What's the difference between RAF and HCC?

RAF (Risk Adjustment Factor) is the risk score used to represent expected cost of care based on demographics and diagnosis-driven risk models, specifically the CMS-HCC model for Medicare Advantage populations. HCCs (Hierarchical Condition Categories) are diagnosis groupings derived from ICD-10-CM codes that feed into the risk model. CMS publishes the official Medicare Advantage risk adjustment model software, diagnosis-to-HCC mappings, and documentation annually. In simple terms: HCCs are the building blocks (diagnosis categories), and RAF is the final score calculated from those HCCs plus demographic factors.

How often do HCCs need to be captured?

Risk adjustment follows the calendar year, and risk scores reset on January 1—which is why chronic conditions often need annual re-capture when clinically active and addressed. This doesn't mean automatically carrying forward last year's codes; it means documenting active chronic conditions that are clinically relevant and impact current care during at least one visit in the current calendar year. The condition must be addressed (MEAT/TAMPER evidence), not just copied from a problem list. Most organizations operationalize this through quarterly or semi-annual chronic disease management visits for high-risk Medicare Advantage patients.

What documentation standard is commonly used for risk adjustment?

MEAT (Monitor, Evaluate, Assess/Address, Treat) or TAMPER (similar framework) are commonly used documentation standards to demonstrate that a condition was clinically relevant and actively managed during the encounter. For a condition to support HCC capture, the documentation must show at least one MEAT element: Monitor (reviewed lab results, vital signs, symptoms), Evaluate (ordered tests, consulted specialist, assessed progression), Assess/Address (discussed in clinical decision-making, addressed in care plan), or Treat (prescribed medication, therapy, or other intervention). Simply listing a condition on the problem list without MEAT evidence is insufficient for compliant risk adjustment and will not survive a RADV (Risk Adjustment Data Validation) audit.

Why does ICD-10 specificity matter for HCC capture?

Coding specificity can directly impact whether a diagnosis maps to an HCC in the CMS-HCC model. For example, E11.9 (type 2 diabetes without complications) does not map to an HCC, but E11.65 (type 2 diabetes with hyperglycemia) maps to HCC 19 (Diabetes with Chronic Complications). Similarly, I50.9 (heart failure, unspecified) is less specific than I50.23 (acute on chronic systolic heart failure), which can affect HCC mapping and RAF score. Best practice is to code to the highest supported specificity in the medical record—this ensures accurate risk representation and defensible HCC capture. CMS publishes annual ICD-10-CM to HCC crosswalk files, and specificity requirements change yearly, so staying current is essential.

Is RAF/HCC optimization the same as upcoding?

No. Compliance-first RAF/HCC optimization focuses on accurate, clinically supported documentation and coding—not selecting unsupported diagnoses or inflating risk scores. Upcoding means coding for conditions that were not documented, not clinically relevant, or not supported by MEAT evidence, which is fraudulent and subject to severe penalties under the False Claims Act. Legitimate RAF/HCC work is about closing documentation gaps (capturing conditions that were treated but not documented with sufficient specificity or MEAT evidence), educating providers on compliant chronic disease documentation, and coding to the highest supported specificity when clinical evidence exists. The goal is accuracy and completeness, not inflation. RADV audits specifically target unsupported HCCs, making compliance the only sustainable approach.

What is a RADV audit and how should practices prepare?

RADV (Risk Adjustment Data Validation) audits are conducted by CMS and Medicare Advantage Organizations (MAOs) to verify that HCC diagnoses submitted for risk adjustment are supported by medical record documentation. CMS samples a subset of enrollees and requests complete medical records for review. If HCCs are not supported by documentation (missing MEAT evidence, insufficient specificity, or no clinical relevance), they are disallowed, and extrapolated payment adjustments can be substantial. Best preparation practices: 1) Implement MEAT documentation standards organization-wide, 2) Conduct internal pre-RADV audits on high-impact HCCs, 3) Standardize provider templates to prompt specificity and MEAT evidence, 4) Train coders on compliant HCC abstraction (only code what's documented and relevant), 5) Establish a query process for incomplete documentation, 6) Maintain audit-ready documentation (every HCC must be defensible). Organizations with strong internal audit programs and provider education typically see 90%+ validation rates in RADV audits.

