High-Risk Diagnosis Code Risk Assessment
Identify potentially miscoded diagnosis codes based on CMS/OIG high-risk filters
Revolutionize Your Medicare Advantage Risk Adjustment Process
The Problem
Medicare Advantage organizations face increasing scrutiny from CMS and OIG audits, with penalties reaching millions of dollars for improper coding. Recent reports show:
- Over $650 million in improper payments annually due to unsupported diagnosis codes
- 12.5% average error rate in high-risk diagnostic categories
- Growing compliance requirements with RADV audits targeting specific high-risk conditions
- Significant resource drain on clinical and coding teams during manual reviews
Business Benefits
Our FHIR-compliant risk assessment API delivers powerful business advantages:
- Reduced Audit Risk: Cut payment error rates by up to 83% with pre-submission validation
- Financial Protection: Prevent revenue recoupment and avoid costly penalties
- Operational Efficiency: Reduce manual review time by 65% with automated risk flagging
- Improved Accuracy: Ensure proper documentation for legitimate conditions, protecting rightful reimbursement
- Compliance Confidence: Stay ahead of evolving regulatory requirements with continuous updates
Technical Advantages
- FHIR Standard Compliance: Seamless integration with existing health information systems
- Real-time Analysis: Process diagnosis codes with millisecond response times
- Flexible Deployment: Available as cloud API or on-premises solution
- Comprehensive Coverage: Validates across four critical high-risk categories
- Secure Processing: HIPAA-compliant with end-to-end encryption
- Detailed Validation: Precise mapping of supporting documentation to diagnoses
- Intelligent Rules Engine: Employs CMS/OIG risk filters to identify potential issues
- Easy Integration: REST API with comprehensive documentation and example code
Self-Guided Demo Instructions
Follow these steps to experience how the risk assessment tool works:
Load Sample FHIR Data
Click the "Load Sample" button in section 1 below to populate the text area with FHIR-compliant patient data including diagnosis codes and supporting evidence.
Technical Context: This loads a JSON bundle containing Condition, Encounter, MedicationRequest, and Procedure resources that follow the FHIR standard format.
Go to Section 1Submit for Risk Assessment
Click the "Assess Risk" button in section 1 to send the FHIR data to the risk assessment engine.
Technical Context: The API validates the FHIR resources, extracts diagnosis codes, and applies CMS/OIG high-risk validation rules.
Go to Section 1Review Business Overview
In section 2, examine the "Business Overview" tab to see a summary of risk levels and a visual breakdown of the assessment results.
Business Context: This view helps Medicare Advantage organizations quickly identify which diagnosis codes need additional documentation or review before submission.
Go to Section 2Examine Technical Details
Click the "Technical Output" tab in section 2 to see the detailed JSON response from the API.
Technical Context: This JSON output shows exactly why each diagnosis code was flagged, including specific missing documentation or validation failures.
Go to Section 2Explore Error Rate Data
Scroll down to the "CMS/OIG Reported Error Rates" chart in section 3 to see industry benchmarks for high-risk diagnosis categories.
Business Context: These error rates from official CMS/OIG audits demonstrate the financial risk associated with improper coding in Medicare Advantage programs.
Go to Section 31. FHIR Resource Input
2. Assessment Results
Risk Summary
0 High Risk 0 Moderate Risk 0 Low Risk
Total Diagnoses: 0
| Code | Description | Risk Level | Reason |
|---|
3. CMS/OIG Reported Error Rates
Data source: Office of Inspector General (OIG) Toolkit To Help Decrease Improper Payments in Medicare Advantage
Improve Your Medicare Advantage Coding Accuracy
High-risk diagnosis codes can lead to improper payments and audit failures. Our comprehensive solutions help Medicare Advantage plans identify and correct coding issues before claims submission.
JSON Response
Risk Assessment Rules
Rule Logic for High-Risk Categories:
API Usage
curl -X POST https://your-domain.com/api/assess \
-H "Content-Type: application/json" \
-d '{"resourceType": "Condition", "code": {"coding": [{"system": "http://hl7.org/fhir/sid/icd-10", "code": "I213"}]}, "subject": {"reference": "Patient/123"}}'