risk-adjustment-strategy

Apply CMS-HCC model versioning and hierarchy rules to identify coding gaps.

13|5|Updated May 4, 2026

Search Tags:#compliance #coding #healthcare #risk-adjustment #hcc #medicare

Ready to run

npx skills add https://github.com/awslabs/hcls-agent-skills --skill risk-adjustment-strategy

💬 Prompt for ChatGPT / Claude Chat▼

Please help me install this Agent Skill.
Skill: risk-adjustment-strategy
Source: https://github.com/awslabs/hcls-agent-skills/tree/main/skills/risk-adjustment-strategy
Command: npx skills add https://github.com/awslabs/hcls-agent-skills --skill risk-adjustment-strategy

SYSTEM DOCUMENTATION & REQUIREMENTS

What problem does it solve?

This skill resolves the complexity of CMS-HCC risk adjustment by providing a structured methodology for model version selection, hierarchy resolution, and audit-defensible documentation.

Core Features & Use Cases

Model Versioning: Navigates the transition between V24 and V28 models, including blended payment calculations.
Coding Gap Identification: Uses Rx and lab proxies to identify potential recapture opportunities for chronic conditions.
Audit Readiness: Provides a decision framework to ensure documentation meets RADV audit standards.

Quick Start

Use the risk-adjustment-strategy skill to evaluate the current coding gaps for a patient with diabetes and heart failure under the 2025 blended model.

Frequently Asked Questions about risk-adjustment-strategy

High-intent search queries and answers about installing and using this skill.

FAQPage Schema

How do I resolve CMS-HCC coding gaps for chronic conditions in Medicare Advantage?▼

CMS-HCC coding gaps are resolved by applying Rx and lab proxies to identify potential recapture opportunities for chronic conditions, ensuring diagnoses meet regulatory documentation standards. This approach supports clinical and actuarial workflows by applying specific ICD-10-to-HCC mapping logic.

What is the difference between V24 and V28 CMS-HCC risk adjustment models?▼

The difference between V24 and V28 CMS-HCC risk adjustment models involves hierarchy resolution changes and specific ICD-10-to-HCC mapping logic updates. Navigating the transition requires calculating blended payment calculations to ensure accurate revenue capture under the updated regulatory guidelines.

How do I prepare diagnosis documentation for a RADV audit?▼

To prepare diagnosis documentation for a RADV audit, you must ensure all records meet face-to-face encounter rules and specific ICD-10-to-HCC mapping logic. Applying this decision framework ensures audit-defensible revenue capture for Medicare Advantage programs.

Can I use lab and prescription proxies to identify risk adjustment recapture opportunities?▼

Yes, you can use lab and prescription proxies to identify risk adjustment recapture opportunities for chronic conditions. This method targets clinical and actuarial workflows by highlighting undocumented diagnoses that require proper coding to achieve audit-defensible revenue capture.

Does CMS-HCC risk adjustment require face-to-face encounter documentation?▼

CMS-HCC risk adjustment requires strict adherence to face-to-face encounter rules to ensure audit-defensible revenue capture. This documentation is mandatory for applying regulatory guidelines to diagnosis documentation within Medicare Advantage programs.

What is the best way to calculate blended payments under the 2025 CMS-HCC model?▼

The best way to calculate blended payments under the 2025 CMS-HCC model is by navigating the transition between V24 and V28 models. This structured methodology applies model versioning and hierarchy resolution to ensure accurate Medicare Advantage payment calculations.