Risk Score Optimization through CDI


A major university-based health system wanted a thorough review of their documentation to see if it was supporting the level of care they are providing to the risk-adjusted patient population. Clinical documentation review is a vital process for any patient encounter because this facilitates accurate representation of a patient’s clinical status that translates into capturing the ICD-10 codes to the highest specificity.

Correct medical record documentation helps in increasing the risk scores of the patient that in turn translates into higher reimbursement because of increased risk adjustment factor.


This university health system client’s overall risk score was not representing the actual care they provided to the Medicare advantage patient population. Documentation oversight was costing a lot and negatively impacting the client economically. Their providers were not documenting the medical conditions to the greatest level of specificity. Minor and critical documentation requirements are often missed by the providers which in turn impacted the revenue generation and also caused compliance issues. Also, providers were unaware of how the clinical documentation influences claims reimbursement and how the clinical coding works in general.


Vee Healthtek’s certified coders, with over 10 years of experience in clinical documentation improvement, were deployed to do a random sampling and identify the areas for improvement. Vee’s auditors selected 200 providers and randomly selected 201 patients for each provider to perform the audit. The CDI findings were focused to identify the gaps in documentation and to identify missed opportunities. Samples selected represented four quarters of the previous year.


Example 1

A/P: Chronic kidney disease – currently stable GFR is 22ml/min

Continue Lasix avoid NSAIDs.

CDI Analysis: ICD 10 CM code: N18.9 – Non HCC – CKD (RAF Score 0) captured since it is currently stable and provider suggested continuing current medication regimen.

  • Provider missed to document stages of the CKD.
  • Current GFR rate for this patient is 22 ml/min, so Patient’s CKD qualify for Stage 4 CKD and this code having HCC value (RAF Score of 0.224).
  • Unspecified Chronic Kidney Disease is a non-HCC code - if provider documents more specific stage, such as Chronic Kidney Disease 4- this helps in increasing the revenue component as it has HCC value

Example 2:

Patient undergoing dialysis thrice weekly was documented in HPI without further documentation of the patient having ESRD.

CDI Analysis: The provider missed to document End Stage Renal Disease in the medical record. When this scenario was queried, the provider amended the note and sent back documenting ESRD on Dialysis under Assessment. This prompted the coder to capture ESRD and thereby increasing the RAF score for this patient ICD 10 CM code: N18.6 – ESRD and Z99.2 – Dialysis Status (ESRD is captured as it documented patient undergoing dialysis thrice weekly.) The overall score improved from 1.93 to 2.40.

The following are the few examples on educational opportunities and feedback given to the provider for documentation improvement:

  • Diagnostic ECG interpretation showed the EF to be less than 20% - this gave the indication that the patient might be having Congestive Heart Failure, which was not documented in the medical record. On top of it, the patient even had cardiomyopathy, which prompted us to query the provider to know if the patient is having Congestive Heart Failure. Based on the provider query, the physician returned the medical record by appending Congestive Heart Failure under assessment, which was later captured, thus resulting in increased RAF.
  • There was a missed opportunity for gangrene because physical examination documented as "pain and massive edema in the right lower extremity. There were skin discolorations as well with some foul-smelling discharge from the extremity. The patient also had a fever along with these symptoms." Provider feedback was given to check if gangrene was missed in the encounter visit for which the physician responded by stating the patient was indeed having gangrene along with atherosclerosis of the right superficial femoral artery. Later, the note was amended with "gangrene due to Atherosclerosis" instead of just Peripheral Vascular Disease from the previous report. This, in fact, enhanced the risk score of the patient.

Impact Analysis: Vee Healthtek's CDI specialists follow unique procedures to guarantee value-added patient outcomes, along with optimum reimbursements. This is achieved by providing continuous physician education and feedback based on the documentation deficiencies

Before Vee Healthtek completed these CDI audits and provider education, this major university-based health system’s overall risk score was close to 0.69 per patient. Based on the audit findings and focussed provider education for CDI, Vee Healthtek was able to help the client by improvising its overall risk score per patient to 1.03. This helped the client to get reimbursed at an optimum level that was proportional to the level of care it was providing.