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Medicare Part C High-Risk Diagnosis Codes Tool Kit

Payments to Medicare Advantage (MA) organizations are risk adjusted on the basis of each enrollee's health status (SSA § 1853(a)). MA organizations are required to submit risk adjustment data to CMS according to CMS instructions (42 CFR § 422.310(b)). Miscoded diagnoses may cause CMS to pay MA organizations improper amounts. For this toolkit, we will develop a resource that will provide highly technical information to assist MA organizations with analyzing the accuracy of the risk adjustment data that they receive from their providers and submit to CMS. We will provide this information as a starting point to allow MA organizations to research enrollees who receive diagnoses that are at high risk for being miscoded and to take appropriate action if needed.

Announced or Revised Agency Title Component Report Number(s) Expected Issue Date (FY)
Revised Centers for Medicare and Medicaid Services Medicare Part C High-Risk Diagnosis Codes Tool Kit Office of Audit Services WA-23-0025 (W-00-23-35899) 2024