Can ChartWhisper help with RAF/HCC program compliance?

ChartWhisper is positioned as a clinical documentation audit engine that can support RAF/HCC programs by: 1) Identifying documentation gaps that weaken HCC support (missing MEAT evidence, insufficient linkage, vague language), 2) Surfacing ICD-10 specificity opportunities when clinical evidence exists in the note, 3) Standardizing audit workflows across coders and compliance teams, 4) Providing provider feedback loops to improve chronic disease documentation habits, 5) Generating audit trails for internal RADV readiness assessments. Important notice: ChartWhisper provides documentation assistance and identifies potential gaps and compliance considerations, but it does not replace clinician judgment and does not guarantee coding accuracy or HCC validation outcomes. Final documentation and coding decisions remain the responsibility of the provider and coding professional. Book a demo to walk through Medicare Advantage and ACO RAF/HCC workflows using your real encounter patterns.

What are the most common RAF/HCC documentation gaps?

The most common RAF/HCC documentation gaps that weaken HCC support and increase RADV audit risk are: 1) Chronic conditions not re-addressed annually (condition was treated but not documented in current calendar year), 2) Missing MEAT evidence (condition listed on problem list but no Monitor, Evaluate, Assess/Address, or Treat documented in note), 3) ICD-10 specificity missed (e.g., CKD without stage, heart failure without type/acuity, diabetes without complication when evidence exists), 4) 'History of' language when condition is still active (e.g., 'history of CHF' when patient is still on diuretics and being actively managed), 5) Missing explicit clinical linkages (e.g., 'CKD due to diabetes' vs. two unrelated diagnoses—linkage affects HCC hierarchy), 6) Inconsistent documentation across clinicians and sites (same patient, different providers document differently). All of these are fixable with provider education, standardized templates, and regular feedback loops.

Compliance-First Risk Adjustment

RAF/HCC Optimization (CMS-HCC)

Risk adjustment only works when documentation reflects the true, clinically supported disease burden — and when codes are captured accurately and submitted appropriately.

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This guide is designed for:

Provider Groups

Documentation consistency + point-of-care support

Coders & Compliance

Defensible abstraction + audit-ready evidence

Health Plans/MAOs

Prospective/retrospective review + RADV readiness

ACOs

Accurate risk + population health prioritization

What RAF and HCC Mean (and How They Work)

What is RAF?

RAF (Risk Adjustment Factor) is the risk score used to represent expected cost of care based on demographics + diagnosis-driven risk models (e.g., CMS-HCC for Medicare Advantage). CMS maintains the official model software and diagnosis-to-HCC mappings by year.

What is an HCC?

HCCs (Hierarchical Condition Categories) group ICD-10-CM diagnoses into clinically meaningful categories used in risk models. In CMS-HCC, the model is primarily used for Medicare Advantage populations; other models (like HHS-HCC) serve different populations.

Important operational reality:

Risk adjustment follows the calendar year, and risk scores reset on January 1 — which is why chronic conditions often need annual re-capture when clinically active and addressed.

Compliance Rules That Make or Break Risk Adjustment

A sustainable RAF/HCC program is built on a simple rule:

Coding follows documentation, and documentation follows clinical reality.

What "audit-defensible" looks like in practice:

Clinical relevance / medical necessity first (the condition must matter to care today)

MEAT or TAMPER evidence in the note (Monitor, Evaluate, Assess/Address, Treat — or equivalent)

Specificity matters: coding specificity can directly impact whether a condition maps to an HCC, so capture the highest supported specificity in the record

Submission integrity: programs fail when diagnoses aren't consistently captured in the EHR and correctly transmitted/submitted through claims workflows

Plain-English compliance stance: RAF/HCC optimization is accuracy and completeness, not inflation.

