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.
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.