Audit
Risk Adjustment Data Validation Audit(RADV)
CMS audit that verifies submitted MA / ACA diagnosis codes are supported by the medical record.
Definition
Risk Adjustment Data Validation (RADV) is the CMS process for verifying that diagnosis codes submitted by Medicare Advantage Organizations (and Affordable Care Act issuers) are supported by the corresponding medical record. CMS samples enrollees, requests medical records, and has CMS contractors review whether each HCC-eligible code is documented to MEAT criteria (Monitor, Evaluate, Assess, Treat) and signed by an acceptable provider type.
When a code can't be substantiated, the corresponding HCC is removed from the member's RAF and the plan must repay the associated capitation. Starting with PY2018, CMS extrapolates audit findings to the larger population, exposing plans to multimillion-dollar recoveries on unsupported codes.
AutoICD's RADV audit module performs a documentation-quality second pass: it asks an LLM to attempt to defend each submitted HCC-driving code against the chart text and flags codes that fail ("unsupported" candidates) so plans can pre-empt findings before CMS does.
When to use
- •You're a Medicare Advantage plan or RCM vendor preparing for a CMS RADV sample.
- •You want to spot-check a submitted superbill for documentation gaps before claim submission.
- •You're building internal compliance audits before submitting EDS / RAPS data.
Try it in AutoICD API
Run a RADV defense pass
curl -X POST https://autoicdapi.com/v1/audit \
-H "Authorization: Bearer $AUTOICD_API_KEY" \
-H "Content-Type: application/json" \
-d '{
"text": "Patient seen today, BP 138/86, no acute issues, refilled metformin.",
"submitted_codes": ["E11.22", "I12.9"],
"capabilities": ["radv"]
}'Language: bash. View full API docs · Get an API key.