The Most Common RAF/HCC Gaps (and How to Fix Them)

1. Chronic conditions not re-addressed (or written as 'history of')

Problem: Conditions documented as 'history of' when still active and impacting care.

Fix: If the condition is active and impacts care, document it as active, then show the work (MEAT/TAMPER).

2. ICD-10 specificity missed (even when evidence exists)

Problem: Examples: CKD without stage, Heart failure without type/acuity, Diabetes without complication linkage.

Fix: Train providers + coders on 'specificity cues,' and standardize SmartPhrases/templates that naturally pull specificity into the A/P.

3. Missing explicit linkages that are clinically appropriate

Problem: Example: 'CKD due to diabetes' vs two unrelated diagnoses.

Fix: Use provider-confirmed linking language only when clinically supported.

4. Inconsistent documentation across clinicians and sites

Problem: Different providers document same conditions differently.

Fix: One standard: shared templates + coder feedback loops + periodic calibration audits.

Workflows by Audience

Provider Groups

Primary care, multi-specialty, clinics

Pre-visit huddles for high-risk patients

Visit templates that make MEAT effortless

Post-visit coding review for MA/high-impact cohorts

Provider education that is case-based, not generic

MAOs / Health Plans

Medicare Advantage Organizations

Prospectively identify likely gaps (without 'auto-adding' diagnoses)

Retrospective chart review with tight evidence standards

Documentation integrity programs that reduce audit exposure

ACOs / Value-Based Orgs

Accountable Care Organizations

Standardized problem list governance

Chronic disease workflows tied to quality + outcomes

Risk documentation integrated into care management prioritization

A Practical RAF/HCC Checklist

Pre-Visit

Identify high-risk members and prior-year HCCs

Flag 'needs clinical confirmation' items (not pre-filled diagnoses)

During the Visit

Confirm active chronic conditions that impact care

Add 1–2 sentences in A/P showing MEAT/TAMPER

Use the most specific diagnosis supported by the record

Post-Visit

Code review for MA/high-risk visits

Query process for missing specificity/support

Audit sampling + feedback loop to templates and training

How ChartWhisper Supports RAF/HCC Programs

ChartWhisper is positioned as a clinical documentation audit engine for medical groups, compliance officers, and coding professionals.

For RAF/HCC programs, ChartWhisper can support:

Finding documentation gaps that weaken HCC support

Surfacing specificity opportunities when evidence exists

Standardizing audit workflows and provider feedback loops

Important notice: ChartWhisper provides documentation assistance and identifies potential gaps and compliance considerations, but it does not replace clinician judgment and does not guarantee coding accuracy.

Book a demo to walk through MA/ACO RAF/HCC workflows

RAF/HCC Optimization FAQ

Ready to Build a Compliance-First RAF/HCC Program?

See how ChartWhisper can support your Medicare Advantage, ACO, or value-based care risk adjustment workflows.

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RAF/HCC Optimization (CMS-HCC)

Provider Groups

Coders & Compliance

Health Plans/MAOs

ACOs

What RAF and HCC Mean (and How They Work)

What is RAF?

What is an HCC?

Important operational reality:

Compliance Rules That Make or Break Risk Adjustment

What "audit-defensible" looks like in practice:

The Most Common RAF/HCC Gaps (and How to Fix Them)

1. Chronic conditions not re-addressed (or written as 'history of')

2. ICD-10 specificity missed (even when evidence exists)

3. Missing explicit linkages that are clinically appropriate

4. Inconsistent documentation across clinicians and sites

Workflows by Audience

Provider Groups

MAOs / Health Plans

ACOs / Value-Based Orgs

A Practical RAF/HCC Checklist

Pre-Visit

During the Visit

Post-Visit

How ChartWhisper Supports RAF/HCC Programs

For RAF/HCC programs, ChartWhisper can support:

RAF/HCC Optimization FAQ

What's the difference between RAF and HCC?

How often do HCCs need to be captured?

What documentation standard is commonly used for risk adjustment?

Why does ICD-10 specificity matter so much?

Is RAF/HCC optimization the same as upcoding?

Ready to Build a Compliance-First RAF/HCC Program?