Medicare risk adjustment
What is risk adjustment?
Risk adjustment is the process of estimating expected health care resource use based on a patient’s documented and validated health status, as reflected in the medical record. Risk scores are used by the Centers for Medicare & Medicaid Services (CMS) to determine appropriate reimbursement based on the seriousness and complexity of patient health conditions.1
What is Clinical Documentation Integrity (CDI)?
CDI focuses on ensuring clear, complete, and accurate clinical documentation so that patient conditions, severity, and the care provided are accurately represented in the medical record.2
The impact of clinical documentation
Clinical documentation provides the foundation for accurately communicating a patient's health status. Documenting conditions to the appropriate level of clinical detail (e.g., acuity, severity, and related complications) supports continuity of care, effective care management, compliance with CMS standards, and accurate reporting.
When a condition must be described using less specific terminology, documentation should clearly explain the clinical basis for the diagnosis and why greater specificity is not available. Clear and thorough documentation enables an accurate depiction of the patient's condition and supports reliable data for clinical decision-making and population health analysis.
For clinical documentation support (and, when applicable, diagnosis coding), the Centers for Disease Control and Prevention's (CDC) National Center for Health Statistics (NCHS) ICD-10-CM search tool can help you identify the appropriate level of specificity to document for a patient’s condition.
Resources
For your reference, we have created a repository of common medical diagnoses and documentation challenges:
- Cancer/malignant neoplasms
- Chronic kidney disease
- Dementia
- Embolism and thrombosis
- Fractures
- Major depressive disorder
- Morbid obesity
- Myocardial infarction
- Stroke
- Telehealth documentation and modifiers
If you have questions after reviewing these resources, please contact the AmeriHealth CDI – Education Support Team at ahcdieducationsupport@amerihealth.com.
Chronic Conditions Codebook
Managing chronic conditions can slow disease progression, prevent or delay complications, reduce the risk of hospitalization, ensure patients receive appropriate care, and improve overall health outcomes and quality of life.
Documenting chronic conditions is required annually, as CMS resets each member’s risk score on January 1 of every year. Accurate documentation and coding ensure that current conditions are evaluated and documented at the point of care.
About this codebook
The Chronic Conditions Codebook is derived from the Healthcare Cost and Utilization Project (HCUP) Chronic Condition Indicator Refined (CCIR) list. Its purpose is to help provider practices more easily identify chronic diagnosis codes.
The AmeriHealth clinical team reviews the latest CCIR list and updates the codebook as needed to support care improvement initiatives and access to other AmeriHealth programs.
This codebook supports the identification of chronic conditions in:
- The Provider Engagement, Analytics & Reporting (PEAR) portal Comprehensive Visit (CV) application in the Comprehensive Visit – Diagnosis Considerations to Address section of the CV form
- Monthly risk gap files used by certain health system partners to generate chronic condition point-of-care alerts within their electronic medical record (EMR) workflows
To support accurate documentation of chronic conditions, practices should evaluate whether their disease management workflows are configured to recognize all diagnosis codes identified as chronic when those conditions are present at the time of a patient encounter.
Download the latest Chronic Conditions Codebook.
1Centers for Medicare & Medicaid Services. “Risk Adjustment.” CMS Innovation Center: Key Concepts, n.d., cms.gov/priorities/innovation/key-concepts/risk-adjustment.
2Sanderson, Amy L., et al. “The Impact of Clinical Documentation Integrity Programs on Diagnosis Documentation.” Advances in Health Information Science and Practice, vol. 1, no. 2, Nov. 19, 2025, doi:10.63116/CGJA8827.