If RADV audits were a clinical exam, your plan doesn’t get partial credit—you get one shot per diagnosis. That’s because CMS only uses a single “best” medical record (MR) to validate each HCC for every audited enrollee. Think of it like choosing your strongest lab value or most telling X-ray—you want to lead with your best evidence, not your full chart.

CMS’s “One and Done” Rule: What’s Really Happening?

When CMS conducts a RADV (Risk Adjustment Data Validation) audit, it’s not flipping through an entire patient file or cross-referencing all the SOAP notes you sent in. Nope. For each Hierarchical Condition Category (HCC) under audit, they select just one medical record—and that’s the only one that counts.

This selected MR is used to determine whether the diagnosis is valid or discrepant. If it doesn't confirm the HCC, even if another one might have, tough luck. That diagnosis doesn’t count. It’s the healthcare equivalent of submitting just one vital sign to determine an entire treatment plan—so make sure it’s the right one.

How Does CMS Pick That One Record?

Good news: CMS usually starts with the records you submit and the order in which you rank them. Bad news: they don’t have to follow your ranking. CMS applies its own clinical logic to identify the most appropriate record based on a few core principles:

Top-Down Clinical Validation: If a lower-ranked record supports a more severe diagnosis (i.e., a higher-weighted HCC in the same hierarchy), CMS picks that.
Direct Confirmation Wins: If a record directly confirms the exact HCC being audited, it may be selected—unless another supports a higher HCC.
If No Record Confirms the HCC: The HCC is marked as a discrepancy, which could lead to extrapolated overpayment calculations.

This means that record prioritization isn’t just admin—it’s a clinical strategy.

Why It’s a Big Deal

Let’s say you submit five records for a patient with metastatic cancer. Four mention “malignancy,” but only one ties the primary site to the metastatic spread with the right documentation. If you rank that golden chart last, and CMS uses your top pick instead—which lacks the necessary detail—you risk a discrepancy.

In RADV, one bad pick can cost thousands. Or, put another way: You don't bring your whole surgical tray to the table—you bring the instrument you trust most.

Practical Takeaways

Here’s what every Medicare Advantage Organization should keep in mind:

Rank Smart, Not Just Fast: Know which records have the strongest documentation and rank them accordingly.
Audit-Proof the Chart: The selected chart needs to stand on its own. Don’t assume context from other records will help—it won’t.
Train Like It’s an Exam: Abstractors, coders, and auditors should be trained to recognize the gold standard of documentation per HCC.
Use Tech That Thinks Like a Clinician: AI-powered tools (like ours at Health Data Max) can help flag the most defensible charts, rank records automatically, and simulate audit scenarios—before CMS comes knocking.

The Bottom Line

In RADV audits, every HCC only gets one lifeline. One medical record. One shot. So don’t gamble. Make sure the record CMS uses is the one you’d take to grand rounds.

Ready to make your chart submissions audit-proof? Let Health Data Max help you with documentation validation, and risk analytics that speak CMS’s language.