RADV Audit White Paper – Top 5 Takeaways

RADV Audit White Paper – Planning Ahead For Strict HCC Compliance Protocols

Key Findings on  From 400 RADV Audits, 2011-2021 


What is a RADV Audit?

The Medicare Risk Adjustment Validation Program (RADV Audit) was created to identify and correct past improper payments to Medicare providers and implement procedures to help the Centers for Medicare & Medicaid Services (CMS), Medicare carriers, fiscal intermediaries, and Medicare Administrative Contractors (MACs) implement actions that will prevent future improper payments.


Simply put, it is a process whereby CMS validates payments and recoups over-payments.


How does a RADV Audit work?

CMS selects a statistically valid sample of members enrolled in an Affordable Care Act (ACA) compliant plan. Providers whose patients are selected for an audit receive requests and must provide copies of medical records.The audit seeks to verify that diagnosis codes, submitted on claims and reported to CMS, are accurate, properly documented, and coded with appropriate levels of specificity.

In accordance with the provisions of the Patient Protection and Affordable Care Act (PPACA) and its risk adjustment data validation standards, CMS then takes that statistical information and extrapolates from it the amount of overpayment that the health plan or billing entity is responsible for. In many cases this can range from several $100Ks to several $MMs.

HCC Compliance RADV Audit

Takeaway 1: Small errors return large chargebacks

Extrapolating from statistics based on errors yields significant sums.


In the three case studies referenced in the white paper, the overpayment ranged from 10% – 12% of total annual revenue. As a percentage of profit, that is a sizable number. While Einstein may have said that compound interest is the most powerful force on earth, we say that extrapolated overpayments are the most powerful force in ruining your year.


Takeaway 2: Some codes get misused more than others


These are the top three misused HCC codes from the audits data:


HCC Description HCCs added by unlinked chart reviews Estimated payments from unlinked chart reviews Percentage of unlinked payments
HCC108 Vascular Disease 105,607 $269,536,256 10%
HCC18 Diabetes w/ comp 74,221 $208,226,576 8%
HCC111 COPD 67,703 $189,101,725 7%


Takeaway 3: Provider behavior is the first thing to fix

While there are many ways to chase down diagnoses after the fact, the gold standard for HCC coding is at the point-of-care, right there with the patient. The opportunity for improvement in this stage has more to do with the tools that change behavior than the tools that chase data. Changing behavior is difficult, and the old-fashioned lecture approach to HCC learning is not likely to succeed.


Takeaway 4: Proper documentation fixes everything

Once the challenge of changing provider behavior has been tamed, the next beast lives inside the EMR. Whether you’re talking recapture rates or suspecting, there are significant financial risks in coding without proper documentation. Solutions that connect encounter data to HCC documentation to automate compliance are mission-critical for physician groups. These solutions will help groups provide top-quality care and protect them from negative RADV audits.


Takeaway 5: Without proper tools, documentation is daunting

At the risk of shameless self-promotion, we have enabled myriad providers with the tools to ensure the best possible outcome from a RADV audit. From capturing diagnoses at the point-of-care to ensuring documentation compliance — the DoctusTech family is ready for an audit. Our tools mean you are unlikely to be caught with your hand in the CMS cookie jar, and be put in the uncomfortable position of watching your revenue evaporate.


To learn more about how we prepare you for a RADV audit, help your providers improve HCC coding, and boost RAF accuracy by 30%, book some time with our HCC expert HERE.



Access the full white paper here

Planning Ahead For Strict HCC Compliance Protocols
Key Findings From 400 RADV Audits, 2011-2021

HCC Compliance RADV Audit White Paper

HCC Quick Start Guide


Diagnosis Coding For Risk Adjustment – Are You Ready (AAFP)

The AAFP is a great first-stop for information on Risk Adjustment and HCC Diagnosis Coding. And although this article is a few years old (2018), their take on HCC Diagnosis Coding for Risk Adjustment is both unique and extremely helpful.

First, they lay out what it is and how it works. Then they tie it in with IDC-10 codes and HCC coding, to paint—with a broad brush—the full picture of what a practice will need to know, do and master to step into a risk adjustment payment model.





