Certified Risk Adjustment Coder (CRC)

What is essential to consider when submitting records for RADV audits?

1. All past diagnoses must be included

2. Records must reflect a face-to-face encounter with an acceptable provider

3. Diagnostic tests must be available at the time of submission

4. Claims data should only include current conditions

The correct answer is: Records must reflect a face-to-face encounter with an acceptable provider

When submitting records for Risk Adjustment Data Validation (RADV) audits, it's essential to ensure that the documentation reflects a face-to-face encounter with an acceptable provider. This is crucial because the purpose of these audits is to validate the accuracy of the risk adjustment coding and ensure that the diagnoses reported for reimbursement are substantiated by appropriate clinical documentation. A face-to-face encounter with a provider indicates that there has been an actual interaction where the patient's conditions were assessed and documented, linking the diagnosis directly to the care rendered. Without such encounters, it becomes challenging to verify the legitimacy of the diagnoses reported. This supports the integrity of the risk adjustment process and the associated reimbursements tied to those diagnoses. In contrast, while including all past diagnoses may seem relevant, the focus of RADV audits is primarily on the diagnoses that pertain to the patient's condition as it relates to the most recent care provided and not necessarily historical data. Similarly, while having diagnostic tests available can enhance the completeness of medical records, it does not take precedence over ensuring direct provider engagement through face-to-face encounters. Lastly, while claims data should accurately reflect the patient's current conditions, this does not alone ensure the validity needed for RADV audits without the necessary provider encounter documentation.