Effectiveness Data and Information Set (HEDIS) and Star Ratings are both tools used to measure and improve healthcare effectiveness. HEDIS is a performance measurement tool for health plans, while Star Ratings are used to measure the quality of Medicare Advantage and Part D plans. Both tools are used to provide consumers and employers with objective information to compare healthcare quality and outcomes.
HEDIS measures are managed by the National Committee for Quality Assurance (NCQA) and track performance on key aspects of care and service. HEDIS measures are developed and evaluated through a rigorous process that includes public comment and input from advisory panels. Some HEDIS measures are based on six domains of care, effectiveness, access, experience, utilization, descriptive information, and electronic systems. For example, Medicare plans use HEDIS to record follow-up doctor visits for people with multiple high-risk chronic conditions after an emergency department admission. Medicaid plans also use HEDIS surveys to measure the health conditions of children with chronic diseases.
Purpose and use of risk adjustment models (10 questions)
This section will ask that you explain the use of data mining and Predictive modeling from data captured through risk adjustment coding. You must also demonstrate the ability to apply trumping in the risk adjustment hierarchy.
Medical coding data mining is a skill that uses computational techniques to interpret data and identify relationships or predict variables. It can help coding professionals determine which cases should be audited before billing, such as those involving complex conditions or new technology.
Predictive modeling in healthcare uses data analysis and statistical algorithms to forecast future outcomes, trends, or events in the medical field. This complex methodology can help healthcare providers and organizations make informed decisions, optimize resources, and improve patient care. 
Trumping in the risk adjustment hierarchy refers to the idea that the most severe condition in a related category of hierarchical condition categories (HCCs) takes precedence over less severe conditions.  This structure is based on the severity of the documented disease.
For example, if a provider documents metastatic cancer (HCC 8) and primary cancers (HCCs 9, 10, 11, and 12), only the HCC 8 would be considered. This means that the provider would only receive credit for the most severe and highest weighted HCC within that disease hierarchy.
Risk adjustment models (15 questions)
This section will assess your ability to apply the ACA, CDPS, HCC, and private payer risk adjustment models. You also will be asked to list the elements needed to determine the risk adjustment score.
The CMS HCC model was created by the Centers for Medicare and Medicaid Services (CMS), to help in forecasting medical costs for patients over 65 with more complex healthcare needs.
Hierarchical Condition Category (HCC) risk adjustment models are statistical methods that use a patient’s medical history to estimate future healthcare costs.  These models are used by health insurance companies to determine premiums and by Medicare and Medicaid to allocate payments to health plans.
The two HCC risk adjustment models are the CMS-HCC model and the HHS-HCC model:
  • CMS-HCC model
    Created by the Centers for Medicare and Medicaid Services (CMS) in 2004, this model was designed to help predict medical costs for patients over 65 with complex healthcare needs.
  • HHS-HCC model

    Created by the U.S. Department of Health and Human Services (HHS), this model is based on a similar scoring mechanism and category structure as the CMS-HCC model but is used for the general population. It’s primarily used for commercial payers of the Affordable Care Act (ACA). 

Both models use ICD-10-CM coding to assign risk scores to patients based on their health and demographic details, such as age and gender. For example, a patient’s medical history might include a diagnosis of diabetes without complications (HCC 38) and another diagnosis of diabetes with chronic complications (HCC 37). Because of the severity hierarchy, only the RAF for the more severe diagnosis (HCC 37) would be used for risk score calculation
Cases (10 cases): Each case will test your ability to accurately code diagnoses based on medical record documentation and to report diagnoses that risk adjust.

https://www.aapc.com/certifications/crc/taking-the-crc-exam

Coding Clarified Blog Abstracting from the EHR:

https://codingclarified.com/ehr-abstracting/

Understanding the Basics of Risk Adjustment

Risk adjustment is a method used by health insurers to compensate health plans that enroll a higher proportion of sicker members. This involves assigning diagnostic codes to patients based on their health conditions, which directly impacts reimbursement rates.

