Risk-Adjustment Data Validation Readiness: Key Strategies for Compliance

Did you know that there are publicly accessible resources identifying highly scrutinized Hierarchical Condition Category (HCC) codes that may be problematic for your plan? Did you know there’s an annual report of the most commonly miscoded HCC codes across the US? Are you being selected for Payment Year (PY) 2018 Risk Adjustment Data Validation (RADV) audits happening as we speak?

In November 2024, CMS issued a Questions and Answers memo regarding PY2018 RADV audits that kicked off on November 14, 2024, identifying 60 Medicare Advantage contracts that will be audited. These audits may result in overpayment determinations and overpayment collections if it’s determined that Medicare Advantage Organizations (MAOs) are unable to confirm submitted diagnoses. Audit results are expected mid-year 2026. MAOs who do not agree with review determinations and/or payment error calculations will have 60 days to appeal the findings. More information about the RADV appeals process can be found at 42 CFR 422.311(c).

Looking forward

While you may not be able to impact your PY 2018 medical record documentation, now is the time tobegin focusing on trends in documentation and areas of opportunity. The 2024 CMS-HCC model had several changes that will be phased in over a three-year timespan, from 2023 to 2025. New HCC codes have been added, bringing the total number to 266, with a total of 115 codes in the payment model. There are also code numbering changes made to better align these HCCs with the most appropriate disease category avoiding the need for large scale renumbering in the future.

Some of the new diagnoses in the 2024 model include, but are not limited to:

• Alcoholic hepatitis with and without ascites,
• Toxic liver disease with hepatitis,
• Malignant ascites,
• Anorexia nervosa and bulimia nervosa, and
• Severe, persistent asthma.

Miscoded HCCs

Last year, the Office of Inspector General (OIG) noted the following high-risk for miscoding groups in their audit which can be found here:

• Acute stroke
• Acute heart attack
• Embolism
• Lung cancer
• Breast cancer
• Colon cancer
• Prostate cancer
• Potentially mis-keyed diagnosis codes

Common trends in errors include active treatment (for disease) vs. a history (of disease), abuse vs. use, and history of (diagnosis) vs. acute (diagnosis) to name a few. An example of one of these errors was related to HCC 100 Ischemic or unspecific stroke. This HCC is for an acute stroke event and does not map to diagnosis codes for a history of stroke. In many cases, this HCC was coded for an acute stroke when the documentation reflected a history of stroke being the appropriate diagnosis. Rarely would it be expected to see an acute stroke diagnosis made at an outpatient office visit however, this was noted as a common occurrence when patients were seen for their hospital follow-up. Plans should partner with their providers to ensure accurate coding and provide education in areas of concern as indicated by trends in their coding data.