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Risk Adjustment Coding

Risk Adjustment Coding Services

Risk adjustment coding determines per-member payments across Medicare Advantage (CMS-HCC), ACA commercial (HHS-HCC) and several Medicaid managed care models (CDPS). Our certified risk adjustment coders apply the model logic that matches each contract — not a one-size approach — and validate every captured condition against documentation.

Request a Service Review Industries We Support

Risk Adjustment Models We Support

Different contracts use different risk models with different code-to-payment mappings. We code to the model that applies, rather than coding once and assuming the score translates.

  • CMS-HCC for Medicare Advantage plans and direct contracting entities
  • HHS-HCC for ACA commercial individual and small group
  • CDPS for several Medicaid managed care contracts
  • Model-specific specificity and combination rules
  • Mapping of chronic conditions to current-year payment year
  • Coordination with quality measure capture where applicable

Audit Defensibility

Risk adjustment is one of the most actively audited areas of CMS oversight. We treat every captured condition as if it will be reviewed under RADV — with provider documentation that supports the condition, the assessment and the treatment plan for the date of service.

  • MEAT-supported documentation on every chronic condition
  • Specificity required per ICD-10-CM guidelines
  • Audit trail and coder rationale retained per encounter
  • Provider queries routed for any unsupported suspect condition
Healthcare analytics dashboard showing RAF score capture and recapture trends
Model-aligned coding (CMS-HCC, HHS-HCC, CDPS) with audit-defensible rationale per encounter.

Operating Model

We work retrospective, prospective and concurrent workflows depending on contract economics and EHR readiness. Each engagement begins with a documentation baseline assessment that identifies the practical recapture opportunity and the documentation gaps that are blocking it.

Measurable Outcomes Our Clients Track

  • Accurate RAF capture matched to documentation
  • Improved chronic condition recapture rates
  • Reduced exposure on RADV and OIG audits
  • Provider documentation improvement over time
  • Model-aligned coding (CMS-HCC, HHS-HCC, CDPS)
  • Clear reporting on recapture and gap closure

Discuss Your Revenue Cycle Goals

Speak with our team about how risk adjustment coding services can be structured around your specialty, payer mix and current performance benchmarks.

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