Support HCC coding accuracy, RAF score optimization, and risk adjustment documentation completeness for Medicare Advantage and ACA populations. Use when analyzing risk adjustment factor scores, identifying suspected coding gaps, validating HCC capture, or preparing for RADV audits.
This skill analyzes diagnostic coding patterns, clinical documentation, and claims data to identify risk adjustment opportunities and documentation gaps. It applies CMS-HCC v28 model logic, RAF score calculations, and coding accuracy validation to support compliant revenue integrity for Medicare Advantage, ACA marketplace, and Medicaid managed care programs.
| Input | Description | Format |
|---|---|---|
| Diagnosis claims |
| ICD-10-CM codes with claim type, provider, DOS |
| Claims detail |
| Member demographics | DOB, sex, Medicaid dual status, disability status | Enrollment file |
| CMS-HCC model mappings | ICD-10 to HCC crosswalk (v28) | Reference table |
| RAF score output | Current and prior year RAF scores by member | Score file |
| Clinical notes (optional) | Provider documentation for chart review validation | Unstructured text |
| Pharmacy claims (optional) | Medication history for condition inference | Rx claims |
Process all diagnosis codes through the CMS-HCC v28 model:
Detect conditions likely present but not captured in current-year claims:
Review coding specificity for revenue-impacting distinctions:
Calculate the financial impact of identified gaps and specificity improvements:
Rank opportunities for provider engagement:
| Priority | Criteria | Action |
|---|---|---|
| Critical | High-RAF HCCs with strong clinical evidence, RADV risk | Immediate chart review + provider query |
| High | Historical drop-offs for well-documented chronic conditions | Prospective visit preparation |
| Medium | Pharmacy/lab inferred gaps needing clinical confirmation | Pre-visit medical record review |
| Low | Specificity improvements with modest RAF impact | Provider education sessions |
Ensure all risk adjustment activities comply with CMS guidelines:
Prepare audit-ready artifacts:
Risk Adjustment Report:
├── RAF Score Summary (avg RAF, distribution, YoY change, benchmark comparison)
├── HCC Gap Inventory (suspected gaps with evidence type and confidence level)
├── Revenue Impact Model (per-member and aggregate, by scenario)
├── Specificity Opportunity List (current vs. optimal code, RAF delta)
├── Provider Scorecard (coding accuracy rate, gap density, capture trends)
├── RADV Readiness Assessment (documentation confidence by HCC)
└── Compliance Attestation (guardrail validation results)
| Population | Expected Avg RAF | Low Concern | Investigate |
|---|---|---|---|
| MA general | 0.95 - 1.10 | 0.85 - 1.20 | < 0.80 or > 1.30 |
| MA D-SNP | 1.30 - 1.60 | 1.10 - 1.80 | < 1.00 or > 2.00 |
| ACA Individual | 1.00 - 1.20 | 0.90 - 1.40 | < 0.80 or > 1.50 |
Example 1 — MA Plan Annual Coding Review Analyze 50,000 MA members. Identify 8,200 suspected HCC gaps based on historical drop-off (4,100), pharmacy inference (2,800), and lab inference (1,300). Estimate $12.4M in recoverable revenue at 70% capture rate. Prioritize top 15 provider groups covering 60% of gaps for prospective chart review.
Example 2 — RADV Audit Preparation Prepare for CMS RADV audit on 200 sampled members. Score documentation confidence for each claimed HCC. Flag 34 HCCs across 22 members with low documentation confidence for pre-audit chart improvement. Estimate financial exposure of $890K if flagged HCCs are invalidated.
This skill processes Protected Health Information (PHI) including diagnosis codes, clinical documentation, and member identifiers. All outputs must comply with HIPAA Privacy and Security Rules. Risk adjustment analytics must be conducted under covered entity or business associate authority. De-identify outputs per 45 CFR §164.514 before sharing outside authorized workforce. Audit trails must be maintained for all chart review and coding modification activities.