HCC Documentation Requirements: What Must Be Supported to Count

Answer in brief
For Medicare Advantage RADV purposes, a submitted diagnosis has to be supported in the medical record. CMS says RADV confirms whether diagnoses submitted for risk adjustment are supported in enrollees’ medical records, and unsupported diagnoses can lead to overpayment recovery. 

What the medical record must show

CMS reviewer guidance says documentation must support that the provider was present with the patient, and that conditions are evaluated for chronicity and support in the full medical record, including items such as history, medications, and final assessment. The same guidance says HRA screening portions are not treated as confirmed diagnoses unless supported by the final assessment documentation.

Encounter and code-path requirements

CMS maintains a current list of risk-adjustment-eligible CPT/HCPCS codes, which means not every visit or service path is equally useful for risk adjustment capture. CMS also states that diagnoses from telehealth services can meet the face-to-face requirement when furnished through real-time interactive audio-video communication.