Optimize RAF with the Right Clinical Documentation for Risk Adjustment – Part 6

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 80-year-old female patient with Atrial Fibrillation, Sarcoidosis unspecified, Malignant (primary) neoplasm unspecified, Atherosclerosis 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
Demographic	-	-	-	0.525	$5283.90
Diagnosis
I4891	Unspecified atrial fibrillation	HCC 96	HCC 238	0.289	$2912.18
D869	Sarcoidosis, unspecified (Non-HCC ICD10 Code)	-	-	-	-
C801	Malignant (primary) neoplasm, unspecified	HCC 12	HCC 23	0.174	$1759.94
I7090	Unspecified atherosclerosis (Non-HCC ICD10 Code)	-	-	-	-
Grand Total	-	-	-	0.988	$9956.02

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 80-year-old female patient with Ventricular Fibrillation, Sarcoidosis of Skin, Malignant (primary) neoplasm Lung, Atherosclerosis of Aorta.

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	-	-	-	0.525	$5283.90
Diagnosis
14901	Ventricular fibrillation	HCC 84	HCC 213	0.341	$3450.30
D863	Sarcoidosis of skin	-	HCC 387	0.272	$2829.64
C3490	Malignant neoplasm of unspecified part of unspecified bronchus or lung	HCC 9	HCC 20	1.099	$11082.22
I700	Atherosclerosis of aorta	HCC 108	-	0.095	$890.10
Grand Total	-	-	-	2.332	$23536.16

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 0.988, while Patient 2 has a RAF score of 2.332

Patient 1	Patient 2	Improvements
Atrial Fibrillation	Ventricular Fibrillation	Site of the fibrillation is mentioned
Sarcoidosis, unspecified	Sarcoidosis of Skin	Site of the Sarcoidosis is mentioned
Malignant (primary) neoplasm, unspecified	Malignant (primary) neoplasm Lung	Site of the neoplasm is mentioned
Atherosclerosis unspecified	Atherosclerosis of Aorta	Site of the atherosclerosis is mentioned

For Patient 1, the diagnosis site is missing. For Patient 2, the diagnosis site is documented. The provider has recorded precise anatomical locations where necessary.

Although both patients have similar complexity, their diagnoses vary, which leads to a significant difference in RAF scores. Patient 1 has a total RAF score of 0.988, resulting in an annual Medicare Advantage payment of $9,956.02, while Patient 2 has a RAF score of 2.332, leading to a potential payment of $23,536.16.

Accurately documenting disease sites and recognizing physicians' efforts in treating chronic or complex cases is essential.

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.