Optimize RAF with the Right Clinical Documentation for Risk Adjustment – Part 2

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 68-year-old female patient with SOB, uncontrolled type 2 diabetes mellitus, kidney disease, Major depressive disorder single episode unspecified, Heart failure and Pressure ulcer of heel unspecified.

Category/ ICD10	Diagnosis Description	CMS-HCC-V24	CMS-HCC-V28	CY2024
Category/ ICD10	Diagnosis Description	CMS-HCC-V24	CMS-HCC-V28	Raf Score	MA Payment
-	-	-	-	0.328	$3298.23
Diagnosis
E119	Type 2 diabetes mellitus without complications	HCC 19	HCC 38	0.146	$1481.46
I519	Heart disease, unspecified (Non-HCC ICD10 Code)	HCC 85	HCC 226	0.350	$3532.04
N19	Unspecified kidney failure (Non-HCC ICD10 Code)	-	-	-	-
L89609	Pressure ulcer of unspecified heel,unspecified stage (Non-HCC ICD10 Code)	-	-	-	-
R0602	Shortness of breath (Non-HCC ICD10 Code)	-	-	-	-
F329	Major depressive disorder, single episode, unspecified (Non-HCC ICD10 Code)	-	-	-	-
Disease Interactions
DIABETES_CHF	-	-	-	0.115	$1154.56
Grand Total	-	-	-	0.939	$9466.28

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

Patient 2:

A 68-year-old female patient with COPD, type 2 diabetes mellitus with hyperglycemia, chronic kidney disease -stage4, Major depressive disorder single episode- Mild, Heart failure and Pressure ulcer of right heel- Stage3.

Category/ ICD10	Diagnosis Description	CMS-HCC-V24	CMS-HCC-V28	CY2024
Category/ ICD10	Diagnosis Description	CMS-HCC-V24	CMS-HCC-V28	Raf Score	MA Payment
Demographic	-	-	-	0.328	$3298.23
Diagnosis
E119	Type 2 diabetes mellitus without complications	HCC 18	HCC 38	0.211	$2090.31
I509	Heart disease, unspecified	HCC 85	HCC 226	0.350	$3532.04
N184	Chronic kidney disease, stage 4 (severe)	HCC 137	HCC 327	0.440	$4475.54
L89613	Pressure ulcer of right heel, stage 3	HCC 158	HCC 381	1.073	$10796.16
J449	Chronic obstructive pulmonary disease, unspecified	HCC 111	HCC 280	0.324	$3258.65
F320	Major depressive disorder, single episode, mild	HCC 59	-	0.102	$955.00
HCC COUNT	-	-	-	0.059	$586.46
Disease Interactions
CHF_COPD	-	-	-	0.103	$1022.67
CHF_RENAL	-	-	-	0.169	$1708.78
DIABETES_CHF	-	-	-	0.115	$1154.56
Grand Total	-	-	-	3.275	$32878.39

Comparison of Patient 1 and 2:

Patient 1	Patient 2	Improvements
Type 2 Diabetes - Uncontrolled	Type 2 diabetes with hyperglycemia	Confirmed the states of uncontrolled as hyperglycemia
Heart failure	Congestive heart failure - systolic	Confirmed specificity of heart failure as systolic
BMI	Morbid obesity	Documented diagnosis from value of BMI
Kidney failure	Chronic Kidney Failure stage 4	Confirmed specificity of kidney failure with stage 4
Pressure ulcer of heel	Pressure ulcer of right heel wih stage 3	Confirmed stage 3 of pressure ulcer
Shortness of breath	COPD	Specified more form of diagosis
Major depressive disorder single episode	Major depressive disorder single episode, Mild	Confirmed severity of condition

Patient 1 shows a diagnosis of SOB, resulting in an HCC Risk Score of zero. Patient 2 shows a diagnosis of COPD, leading to an HCC Risk Score of 0.324. Similarly, Patient 1 presents with Type 2 Diabetes- Uncontrolled, resulting in an HCC Risk Score of 0.146, while Patient 2's uncontrolled DM implies hyperglycemia and carries a risk score of 0.211. (Uncontrolled means, should confirm with Hyperglycemia or Hypoglycemia).

If a patient is diagnosed with major depression, leaving it uncategorized adds no value. However, selecting any category, such as "single episode" and "severity of condition" as in patient 2, adds a risk score of 0.102. Unspecified kidney failure carries an HCC risk score of zero, while Patient 2, diagnosed with chronic kidney failure and stages, has an HCC risk score of 0.440.

Similarly, Patient 1 diagnosed with pressure ulcer of heel unspecified has a HCC risk score value of zero, while Patient 2 diagnosed with pressure ulcer of right heel-Stage3 has an HCC risk score value of 1.073.

Patient 1 has a total RAF score of 0.939, which corresponds to a potential annual Medicare Advantage payment of $9,466.28. Patient 2 has a RAF score of 3.275, indicating a potential annual Medicare Advantage payment of $32,878.39.