Are Your Providers Following These Best Practices in Risk Adjustment? - AnewHealth

Are Your Providers Following These Best Practices in Risk Adjustment?

Blogs | 5 Minute Read

The Centers for Medicare & Medicaid Services (CMS) recently released the Risk Adjustment Data Validation (RADV) Final Rule, which will result in closer and more frequent auditing, among other  significant changes for Medicare Advantage organizations.1 Risk adjustment in itself is no walk in the park; accuracy is imperative to ensure compliance. And assigning proper Hierarchical Condition Categories (HCCs) requires careful documentation and coding, so the final rule brings challenging implications for all Medicare Advantage organizations.  

But risk adjustment doesn’t have to be the headache it always tends to be. By training your providers and coders in these six best practices, your organization can keep accurate reporting and ensure successful RADV audits.

1. Be specific.

Without specific documentation, it is impossible to code accurately. But what does “specific” mean? Consider the following motto when asking yourself that question: When able, always be more specific.

If you question whether certain elements matter, they most likely do. For a patient with mild major depressive disorder, for example, the condition will often translate to an HCC if severity is specified; however, documented it as “major depressive disorder” alone, it will not.2

Another thing to keep in mind is that specificity goes beyond documentation of a single episode or diagnosis but should also include details such as cause-and-effect relationships and complications of a condition. Most importantly, remember that adding specificity will improve quality patient care!

2. Words matter – use them properly.

In clinical documentation, one word can make the difference between accuracy and inaccuracy. When capturing conditions, avoid truncating or changing words around. Here’s an example:

A provider treating a patient with a remote history of breast cancer and documenting it as such does not influence risk score for that condition. Including “history of” when documenting the previous breast cancer is necessary for accuracy. If the provider were to document, for instance, “breast cancer, monitoring,” or “breast cancer no evidence of disease,” it would be coded and reported as if breast cancer were present or that it was currently being treated.

Just a simple alteration in wording, like the example given above, can result in noncompliance or inaccurate reimbursement. Be careful with your words.

3. Use the right language.

Coding is its own language, so it’s important that providers learn how to translate provider language from documentation into coding language. Providing clear and accurate statements in documentation results in proper translation to HCCs. The more specific documentation is (see point #1), the easier it will be to properly code. To help determine disease prevalence and identify potential gaps in documentation, providers and coders can reference data analytics using disease registries, claims, and other sources.

4. Capture relevant conditions every year.

HCCs do not roll over from year to year, so be sure to gather that information from all patients each year. Quiescent chronic conditions, specifically, are often missed in documentation because providers are focused on treating the acute conditions, but they must be documented to ensure accurate reimbursement.2

Continuous review throughout the year helps ensure complete documentation. Providers might use the encounter devoted to a Medicare Annual Wellness visit as an opportunity to address the presence and ongoing treatment of all chronic conditions This process may look different from one organization to another, but find what works for your organization and stick to it.

5. Avoid upcoding.

Upcoding is when a provider submits a more severe or expensive diagnosis than what a patient’s record reflects. Doing this knowingly or inadvertently is a violation of the False Claims Act. But even if you want to follow the rules, you can erroneously upcode if you aren’t careful, and it’s a primary reason CMS is implementing the final rule.

To support an HCC, a patient’s health record must both indicate the presence of the condition and show the provider’s management assessment and/or plan for the condition. Think back to the breast cancer example in point #2. If a provider is not treating the patient’s breast cancer but they document it without adding the prefix that it is a “History of Breast Cancer,” their organization is being credited for a diagnosis that does not exist. Again, this violates the False Claims Act.

It’s easier to accidentally upcode than one would think, but if you are specific and accurate in documentation—following what’s outlined in points one through three—you can keep your coding accurate.

6. Stay up to date on federal regulations and annual ICD-10 coding guidelines.

All organizations should have their own internal coding management strategies, but it’s important for those overseeing risk adjustment to be updated on federal guidance. Providers and coders should also read the ICD-10-CM Official Guidelines for Coding and Reporting every year to stay up to date on the proper coding practices. The guidelines are available on the CDC website and provide solutions for many issues that risk adjustment professionals come across when coding.

Complete and accurate reporting has always been critical to ensure compliance, and with CMS’ final rule, Medicare Advantage organizations need to take even more care in their processes. But train your providers properly, and you can ensure accuracy with every patient. When you incorporate the practical guidelines mentioned above, you will have more confidence in your compliance and assurance of proper reimbursement.


  1. CMS. Medicare Advantage Risk Adjustment Data Validation Final Rule (CMS-4185-F2) Fact Sheet. 30 Jan 2023.
  2. Watson MM. Documentation and coding practices for risk adjustment and Hierarchical Condition Categories. Journal of AHIMA. June 2018;89(6).

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