Risk Adjustment Data Integrity (RADI) Review

The Capstone Performance Systems’ Risk Adjustment Data Integrity (RADI) Review assists organizations with the CMS required Internal Monitoring and Auditing Standards and with risk adjustment completeness and accuracy. This independent review consists of analyzing accepted risk adjustment data for a specified period. The review targets four key areas of potential risk adjustment error. The results following the review can be tracked and measured.

Conducting a routine review of RAPS will provide your organization and CMS with the security of making reasonable efforts to identify inaccurate RAPS data.

To start this process the organization’s accepted RAPS data is grouped into four review sub-categories of improbable diagnosis data. The records from this list are validated by Capstone staff with a full report.  Findings in our report allow your staff to take appropriate corrective actions to be sure appropriate codes are either deleted, reviewed for coding accuracy, or re-submitted with more specific coding.

The four diagnosis categories in a RADI review are:

1. Accepted Diagnosis is impossible for PACE participants: Provide a way to either delete unacceptable data or resubmit with a more appropriate code after further review.

2. Accepted Diagnosis is not likely for PACE participants: A review in this key area will provide a way to identify codes that require further review for accuracy.

3. Accepted Diagnosis is Oncology Related: A review in this key area will identify specific Oncology codes. A review of this specific set of codes provides the opportunity to determine if Medical Record documentation validats the coding already accepted by CMS.

4. Accepted Diagnosis is Acute Care related: A review in this area will identify ICD-9 codes that are acute conditions in nature, often generated by an emergency room or outpatient hospital service. This review category provides a vehicle for the plan to validate the codes with proper documentation.

Capstone recommends programs review their RAPS data integrity at least twice a year before the RAPS sweeps. The RADI review helps your organization understand if the accepted RAPS records are documented and complete. The RADI review may create a need for further accuracy reviews of other specific groups of codes (HCC specific reviews).

Contact us today to learn more.