Documentation is a key factor in Ensure Data Solutions

The Center for Medicare & Medicaid Services (CMS) Risk Adjustment Model ensures adequate resources to care for our high-risk Medicare Advantage members. Mandated by the Balance Budget Act (BBA) signed back on 1997. Prior to that the Risk Adjustment payments to MA plans were based on demographic information; age, gender, county of residence, Medicaid eligibility, etc.

The MRA model utilize a reimbursement method commonly referred as Risk Adjustment Factor-Hierarchical Conditions Categories (RAF-HCC) to adjust capitation payments to health plans.

Reimbursement Model

Data collection is the key for risk scores, since payments are based on diagnosis and conditions recorded the prior calendar year.

CMS will use de date of service and over 8830 diagnosis codes, for 2021 year the payment model is based 100% of the 2020 CMS-HCC mapping.

RAF Score

The RAF score identifies the members health status and drives reimbursement.

Lower RAF score not always indicates healthier population, lower RAF score can also indicate; lack of adequate chart documentation, lack of complete and accurate coding or patients have not been seen. To help identifying the reason of a low RAF score physicians can us

Clinical encounter data is submitted to CMS by Health Plans or their Business Associates throughout the year.

Medicare Risk Adjustment

What is the role of providers

 Providers must report the diagnosis codes to the higher level of specificity, they have to accurate complete medical record documentation and reports codes and complete clinical documentation to increases the accuracy of the patient’s RAF score.

After that each member is assigned a Risk Adjustment Factor (RAF), that is the numeric value assigned by CMS to identify the health status of a patient.  If two or more conditions are mapped to the same HCC category, will result in payment for only one and will be to the highest specificity code. Each diagnostic code falls into one diagnosis group and codes are grouped into condition categories.

CMS designed the equation so that the average Medicare patient has a score of 1.00

Related codes from different categories will result in payments for only the most severe manifestation of a disease, for example if an individual with diabetes has progress over a year from having no complications to having acute complications would trigger the payments for complication and the diabetes without complications would become irrelevant for scoring effects.


As we mentioned, documentation is a key factor and is also the law. Code all documented conditions that coexist at the time of the visit and require or affect patient care, treatment or management.

Conditions that were previously treated and no longer exist cannot be reported. However, history codes may be used ad secondary codes if the historical condition or family history has an impact on current care or influences treatment.

Accurate diagnosis code reporting and complete clinical documentation increases the accuracy of a patient’s RAF score

In the past in order for CMS to make a payment, documentation submitted must be from a face-to-face visit and must indicate how the provider is treating, managing or addressing the chronic conditions. Starting March 6, 2020 under the 1135 waiver CMS recognize telehealth as a way to see and diagnose the patient, for a full list of telehealth accepted services visit; 

Ensure Data Solutions Short Video

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