How are risk scores calculated for RADV audit purposes?

The calculation of risk scores for Risk Adjustment Data Validation (RADV) audit purposes relies heavily on diagnosis codes documented and the risk adjustment methodology utilized by the Centers for Medicare & Medicaid Services (CMS). This methodology factors in the health status of the patient, which is represented through various diagnostic codes. Each diagnosis code corresponds to specific health conditions that can influence the expected healthcare costs for a patient.

In the context of risk adjustment, CMS applies a system known as Hierarchical Condition Categories (HCC), which groups together certain conditions to reflect the increased risk of healthcare utilization associated with those conditions. The accurate documentation of these diagnosis codes is fundamental because it directly impacts the risk score assigned. A higher risk score indicates patients who are expected to incur higher costs due to their health conditions, which is critical for appropriate reimbursement and resource allocation.

Other options, while related to patient health in some way, do not appropriately capture the comprehensive factors that go into calculating risk scores. Focusing solely on a patient’s age, the treatment they received, or their visit frequency does not encompass the complete picture of a patient’s health status that is crucial for risk adjustment purposes.