RAF Score Calculation

Inputs Needed to Calculate RAF

Accurate RAF calculation requires several key data inputs:

• ICD-10 diagnosis codes: From claims or encounter data for the payment year
• Date of birth: To determine age bracket coefficients
• Gender: For gender-specific model coefficients
• Eligibility status: Community, institutional, or dual-eligible
• Model version: CMS-HCC V24, V28, or applicable model year

Diagnoses to HCC Mapping (High-Level)

The mapping process follows several steps:

1. Code validation: Verify ICD-10 codes are valid and applicable
2. HCC assignment: Map each diagnosis to its corresponding HCC (if any)
3. Hierarchy application: Apply hierarchies to related HCCs, keeping only highest-value
4. Interaction identification: Identify HCC combinations that trigger interaction coefficients
5. Coefficient lookup: Retrieve coefficients for all applicable HCCs and interactions

Demographics and Other Contributing Factors

Beyond diagnoses, demographic factors contribute to RAF:

Common Pitfalls: Incomplete Capture and Specificity

Several issues can lead to inaccurate RAF calculations:

• Incomplete diagnosis capture: Missing conditions that should be documented
• Non-specific codes: Using unspecified codes when specificity is available
• Invalid encounter types: Including diagnoses from non-qualifying encounters
• Outdated mappings: Using incorrect HCC crosswalks for the model year
• Missing hierarchies: Not applying HCC hierarchy logic correctly

Validating and Reconciling Calculation Outputs

Ensure calculation accuracy through validation:

• Audit trail: Track each step from diagnosis to final RAF
• Benchmark comparison: Compare results against known baselines
• Reconciliation: Match calculated RAF against CMS feedback reports
• Version control: Ensure model versions match CMS requirements