Optimize RAF with the Right Clinical Documentation for Risk Adjustment – Part 4

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:

Assessment says a 65-year-old male patient with Pancreatitis unspecified, Myasthenia gravis, Major depressive disorder single episode severe, coronary artery disease.

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	-	-	-	0.324	$3265.81
Diagnosis
K8510	Biliary acute pancreatitis without necrosis or infection (Non-HCC ICD10 Code)	-	-	-	-
G7000	Myasthenia gravis without (acute) exacerbation	HCC 75	HCC 196	0.501	$5055.07
F322	Major depressive disorder, single episode, severe without psychotic features	HCC 59	HCC 155	0.302	$3038.90
I2510	Atherosclerotic heart disease of native coronary artery without angina pectoris (Non-HCC ICD10 Code)	-	-	-	-
Grand Total	-	-	-	1.128	$ 11359.78

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:

Assessment says a 65-year-old male patient with Chronic Pancreatitis, Myasthenia gravis with (acute) exacerbation, Major depressive disorder single episode severe with psychotic features, coronary artery disease with angina.

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	-	-	-	0.324	$3265.81
Diagnosis
K861	Other chronic pancreatitis	HCC 34	HCC 79	0.334	$3375.15
G7001	Myasthenia gravis with (acute) exacerbation	HCC 75	HCC 195	2.105	$21733.25
F323	Major depressive disorder, single episode, severe with psychotic features	HCC 59	HCC 152	0.426	$4328.27
I25119	Atherosclerotic heart disease of native coronary artery with unspecified angina pectoris	HCC 88	-	0.045	$417.23
HCC COUNT	-	-	-	0.002	$18.54
Grand Total	-	-	-	3.236	$33138.24

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

Comparison of Patient 1 and 2:

Patient 1 has a RAF score of 1.128, while Patient 2 has a RAF score of 3.236

Patient 1	Patient 2	Improvements
Pancreatitis unspecified	Chronic Pancreatitis	Chronic Severity is mentioned
Myasthenia gravis	Myasthenia gravis with (acute) exacerbation	Exacerbation Severity is mentioned
Major depressive disorder, single episode, severe	Major depressive disorder, single episode, severe with psychotic features	Psychotic features Severity is mentioned
Coronary artery disease	Coronary artery disease with Angina	With angina Severity is mentioned

For Patient 1, we have unspecified Severity of diagnoses.

For Patient 2, we have severity of the same diagnoses. Provider have documented correct severity when applicable.

The two patients, despite having similar complexity, exhibit varying diagnoses, leading to significantly different RAF Score. Patient 1 had a total RAF score of 1.128, resulting in an annual Medicare Advantage member payment of $11359.78, while Patient 2 had a RAF score of 3.326, with a potential Medicare Advantage member payment of $33138.24

It is crucial to accurately document disease severity and appropriately acknowledge the effort of physician in serving a chronic conditions or complex population.

Note: 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.