7 Pointers Prepare You for RADV Audits

7 Pointers Prepare You for RADV Audits

Perform well when faced with a RADV audit.

If you’re a hierarchical condition category (HCC) coder, no doubt you’ve heard of risk adjustment data validation (RADV) audits. There are various types of RADV audits that are performed by the Centers for Medicare & Medicaid Services (CMS) including contract-level RADV audits and improper payment measure audits (formally known as national-level audits). While the different types of RADV audits are similar, this article focuses specifically on the contract-level RADV audit and how you can perform well when your Medicare Advantage Organization (MAO) is being audited.

What Is a Contract-Level RADV Audit?

CMS selects a subset of Part C contracts for each annual RADV audit cycle. Enrollees are sampled from each selected Medicare Advantage (MA) contract to estimate payment error related to risk adjustment. Once the enrollees have been selected, the MAO is required to submit medical records to support all CMS-HCCs in the sampled beneficiaries’ risk scores for the payment year.

MAOs are selected for audit using pre-determined eligibility criteria, then beneficiaries from these plans are chosen using a suspected improper payment targeting model. MAOs are typically granted 25 weeks to request and obtain medical records; review those records for best representation of audited HCCs; prepare the chart in a PDF format file with a cover sheet identifying the HCCs; and submit to a secure system such as the centralized data abstraction tool.

Put Your Best Foot Forward

Here are a few tips for surviving a contract-level RADV audit based on lessons learned:

1. Be organized. There is a large amount of information that is involved in a RADV audit, and a fixed deadline is set by CMS. Efficiently managing your time and using effective tools such as spreadsheets, databases, or coding software to capture and track pertinent information will aid in completing an audit successfully. Organization is necessary to stay on track and focused on the end goal.

2. Prioritize and retrieve the best charts. Subsection 422.310(e) requires MAOs and their providers and practitioners to submit a sample of medical records to validate risk adjustment data. While it might be tempting to retrieve every chart that contains information for the plan year being audited, there is value in retrieving high-priority charts first. This may include charts where the HCC was initially generated from. Inpatient hospital charts are also a great source to find HCCs that need to be submitted for validation.

3. Know coding guidelines. It is essential for medical records to be coded according to the ICD-9-CM or ICD-10-CM Official Guidelines for Coding and Reporting. Consider using guidance provided in applicable AHA Coding Clinic newsletters (subscription required).

Note: RADV Medical Record Reviewer Guidance Version 2.0, which took effect Jan. 10, 2020, is the most up-to-date version for contract-level 15 RADV and applicable to dates of services that were coded using ICD-9.

RADV audits are done retrospectively, so there is no way to query a provider for clarification when encountering ambiguous documentation. In cases where a query isn’t possible, Coding Clinic “Clinical Criteria and Code Assignment,” 4th quarter 2016 guides us:

The assignment of a diagnosis code is based on the provider’s diagnostic statement that the condition exists. The provider’s statement that the patient has a particular condition is sufficient. Code assignment is not based on clinical criteria used by the provider to establish the diagnosis.

The guideline noted addresses coding, not clinical validation. It is appropriate for facilities to ensure that documentation is complete, accurate, and appropriately reflects the patient’s clinical conditions. Although ultimately related to the accuracy of the coding, clinical validation is a separate function from the coding process and clinical skill.

Coding Clinic goes on to explain that regardless of whether a physician uses new clinical criteria, old criteria, their clinical judgment, or something else to decide a patient has a particular diagnosis, the code can be reported as long as there is documentation to support it.

4. Follow CMS rules for submissions. CMS has set very clear guidance regarding requirements for submissions to avoid discrepant findings. Medical records must include:

  • The correct beneficiary as provided on the CMS RADV cover sheet;
  • Acceptable risk adjustment provider type, source, and physician specialty providing the face-to-face encounter;
  • Dates of service within the data collection period under review; and
  • Valid signatures and credentials.

Entering information correctly on the cover sheet will help avoid unnecessary denials. Remember: The administrative portions of this audit — patient name, acceptable provider type, date of service, signatures — are just as important as the coding itself.

5. Submit your best charts. RADV audits usually offer an option to receive early feedback. Best practice is to submit as many charts for validation as possible prior to this early feedback deadline. This strategy is invaluable to the MAO, as it allows for the submission of additional charts if one is deemed to be discrepant prior to the final deadline.

A “best chart” is generally defined as a face-to-face chart note that validates the requested HCC, plus validates an additional HCC not being audited, and contains all the necessary documentation elements (name, date of service, acceptable provider type, valid signature, and credentials or an attestation if required). Also, consider submitting a chart note that is specific to the diagnosis being validated (for example, an oncology note for a cancer diagnosis).

6. Review results and make changes if necessary. As with any audit, reviewing results is imperative. Be sure to review non-validated HCCs as well as validated results so the MAO can correct errors as needed.

7. Be prepared to appeal denials. At the end of the day, everyone is human, and mistakes happen. That applies to the MAO, as well as CMS auditors. All denials should be thoroughly reviewed, and appeals should be written for any discrepant finding for which you have supporting documentation to prove otherwise.

RADV audits can seem daunting, but if you employ these strategies, they should not be as overwhelming. You, too, can successfully handle RADV audits.


RADV Medical Record Reviewer Guidance Version 2.0: www.cms.gov/files/document/medical-record-reviewer-guidance-january-2020.pdf

Melissa James, CPC, CPMA, CRC
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Melissa James, CPC, CPMA, CRC, has more than 20 years of healthcare experience in coding, billing, physician and coder education, accounts receivables management, compliance, and consulting. She received her associate degree from Pueblo Community College. James is a member of the Pueblo local chapter in Pueblo, Colo.

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