Optimize RAF with the Right Clinical Documentation for Risk Adjustment – Part 7

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 77-year-old male patient with Liver disease, Kidney disease, Cardiac arrhythmia unspecified, Abnormal coagulation profile.

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	-	-	-	0.492	$4960.58
Diagnosis
K769	Liver disease, unspecified (Non-HCC ICD10 Code)	-	-	-	-
N289	Disorder of kidney and ureter, unspecified (Non-HCC ICD10 Code)	-	-	-	-
I499	Cardiac arrhythmia, unspecified (Non-HCC ICD10 Code)	-	-	-	-
R791	Abnormal coagulation profile (Non-HCC ICD10 Code)	-	-	-	-
Grand Total	-	-	-	0.492	$4960.58

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 77-year-old male patient with Liver failure, Chronic Kidney disease stage 3, Atrial Fibrillation, Coagulation defect.

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	-	-	-	0.492	$4960.58
Diagnosis
K7290	Hepatic failure, unspecified without coma	HCC 27	HCC 63	0.936	$9430.65
N1830	Chronic kidney disease, stage 3 unspecified	HCC 138	HCC 329	0.108	$1098.39
I4891	Unspecified atrial fibrillation	HCC 96	HCC 238	0.289	$2912.18
D689	Coagulation defect, unspecified	HCC 48	-	0.063	$593.40
HCC Count	-	-	-	0.002	$18.54
Grand Total	-	-	-	1.890	$19013.74

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 0.492, while Patient 2 has a RAF score of 1.890

Patient 1	Patient 2	Improvements
Liver disease	Liver failure	Liver disease state is failure that is mentioned
Kidney disease	Chronic Kidney disease, stage 3	Kidney disease state is chronic & stage 3 that is mentioned
Cardiac arrhythmia unspecified	Atrial Fibrillation	Arrhythmic state is A Fib that is mentioned
Abnormal coagulation profile	Coagulation defect	Coagulation abnormal state is mentioned as Coagulation defect

For Patient 1, the diagnosis state is not clearly documented. For Patient 2, the state of diagnoses has been clearly documented by the provider whenever applicable.

Although both patients have similar complexity, their diagnoses differ, and that leads to a significant gap in their RAF scores. Patient 1 has a total RAF score of 0.492, corresponding to an annual Medicare Advantage payment of $4,960.58. In contrast, Patient 2 has a RAF score of 1.890, which could result in a payment of $19,013.74.

Properly documenting the state of disease conditions and recognizing the physician's efforts in managing chronic conditions or complex cases is very necessary.

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.