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RAF-HCC Coding Strategies

Incomplete Documentation? Find Clarity with CareThrough

Documenting the complexities of each patient’s disease burden is critical to Risk Adjustment
Factor (RAF) coding success.

The Center for Medicare and Medicaid services (CMS) assigns a score to MedicareAdvantage patients by combining Demographics (age, sex, institutional status) with Hierarchical Condition Categories (HCC) based on ICD-10. The subsequent risk score is used to calculate the annual cost of care for each patient. The RAF score will be lower for healthier patients, and higher for those with multiple chronic illnesses.

CareThrough Navigators Have the Vital Skills for RAF-HCC Coding

Embedded within your care team, our navigators are HIPPA compliant and trained to update EHRs to reflect the most accurate Hierarchical Condition Category (HCC), co-existing conditions, and population health trends.

For proper reimbursement providers must report the HCC code, and show documentation to support the claim. A 65-year-old diabetic patient may have a higher RAF score than a 30-year-old patient with the same condition, however, all too often with incomplete documentation, and lack of medical history notes, you may not be able to tell their health records apart. And neither will CMS…

If your EHR documentation is not kept current and detailed, millions of dollars’ worth of work could vanish. In today’s value-based environment, painting a complete picture of the patient’s disease burden, and the care provided over the course of the calendar year is essential, and impacts every physician’s reimbursement.

Who has the time for more documentation? We do.

To win at reporting in light of the CMS predictive tool, CareThrough Navigators bridge the gap between provider and patient to ensure every encounter is accurately documented in the EHR while addressing the MEAT guidelines: Monitor | Evaluate | Address | Treat. For HCC, providers must write a linking statement for each HCC code, for example “Diabetes with ophthalmological manifestations.” CareThrough Navigators prompt providers to confirm the medical record includes an updated linking statement as well as:

  • Ensure high-risk patients are seen at least once during the calendar year
  • Note history of disease and status
  • Code for highest specificity of disease burden
  • Report complications in between visits
  • Set referral appointments and preventative screenings
  • Identify “rising risk” patients

The Result: Increased Quality of Care and Profitability
We provide patient engagement that not only improves personalized medicine but also minimizes the time providers spend reporting the level of complexities of a patient’s disease burden required by CMS. We facilitate RAF-HCC coding with a workforce of highly skilled navigators to ensure providers are reimbursed for the level of care delivered, and reduce the negative financial impact of late reporting.

To learn more about RAF-HCC coding contact our Client Solutions team at