August Coding Tip Corner

You may be wondering why we are requesting a larger volume of records than normal! 

In 2025, the Centers for Medicare & Medicaid Services (CMS) significantly expanded its audits of Medicare Advantage (MA) plans, focusing on Risk Adjustment Data Validation (RADV). CMS has decided to audit all eligible MA contracts annually and aims to clear a backlog of audits from 2018–2024 by early next year. 

This expansion emphasizes the importance of compliance with CMS regulations and the need for all plans to maintain accurate and well-supported diagnosis codes in the medical records at the time of the visit. Remember, chronic conditions should be evaluated at least annually. 

As you can imagine, this is an enormous undertaking, and we are asking you to submit the records in a timely manner. 

Best Practices

Medical record documentation is the foundation of risk adjustment coding. Each diagnosis submitted for risk adjustment must be supported by clinical evidence in the patient’s chart. To avoid RADV risk adjustment discrepancies, ensure that: 

• All diagnoses are well-documented and linked to an assessment, treatment plan, or medication. 
• Providers are trained on proper Clinical Documentation Improvement (CDI) practices. 
• Periodic internal audits identify and correct potential documentation gaps before CMS data validation audits. 

Passing an RADV Audit

Aligning with the above, here are a couple of ways to ensure your medical records will pass a RADV audit when selected: 

• Accurate and Complete Documentation: Ensure that each diagnosis being submitted for risk adjustment is clearly supported at the time of the visit. This is done through clear, complete, and specific documentation in the patient’s medical record. This includes detailed physician notes, a valid provider signature, and dates consistent with the patient encounter. 
• Adherence to Coding Guidelines: Coded diagnoses should strictly follow the official conventions and instructions provided in the relevant ICD coding guidelines. Be sure you have the most current guidelines available, and if there is a question regarding a diagnosis, query the provider. Pay close attention to coding guidelines for specific conditions and any complications to ensure accurate representation in the medical record. 
• Remember, each diagnosis needs to show that it is supported in the record at the time of the visit.