When it comes to Risk Adjustment Data Validation (RADV) audits, a diagnosis isn't just a diagnosis—it's the heartbeat of your reimbursement. And just like in medicine, even small errors can have serious consequences.
CMS Doesn't Just Look at Yes or No
Think of a RADV audit like a lab test. CMS doesn’t just say “positive” or “negative.” Instead, it gives a more detailed diagnosis of your diagnosis codes. These audit results are placed into different buckets—each one telling a different story about how well your documentation supports your claims.
Here’s a quick look at how CMS classifies them:
Confirmed – The gold standard. Diagnosis is backed by solid documentation.
Confirmed Higher – Surprise bonus! CMS found your documentation supports an even more severe condition than what was originally coded.
Discrepant – Uh-oh. CMS couldn’t find any evidence in the chart to back up the diagnosis.
Discrepant Lower – CMS found a less severe condition than what you coded.
Administrative Exception – Rare, but sometimes CMS decides not to count the HCC in the payment error calculation for certain technical reasons.
But Here's the Catch...
Any diagnosis that doesn’t land in the “Confirmed” category can lead to a financial hit.
Even if the diagnosis is partially correct, or close, it might still cost you. It's like prescribing the right medication for the wrong dosage — the intent was there, but the outcome could still be harmful.
Let’s say your team submitted a code for a complex chronic illness, but CMS only finds support for a mild version. That downgrade might seem small, but across a large population, it adds up quickly—especially with extrapolation involved.
Why Should You Care?
One error = Risk score drop = Less payment.
Repeated errors = Extrapolated losses = Bigger clawbacks.
Even “smaller” errors can cause big overpayment recovery bills.
And remember: CMS audits aren’t just about one patient or one claim. They use these results to estimate payment errors for your entire contract.
So, What’s the Prescription?
Just like you wouldn’t skip a follow-up appointment, don’t skip over “small” errors in your risk adjustment coding. Every diagnosis should be documented like it’s going to be audited—because it just might be.
Here’s your action plan:
Aim for "Confirmed" – Train providers to document thoroughly and specifically.
Check Your Work – Run internal audits before CMS does.
Use Tech to Your Advantage – AI-powered tools like Health Data Max’s Chart Copilot can scan records like a seasoned clinician and flag weak spots before they reach CMS.
Final Thought
Think of your documentation as a patient chart under review by a second opinion specialist—CMS. Your goal is to make sure that when they open the file, everything is clear, specific, and defensible.
In risk adjustment, even small missteps can cause big ripples. So don’t just code. Code carefully. Code completely. And if you’re not sure where to start, Health Data Max is here to help.
Reach out at sales@healthdatamax.com or visit www.healthdatamax.com to explore how we’re making RADV audits less scary—and a lot smarter.