Key Knowledge Areas for the CRC Exam

  1. ICD-10-CM Coding: Proficiency in assigning accurate ICD-10-CM codes to reflect patient diagnoses is fundamental. Focus on understanding the guidelines for coding various conditions and diseases.
    The most common chronic diagnosis conditions for HCCs currently listed by CMS: currently listed by CMS:
    hcc coding cheat sheet 2023

    The most frequently missed ICD-10 codes:

    1. Artificial opening status – tracheostomy (Z93.0 HCC 82), gastrostomy (Z93.1 HCC 188), ileostomy (Z93.2 HCC 188), colostomy (Z93.3 HCC 188), cystostomy (Z93.50 HCC 188), urinary tract (Z93.6 HCC 188)
    2. Dependence on renal dialysis (Z99.2 HCC 134), Dependence on a respirator (ventilator) status (Z99.11 HCC 82)
    3. Long-term (current) use of insulin (Z79.4 HCC 19)
    4. Amputation Status Codes – Acquired absence toe(s), foot, ankle (Z89.411 – Z89.449 HCC 189)
    5. Functional quadriplegia – Complete immobility due to severe physical disability or frailty (R53.2 HCC 70)

HCC Coding: Hierarchical Condition Categories (HCCs) are used in risk adjustment to categorize patients based on their diagnoses. Familiarize yourself with the HCC model and how it impacts reimbursement.

Some HCC codes that are more confusing than others, have a necessity for another ICD-10-CM diagnosis code connection or need detailed specificity.

Here are some examples:

  1. Body mass index (BMI) 40 or greater, adult (Z68.41-Z68.45 HCC 22): According to the Official Coding Guidelines for ICD-10-CM I.B.14, the BMI may be documented by other clinicians involved in the care of the patient (e.g. dietitian); however, the associated diagnosis (such as overweight, obesity, morbid obesity) must be documented by the provider. Many times, the BMI is listed, but there is no documentation of obesity or morbid obesity. Both diagnoses are essential for appropriate code and HCC assignments. For instance, if the patient’s BMI of 40.5 is documented, no code is assigned and, therefore, no HCC. However, if the diagnosis of morbid obesity (E66.01) is also documented, along with the BMI 40.5 (Z68.41), then both codes can be accurately assigned resulting in an HCC 22 (morbid obesity), an additional relative risk factor of 0.250.
  2. COMA Scale (R40.2110 – R40.2444 HCC 80): According to the Official Coding Guidelines for ICD-10-CM I.C.18.e, the coma scale codes (R40.21- to R40.24-) can be used in conjunction with traumatic brain injury codes. They are primarily used by trauma registries, but they may be used in any setting where this information is collected. The Coma Scale codes should be sequenced after the diagnosis code(s). Like the BMI documentation, the Coma Scale may be documented by other clinicians, but the associated diagnosis (traumatic brain injury) must be documented by the provider. Some, but not all, of the Coma Scale codes equate to HCC 80.
  3. Diabetes HCCs 17, 18, 19: Diagnosis specificity documented by the provider is essential for correct HCC code assignments. One of the most common diagnoses documented is “Diabetes,” which is assigned to code E11.9 (Type 2 diabetes without complications) and equates to HCC 19 with a RAF score of 0.105. In comparison, if the provider documents Type 2 diabetes mellitus with hyperosmolarity (E11.00-E11.01) or Type 2 diabetes mellitus with ketoacidosis (E11.10-E11.11), both of which equates to HCC 17 RAF score 0.302. In contrast, if the documentation by the provider states Type 2 diabetes mellitus with diabetic nephropathy E11.21 or Type 2 diabetes mellitus with diabetic cataract E11.36, both of which equate to HCC 18 RAF score 0.302.
  4. History of Cerebral Infarction vs Cerebral Infarction with residual deficits: The documentation details surrounding a “history of stroke” is essential in correct code assignments. ICD-10-CM diagnosis code Z86.73 describes Personal history of transient ischemic attack (TIA), and cerebral infarction without residual deficits, which is an important code assignment for capturing the patient’s clinical history. However, it does not lead to an HCC. However, if the provider documents that the patient does have some residual deficits from a stroke, then an ICD-10-CM diagnosis code from category I69, Sequela of cerebrovascular disease, can be assigned and could be assigned to an HCC. For example, ICD-10-CM diagnosis code I69.051 (Hemiplegia and hemiparesis following nontraumatic subarachnoid hemorrhage affecting the right dominant side) equates to HCC 103 RAF score 0.437.
  5. Chronic Kidney Disease (CKD): As previously stated, documentation specificity is key to correct code and HCC assignment. And for CKD, the documentation of the CKD stage is essential. For example, CKD Stage 4 (N18.4 HCC 137 RAF 0.289) versus CKD unspecified (N18.9 no HCC). Also, many times, CKD is associated with hypertension or diabetes which is guided by the Official Coding Guidelines for ICD-10-CM regarding additional ICD-10-CM codes as well as sequencing. For comparison, CKD Stage 5 due to Type 2 diabetes mellitus with diabetic chronic kidney disease would result in the following code assignments: (E11.22 HCC18 RAF 0.302) and (N18.5 HCC 136 RAF 0.289). https://yes-himconsulting.com/hcc-coding-cheat-sheet-2023-top-missed-and-confusing-hcc-codes/