  1. Mapping ICD-10 codes to Hierarchical Condition Category (HCC) codes determines the severity of illness.
  2. Risk-adjustment factors heavily into new payment models.
  3. Physicians should report any diagnosis codes associated with chronic conditions that affect treatment choices, not just the diagnosis codes that describe why a patient came in .
  4. Physicians should comprehensively code chronic conditions at annual visits, as RAF (patient risk) scores reset every year.


Diagnosis Coding for Risk Adjustment




First it may be helpful to briefly review the connection between coding, risk adjustment, and payment. Risk-adjustment models assign each patient a risk score based on demographics and health status. Demographic variables may include age, gender, dual Medicare/Medicaid eligibility, whether the patient lives at home or in an institution, and whether the patient has end-stage renal disease. Health status is based on the diagnosis codes submitted on inpatient, outpatient, and professional claims in a calendar year. Certain diagnosis codes map to disease groups (HCCs). Demographics and HCCs are weighted and used to calculate a risk-adjustment factor (RAF) score. – AAFP


The author then compiled a series of examples of HCC coding options, and how to determine which codes to use. Full list of examples here.



Family physicians can increase the accuracy of risk-adjustment scoring by focusing on capturing diagnosis codes for the conditions they see frequently. Electronic health record (EHR) systems can help by identifying diagnosis codes that carry an HCC weight, but most do not. A related article in this issue includes a reference tool that physicians can use to keep HCC codes and RAF scoring in mind when selecting diagnosis codes.





Link: https://www.aafp.org/fpm/2018/0300/p21.html




White Paper: Planning Ahead For Strict HCC Compliance Protocols
Key Findings From 400 RADV Audits, 2011-2021

HCC Quick Start Guide

Additional HCC Coding resources from The AAFP: https://www.aafp.org/fpm/2018/0300/fpm20180300p26-rt1.pdf

Value-based Care Contracting 101

Value-Based Care Contracting 101

Value-based Care Contracting is a key component to your VBC program. Fee-for-service contracts continue to be a challenge for VBC. The pandemic led to a drastic reduction in volumes that impacted FFS contracts revenue ($15B loss due to volume dips).

During the pandemic, organizations with value-based contracts were able to pivot operations to maintain revenue even when the volumes dropped. VBC payments will increase rapidly in the near future as hospitals and physician practices look to protect themselves against future downturns.

Value-based Care Contracting
Value-based Care Contracting Image Credit: healthpolicy.usc.edu

Revcycle Intelligence (of Xtelligent Healthcare Media) shared an in-depth article highlighting how to succeed at value-based contracting. We share our takeaways from the article below. 

Prior to engaging in contract negotiations:

  • Have a strong clinical leadership team to engage your physicians as their top priority (not 0.2 FTE). 
  • Build a strong referral network that can be managed tightly with hospitals and specialists
  • Make a meaningful investment in changing FFS workflows to optimize patient care and care coordination. Tracking and accountability are key.
  • Build strong financial models. Do you have the resources that you need to manage those medical costs and administrative costs of that population that you might get?


Heading into contract negotiations:

  • Promote your organization’s quality metrics. Do you have longer clinic hours compared to your neighboring groups? Do you have better STARS/HEDIS scores? Are you leading in patient satisfaction scores?
  • Build an experienced team to handle payor contract negotiations. Every contract is unique, and the fine print matters. Most importantly, understand how your payor will attribute patients.
  • Don’t over-commit on what data you can collect and report. Prepare your IT infrastructure well ahead of time. 
  • Make sure your payors will be good partners in promoting your group and helping you grow your patient base.


After the negotiation:

  • Growth is key because organizations need a panel of patients for contracts to work, and those patients cannot all be high-risk. 
  • Keep close tabs on provider satisfaction, physician growth, and employer satisfaction with the care delivered. 
  • Noticeable dips in quality performance may necessitate change and possibly another round of negotiation. Identify shortfalls early and frequently communicate with your payor partners.
  • Success begets success with payor contracts. 

Read More:  Value-Based Contracting 101: Preparing, Negotiating and Succeeding

Link: https://revcycleintelligence.com/features/value-based-contracting-101-preparing-negotiating-and-succeeding

Doctus Team


5 Strategies for a Highly Effective HCC Coding Program

HCC Coding Program

You need a highly effective HCC Coding Program. If you’re a physician group engaging in value-based care arrangements: coding and documentation accuracy should be your top priorities. And inaction on your part will result in immediate loss of revenue and exposure to heavy audit penalties.

