Certified Risk Adjustment Coder (CRC)

What does the RADV audit primarily verify?

1. Accuracy of CPT codes submitted for payment

2. Provider's use of quality measures

3. Accuracy of the diagnosis submitted for payment

4. Provider's signature authenticity

The correct answer is: Accuracy of the diagnosis submitted for payment

The RADV audit, which stands for Risk Adjustment Data Validation audit, primarily focuses on verifying the accuracy of the diagnosis codes submitted for payment. This process ensures that the diagnostic information reported by healthcare providers accurately reflects the patients' actual health status. The goal is to confirm that the risk adjustment claims reflect true medical conditions in order to maintain the integrity of risk adjustment payments, which are designed to adjust payments based on the health status of the enrolled members. This verification process is critical because incorrect or fraudulent reporting of diagnoses can lead to inflated payments and potential financial repercussions for healthcare organizations. By concentrating on the accuracy of diagnosis codes, the RADV audit helps to uphold the standard of care provided and protects the Medicare program from erroneous billing. While accuracy of CPT codes, provider quality measures, and signature authenticity are important aspects of healthcare documentation and billing, they do not fall under the specific scope of what the RADV audit aims to verify. The emphasis on diagnosis accuracy is what distinguishes the RADV audit from other audits that may focus on those other elements.