How the MSSP Rule Reshapes Risk Adjustment Coding for ACOs

Quick glossary

CMS = Centers for Medicare & Medicaid Services
MSSP = Medicare Shared Savings Program
ACO = Accountable Care Organization
HCC = Hierarchical Condition Categories
RAF = Risk Adjustment Factor

 

CMS released its final Medicare Shared Savings Program rule, called Pathways to Success, for ACOs. The new rule is designed to help establish a path toward risk, with a heavy focus on risk adjustment coding.

 

MSSP outlines a clear transition to risk, allowing ACOs to start at different points, depending on their current organizational status. It extends the agreement period from 3 to 5 years, which provides more time to measure performance against the benchmark. This creates Basic and Enhanced track options en route to risk (see Image A).

Why Risk Adjustment Coding in MSSPs and ACOs matters now

 

Many ACOs historically deprioritized HCC coding because benchmarks leaned heavily on past performance and offered little reward for better specificity. Pathways to Success removes key limitations and introduces a 3 percent cap on upward RAF changes from historical to performance year, altering the incentive math. If your RAF dipped between BY3 and PY1, you can improve beyond 3 percent to offset prior declines.

 

Image A Basic & Enhanced Tracks

Why ACOs that skipped HCC coding should reconsider

 

The adoption of HCC risk adjustment best practices has been recognized by Medicare Advantage plans for several years. In contrast, ACOs that participate in the Medicare Shared Savings Program (MSSP) have opted out of any type of program, as they felt it had little effect on their benchmark. This is often due to an ACO’s experience within the MSSP. 

 

However, the new changes open many doors to those who may have shied away from risk in the past, for reasons such as:

 

• • Benchmarks were based 100% on an ACO’s historical success.
  • No adjustments were made to the true risk score; therefore, no penalty was applied for similar low risk scores year over year.
  • False or inaccurate predictions of condition profiles of beneficiaries.
  • Re-enrolled beneficiaries were given a demographic adjustment only, making it very difficult for an ACO to improve coding and increase benchmarks.

 

What changed: Given the new Pathways to Success rule, ACO groups are being shown risk adjustment in a different light. There are no more restrictions on RAF changes for the historical beneficiary. Instead, there is a 3 percent limit on the total increase from the historical year to the performance year.

 

The data signal ACOs cannot ignore

 

ACOs continue to lag in the adoption of HCC coding practices. According to the most recent 2019 Shared Savings PUF file, 49% of groups have experienced a decrease in RAF from the benchmark year 3 (BY3) to the Performance Year (PY1). RAF scores on these groups dropped from 1.0149 within BY3 to .9819 in PY1 on average, showing a -3.25% drop (see below in Image B). 

 

As a result, ACOs could have faced a significant uphill battle over the next few performance years as they attempt to true up their future benchmarks. This is one significant issue addressed by MSSP.

 

Key implication: Coding improvements are capped at 3 percent; however, the prior drop from BY3 to PY1 means an ACO can improve above the allowed 3 percent in net effect because the increase is measured against the historical performance year change. In practice, that means there is room to regain lost ground.

 

Image B: RAF Decrease PUF file 2019 ACO MSSP

What “good” looks like: best practices you can adopt now

 

There are several best practices an ACO can adopt to help succeed within the new model. Many ACOs are now looking toward Risk Adjustment, which not only allows highlighting of high-risk patient populations, but will also provide a more accurate way of predicting cost and determining reimbursement.

 

By adopting best practices in HCC coding, you can ensure that your medical group achieves the highest specificity in diagnoses, thereby ensuring quality of care and compliance.

 

What exactly are these best Risk Adjustment Coding practices that can be adopted?

 

1) Educating Providers

• • Short, recurring training focused on common chronic conditions, MEAT criteria, and documentation specificity.
    
  • Practical pocket guides and quick tips embedded in the workflow.

 

2) Making correct preparations before an encounter

• • Pre-visit summaries that surface suspected but unconfirmed conditions, open care gaps, recent hospital or ED use, and last-year HCCs that require recapture.

 

3) Documentation of all current chronic conditions

• • Assess, treat, and document active conditions that affect care, even if not the chief complaint.
    
  • Include status, control, and current plan. Avoid vague terms.

 

4) Ensuring a clean clinical workflow to display conditions for clinicians

• • One screen or panel that cues accurate HCCs

 

5) Post-encounter review for quality assurance

• • Same-day or next-day audits of a small sample to catch unsupported codes, missing MEAT, and upcode risks.
    
  • Rapid feedback loop to the clinician.

 

Building the engine: data you will need and how to make it actionable

As value-based care is being adopted on a broader scale, the traditional fee-for-service payment model is slowly being replaced. More time is being spent with patients to treat all chronic conditions during the encounter, which is becoming a best practice.

 

One of the major issues that medical groups contend with is the ability to utilize all relevant data to create an aligned clinical workflow that helps physicians recapture, diagnose, and reject any inaccurate conditions. A melee of data is combined in the form of claims data, RX data, member eligibility, historical diagnosis, and utilization. The ability to organize this data into actionable insights, clinical suggestions, and quality opportunities is a huge task for any ACO. 

 

Here at DoctusTech, we can offer a solution to this issue. Click below to learn how we address Risk Adjustment Coding at DoctusTech.

 

Need better RAF scores and recapture rates in your practice? Demo the DoctusTech integrated tools, and learn how to make your value-based care contracts more profitable. Schedule a demo today.

 

What is Risk Adjustment Coding in MSSP and ACOs?

Risk adjustment coding in the Medicare Shared Savings Program (MSSP) allows Accountable Care Organizations (ACOs) to document patient complexity more accurately. By capturing Hierarchical Condition Categories (HCCs), ACOs can more accurately predict costs, establish fair benchmarks, and enhance reimbursement while maintaining compliance.

What are the best practices for ACOs to improve risk adjustment coding?

Leading ACOs focus on provider education, pre-visit preparation, documentation of all chronic conditions, integrated workflows for clinicians, and post-encounter quality review. These steps ensure specificity, compliance, and higher RAF recapture rates that align with MSSP goals.

How can technology support ACOs in risk adjustment coding?

Technology solutions—like DoctusTech’s tools—integrate claims, pharmacy, eligibility, and historical diagnosis data into actionable insights. They streamline workflows, flag documentation gaps, and ensure MEAT compliance, allowing clinicians to focus on patient care while ACOs improve RAF scores and financial outcomes.