Documentation and Coding Guidelines: Ensure you know the official guidelines for both ICD-10-CM and HCC coding. Pay attention to specificity, sequencing, and documentation requirements.

https://www.cms.gov/files/document/fy-2025-icd-10-cm-coding-guidelines.pdf

Anatomy and Physiology: A solid understanding of human anatomy and physiology is crucial for accurate coding. Be prepared to apply this knowledge to clinical scenarios presented in the exam.

HCC Model:

The Hierarchical Condition Category (HCC) model uses medical coding to impact reimbursement by risk-adjusting payments based on a patient’s health complexity.  Patients with higher HCCs are expected to require more intensive treatment, so providers receive more money from CMS for these patients.
HCC codes are assigned to chronic and acute health conditions, like diabetes and congestive heart failure. A Risk Adjustment Factor (RAF) score is calculated from a patient’s HCCs and demographic information. The RAF score is then multiplied by a base rate to determine the provider’s reimbursement.
Accurate coding is crucial, as errors can significantly impact reimbursement. Undercoding due to incomplete medical records can result in lower payments. Conversely, documenting all health conditions to the correct level of specificity can increase payments.
A Risk Adjustment Factor (RAF) score is a numerical value that estimates how much it will cost to care for a patient in a given year. The score is based on a patient’s health conditions and demographic information and is often used by the Center for Medicaid and Medicare Services (CMS) or other government agencies.

Tips for Effective Preparation

  • Study Resources: Use AAPC’s CRC study guide and other recommended resources to build your knowledge base. AAPC Practice exams are particularly valuable for assessing your readiness.

https://www.aapc.com/shop2/study-guides/crc-study-guide.aspx

https://www.aapc.com/shop2/practice-exams.aspx#crc

  • Hands-on Experience: If possible, seek practical experience in a healthcare setting that deals with risk adjustment coding. Real-world exposure enhances understanding and retention.
  • Stay Updated: Keep abreast of changes in ICD-10-CM codes and guidelines. Subscribe to newsletters and attend webinars to stay informed about industry updates.

Exam Strategy

  • Time Management: Pace yourself during the exam. Allocate time-based on the number of questions and sections. Flag challenging questions for review
The process of elimination for the AAPC CRC exam involves:
  • Reading the question first
  • Scanning the case for keywords
  • Eliminating two answers
Here are some tips for using the process of elimination:
  • Read the guidelines
  • Highlight the guidelines
  • Take notes
  • Look for keywords
  • Check the first character of the code
  • Run straight to the answers
  • Look at the heading
  • Look for “with or with outs”:
  • Look for “do not report”
  • Check sequencing. Is a secondary code listed as a primary code? If so, eliminate this answer. 
  • Can
  • Read notes under the codes. You can often eliminate answers based on note details. 
  • Is a code mentioned in two answers? If so, go directly to that code to see if it fits the op notes and eliminate two answers based on what you find.

Many of the tips for the AAPC CPC exam can also be applied to the AAPC CRC exam:

https://codingclarified.com/tips-to-pass-the-aapc-cpc-exam/

Good Luck!

Share This