Whether you’re building a program from scratch or already have a program in place, the top five strategies for a successful program include:


Clinician Education — One-hour seminars or “codes of the month” emails don’t work.

Concurrent Chart Audits — This is more than checking boxes in the EMR to drag and drop chronic conditions into the progress note.

Point-of-care Clinical Guidance — Contrary to popular belief, we doctors don’t know everything! We make mistakes, and we don’t always have time.

Data Analytics — It’s painful and sometimes daunting, but it doesn’t have to be. Focus on a few critical points below to help drive an effective program.

Accountability — It’s a team effort. No single person should be held liable to be commended for the results.


HCC Coding Program
HCC Coding Program Photo by RODNAE Productions from Pexels


Let’s dive deeper into your HCC Coding Program.


Clinicians, on average, retain 15% of any educational seminar you send them to after residency. Even with 15% knowledge retention, there is a consistent regression to the mean after eight weeks. Out of sight, out mind!

No one size fits all, but we know the Socratic method of teaching, consistent education, and regular feedback result in sustained behavior change amongst clinicians.

Socratic method —

Stop teaching at doctors and start objectively testing their knowledge. Try clinical vignettes in small group settings. Problem-based learning is how most medical education is practiced today, and yet, coding education has not caught up. Customize training to your clinician skill sets and practice patterns to improve buy-in.


Consistent education —

Training is done once a quarter or via email will consistently fall flat. Clinicians have a lot going on, and to cement, any new information must be presented to them multiple times and in various ways. This doesn’t have to be time-consuming but does need to remain consistent.


Regular feedback —

We, clinicians, don’t like to be wrong and always strive to be better. So customized feedback on documentation accuracy and opportunities for improvement are critical. Moving away from clinic-based or team-based results. Make sure each of your clinicians knows their strengths and weakness as it compares to the group.


Clinicians, on average, retain 15% of any educational seminar you send them to.


This will assist you to impact in 2 ways: A) Ensure compliant documentation B) Adjudicating any claims submitted.


A typical clinical documentation improvement program ensures correction of over-and-under coding before billing. Typically institutions “hold” a bill for two business days to make any corrections. During this period, the provider can be asked to clarify inaccurate documentation and adjudicate the superbill to ensure proper 1:1 matching with progress notes to billable codes. Much of this is currently handled at the payor level for smaller physician groups.


As you start to take on more risk as a physician practice, you’ll need a consistent strategy across all your payor contracts. While vendors are currently using a heavily manual process, emerging technology from DoctusTech will help you do this at the point of care with our A.I. This will drop your OpEx, decrease your risk during RAD-V audits, and give you a more accurate line of sight to your risk scores.



Doctors were not trained as coders, and coders were not trained as doctors. The basic premise of accurate documentation is and should be clinical. Clinicians need to take better histories, perform more accurate physical exams, and synthesize data to make clinical diagnoses. No coder or AI can replace and find these diagnoses as the data is inherently flawed with significant gaps.


DoctusTech can help doctors ask better questions, perform accurate exams, and present clinical guidelines to lets doctors practice medicine. This will inherently improve your RAF accuracy and create physician buy-in better than any Natural Language Processing or A.I. alone. Unfortunately, EMRs are limited by their data sets. They operate only off the information inputted, so if your PCP doesn’t have the complete clinical picture from your hospital systems and your specialists inputted into the EMR, the clinical decision support in your EMR will be lacking.


HCC Coding Program
HCC Coding Program Photo by energepic.com from Pexels



No pilot would fly a plane without an operational dashboard, so why do we allow the same for such a critical part of our value-based care business? No excuses, no delays. The ability to aggregate data from outside your EMR, deliver individual physician report cards on HCC documentation, and having visibility to patient annual wellness visits (AWVs) for everyone on the team is critical. If your team doesn’t have bandwidth, vendor it out. Time is critical, and the ROI is clear.


Remember, if the data is not easy to fetch and easy to understand, no one will use it. This does not need to be an expensive endeavor. Make sure you have visibility to the following data points by an individual physician.


