ACDIS CCDS-O Exam - Topic 5 Question 10 Discussion

In outpatient risk adjustment (commonly Medicare Advantage), the patient's predicted cost is derived from the Risk Adjustment Factor (RAF), which is the sum of component risk contributions. Here, the RAF is calculated by adding the HCC diagnoses score (0.166), disease interactions (0.112), and demographic score (0.330). That total equals 0.608. The PMPM (per-member-per-month) baseline cost is $800. To estimate the patient's expected monthly cost, multiply PMPM by RAF: $800 0.608 = $486.40 per month. The question asks for the expected yearly cost, so convert PMPM to annual: $486.40 12 = $5,836.80. ACDIS outpatient CDI teaching emphasizes that accurate documentation and compliant coding directly affect RAF through captured HCCs and interactions (when supported), which in turn drives expected resource needs and plan payment. Missing or unsupported diagnoses can understate RAF; vague documentation can prevent valid HCC capture.