Optimize RAF with the Right Clinical Documentation for Risk Adjustment – Part 5
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 78-year-old female patient with Arthritis unspecified, Angina pectoris, unspecified, Polyneuropathy unspecified
Category/ ICD10 | Diagnosis Description | CMS-HCC-V24 | CMS-HCC-V28 | CY2024 | |
---|---|---|---|---|---|
Raf Score | MA Payment | ||||
Demographic | - | - | - | 0.460 | $4634.72 |
Diagnosis | |||||
M1990 | Unspecified osteoarthritis, unspecified site (Non-HCC ICD10 Code) |
- | - | - | - |
I209 | Angina pectoris, unspecified | HCC 88 | - | 0.045 | $417.23 |
G629 | Polyneuropathy, unspecified (Non-HCC ICD10 Code) |
- | - | - | - |
Grand Total | - | - | - | 0.505 | $5051.95 |
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 78-year-old female patient with Rheumatoid arthritis, Unstable angina, Polyneuropathy due to alcohol.
Category/ ICD10 | Diagnosis Description | CMS-HCC-V24 | CMS-HCC-V28 | CY2024 | |
---|---|---|---|---|---|
Raf Score | MA Payment | ||||
Demographic | - | - | - | 0.460 | $4634.72 |
Diagnosis | |||||
M069 | Rheumatoid arthritis, unspecified | HCC 40 | HCC 93 | 0.139 | $1301.15 |
I200 | Unstable angina | HCC 87 | HCC 229 | 0.225 | $2275.36 |
G621 | Alcoholic polyneuropathy | HCC 75 | - | 0.156 | $1458.77 |
Grand Total | - | - | - | 0.980 | $9670.00 |
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 0.505, while Patient 2 has a RAF score of 0.980
Patient 1 | Patient 2 | Improvements |
---|---|---|
Arthritis unspecified | Rheumatoid arthritis | Type of arthritis is mentioned |
Angina pectoris, unspecified | Unstable angina | Type of angina is mentioned |
Polyneuropathy unspecified | Polyneuropathy due to alcohol | Type of neuropathy is mentioned |
For Patient 1, we have unspecified type of diagnoses.
For Patient 2, we have the type of the same diagnoses. Provider have documented correct type of diagnoses 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 0.505, resulting in an annual Medicare Advantage member payment of $5051.95, while Patient 2 had a RAF score of 0.980, with a potential Medicare Advantage member payment of $9670.00
It is crucial to accurately document disease type and appropriately acknowledge the effort of physician in serving a chronic conditions or complex population.
For Patient 2, we have the type of the same diagnoses. Provider have documented correct type of diagnoses 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 0.505, resulting in an annual Medicare Advantage member payment of $5051.95, while Patient 2 had a RAF score of 0.980, with a potential Medicare Advantage member payment of $9670.00
It is crucial to accurately document disease type 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.