Optimize RAF with the Right Clinical Documentation for Risk Adjustment – Part 8

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 83-year-old male patient with CKD 4 due to Diabetes, Anemia 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	-	-	-	0.566	$5698.01
Diagnosis
E1122	Type 2 diabetes mellitus with diabetic chronic kidney disease	HCC 18	HCC 37	0.211	$2090.31
N184	Chronic kidney disease, stage 4 (severe)	HCC 137	-	0.440	$4475.54
D649	Anemia, unspecified (Non-HCC ICD10 Code)	-	-	-	-
Grand Total	-	-	-	1.217	$12263.87

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 83-year-old male patient with CKD 4 due to Diabetes, On Dialysis, Had one kidney transplanted last year, Anemia due to CKD.

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	-	-	-	0.566	$5698.01
Diagnosis
E1122	Type 2 diabetes mellitus with diabetic chronic kidney disease	HCC 18	HCC 37	0.211	$2090.31
N186	End stage renal disease	HCC 136	HCC 326	0.546	$5680.20
D631	Anemia in chronic kidney disease (Non-HCC ICD10 Code)	-	-	-	-
Z992	Dependence on renal dialysis	HCC 134	-	0.144	$1344.42
Z940	Kidney transplant status (Non-HCC ICD10 Code)	-	-	-	-
Grand Total	-	-	-	1.467	$14812.94

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	Patient 2	Difference
CKD 4 due to Diabetes	CKD 6 due to Diabetes	Stage is higher in the second patient
Not on Dialysis	On Dialysis	Dialysis status related to CKD is added in patient 2, Change in RAF score
No kidney transplant	Had one kidney transplanted	Transplant status related to CKD is added in patient 2, but no change in RAF score
Anemia unspecified	Anemia due to CKD	Cause for anemia is documented in patient 2, but no change in RAF score

Patient 1 has a RAF score of 1.217, while Patient 2 has a RAF score of 1.467

Patient 1 had an RAF score of 1.217, while Patient 2 had an RAF score of 1.467. The higher score for Patient 2 was influenced by stage 6 CKD and dialysis. Despite similar complexity, differences in diagnoses led to varying RAF scores. Patient 1’s RAF score of 1.217 corresponded to an annual Medicare Advantage member payment of $12,263.87, while Patient 2’s score of 1.467 resulted in a payment of $14,812.94.

Precise documentation of disease stage, associated diagnostic details, and acknowledgment of the physician’s role in managing chronic conditions or complex populations remain critical.

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.