    • Patient panel
    • Suspect vs. chronic diagnosis by patient
    • Complete vs. incomplete AWVs
    • % conditions addressed by a physician at each visit
    • Documentation accuracy



Whether you plan to use a stick or a carrot approach to accurate documentation, the strategy needs to be intentional and meaningful. The entire team plays a role in an effective program, and accordingly, the strategies you deploy should touch each individual team member in a meaningful way. Rewards do not need to be financial, and the motivation here is it drives better clinical care. The emphasis in the following areas are compliant and effective:

    • Documentation accuracy
    • % AWVs scheduled
    • Regular engagement with any coding tools


DoctusTech’s proprietary A.I. can be embedded into your EMR or on your mobile phone to help you complete steps 1,2,3,4 very effectively. All you have to do is be ready to hold your team accountable.

Schedule a demo today & let us show you how.

— DoctusTech Team

What is HCC Coding: Risk Adjustment Models in Value-Based Care

What is HCC Coding?

What is HCC coding? 
HCC stands for hierarchical condition category. It is a risk-adjustment coding model exclusively designed for estimating future healthcare costs for patients. The process of HCCs medical coding started in 2004, but it recently gained popularity due to payment models shifting from fee-for-service (FFS) to value-based care (VBC) arrangements.

What is HCC Coding and Risk Adjustment?

Fig 1.
Out of 70,000+ ICD10 codes, approximately 9,500 ICD10s map to a hierarchical condition category. Each HCC ICD10 is subsequently bucketed into 86 individual “condition categories.”

What is HCC Coding and Risk Adjustment?

Fig 2.
Each of the 9,500 HCC codes are put into one of 86 condition categories. Each condition category carries a specific RAF. No matter how many ICD10 conditions a patient has in the same category, they will only be assigned the RAF score one time.


Medicare assigns a risk score known as a risk adjustment factor (RAF) to each of the 86 individual condition categories. RAF scores of patient populations are subsequently used by Medicare and other payors to predict the cost of care, which influences reimbursements.

For the remainder of this article, we will explore the rationale behind HCC coding and why all providers (even those NOT in a value-based care arrangement) should care.

Why should doctors care about HCC coding?

HCC coding is the cornerstone of most value-based care arrangements. Today, “value-based care” is used synonymously with Medicare Advantage, but in the near future, we believe all forms of reimbursement will be tied to some VBC arrangement.


HCC coding falls under the broader term of risk adjustment (RA) models where patient care is paid based on a prospective payment model. Specially designed RA models are used to determine risk scores for patients. In the Medicare Advantage world, these models use the demographics and HCC diagnoses of the patient to assign a risk score known as an RAF. The assumption is the sicker the patient, the higher the RAF, the more dollars it will take to care for this patient during any given year. Therefore the RAF score of any patient population will determine the prospective payment Medicare disburses.

This prospective payment model based on RAF does 2 things:


1. Aligns physician incentives. Currently, clinicians make money from taking care of sick patients. The sicker the patient, the more visits, tests, surgeries they have to do, and the more they are reimbursed. In this model, clinicians are incentivized to keep patients healthy and therefore require LESS tests and surgeries.


2. Spurs clinical innovation the right way. Right now, pharmaceuticals and medical hardware companies are all trying to find ways to treat diseases. The newer the drug or medical device, the more revenue they make. In this model, healthcare groups are incentivized to find new ways of preventing the disease progression from ever needing the latest drug or newest medical surgery equipment.


As Medicare and payers alike are starting to take notice of #1 and #2 above, the market is now trending towards building in value-based care drivers to all types of patients outside of Medicare Advantage. It’s unlikely a brand new risk model will be born for commercial patients. Therefore, all physicians will need to understand the risk adjustment models and the implications of documentation accuracy for reimbursement.



HCC coding is here to stay and will only grow in the years to come. While the market has heavily leveraged medical coders or third party vendors to do much of the lift thus far, V2 of Value-based Care will require all clinicians to understand and participate in it for every patient visit.


HCC coding’s importance is less about the impact on revenue and more about the shift towards VBC models, which have consistently shown better clinical outcomes at lower costs. In our next 2 posts, we will dive deeper into the financial implications of HCC coding, HCC coding tools,  and the clinical outcomes associated with VBC in 2021.


— DoctusTech Team