CMS Risk Adjustment Data Validation (RADV) Practice Exam

What causes a risk score to increase or decrease?

A risk score increases if additional conditions are reported and decreases if chronic conditions are not recaptured from the previous year A risk score decreases with age only A risk score is fixed and never changes A risk score depends only on treatment intensity

Correct Answer:

A risk score increases if additional conditions are reported and decreases if chronic conditions are not recaptured from the previous year

Explanation:

In CMS risk adjustment, the risk score is shaped by the set of diagnosed conditions captured for the year plus whether chronic conditions from the prior year are recaptured in the current year. When additional conditions are reported, the model adds the corresponding condition weights (HCCs), which increases the overall risk score because more predicted costs or resource use are inferred. If chronic conditions from the previous year are not recaptured in the current year, those conditions no longer contribute to the current calculation, so the risk score can decrease. Demographics and other factors can influence the score as well, but the essential idea is that more diagnosed conditions raise the score, and failing to capture prior chronic conditions lowers it.

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