Optimize RAF with the Right Clinical Documentation for Risk Adjustment – Part 1

This compares two simulated patients with similar complexities but different disease conditions to demonstrate how accurate clinical documentation impacts Risk Adjustment Factor (RAF) scores and potential Medicare Advantage (MA) payments. This is intended for CDI educational purposes only and illustrates how variations in disease conditions can affect RAF scores and corresponding MA payments.

Patient 1:

A 71-year-old female patient with type 2 diabetes without complications and body mass index (BMI) of 38.2, asthma, and heart disease

Category/ ICD10 Diagnosis Description CMS-HCC-V24 CMS-HCC-V28 CY2024
Raf Score MA Payment
- - - - 0.392 $3945.95
Diagnosis
E119 Type 2 diabetes mellitus
without complications
HCC 19 HCC 38 0.146 $1481.46
I519 Heart disease, unspecified
(Non-HCC ICD10 Code)
- - - -
Z6838 Body mass index [BMI] 38.0-38.9,
adult (Non-HCC ICD10 Code)
- - - -
J45909 Unspecified asthma, uncomplicated
(Non-HCC ICD10 Code)
- - - -
Grand Total - - - 0.538 $5427.42

Note: The Date of Service (DOS) is assumed to be in 2024, so the RAF scores are blended using both V24 and V28 models

Patient 2:

A 71-year-old female patient with type 2 diabetes without complications and body mass index (BMI) of 38.2, asthma, and heart disease

Category/ ICD10 Diagnosis Description CMS-HCC-V24 CMS-HCC-V28 CY2024
Raf Score MA Payment
- - - - 0.392 $3945.95
Diagnosis
E119 Type 2 diabetes mellitus
without complications
HCC 19 HCC 38 0.146 $1481.46
I519 Heart disease, unspecified
(Non-HCC ICD10 Code)
- - - -
Z6838 Body mass index [BMI] 38.0-38.9,
adult (Non-HCC ICD10 Code)
- - - -
J45909 Unspecified asthma, uncomplicated
(Non-HCC ICD10 Code)
- - - -
Diagnosis
J45909 Unspecified asthma, uncomplicated
(Non-HCC ICD10 Code)
- - - -
J45909 Unspecified asthma, uncomplicated
(Non-HCC ICD10 Code)
- - - -
Grand Total - - - 0.538 $5427.42

Comparison of Patient 1 and 2:

Patient 1 has a RAF score of 0.538, while Patient 2 has a RAF score of 1.705.

Patient 1 Patient 2 Improvements
Type 2 Diabetes Diabetic polyneuropathy Complication of DIABETES is mentioned in Example 2
Heart diseases Heart failure More specified Heart condition is documented
BMI Morbid obesity Documented diagnosis from value of BMI
Asthma COPD Documented high level of specified condition
For Patient 1, with a BMI of 38, there s no RAF Score. In Patient 2, diagnosed with morbid obesity and a BMI of 40, the HCC Risk Score is 0.207. Likewise, Patient 1 has asthma with an HCC Risk Score of zero, while Patient 2 has COPD with a risk score of 0.324.

In Patient 1, the diagnosis of type 2 diabetes without complications contributes 0.146 to the risk score. However, in patient 2, selecting the complication category results in an increased risk score of 0.211.

The two patients, despite having similar complexity, exhibit varying diagnoses, leading to significantly different RAF Score. Patient 1 had a total RAF score of 0.538, resulting in an annual Medicare Advantage member payment of $5427.42, while Patient 2 had a RAF score of 1.705, with a potential Medicare Advantage member payment of $17091.97.

It is crucial to accurately document and appropriately acknowledge the effort of physician in serving a chronic conditions or complex population.
Prior to documenting any diagnosis, physician should assess/evaluate and confirm it during the patient's visit. Unsupported diagnoses in documentation will not be upheld during an audit.