What does RADV stand for?
RADV stands for Risk Adjustment Data Validation. In Medicare Advantage, CMS uses contract-specific RADV audits to check whether diagnoses submitted by Medicare Advantage organizations for risk-adjusted payment are actually supported in beneficiaries' medical records.
Risk adjustment changes payments based in part on a beneficiary's health status. That makes diagnosis data financially important—but it also means the diagnosis data must be accurate and supported.
Why does CMS conduct RADV audits?
CMS describes Medicare Advantage RADV as its primary method for addressing risk-adjustment overpayments. If a diagnosis used for payment is not supported in the medical record, CMS can identify a payment error and recover an overpayment.
The purpose is program integrity: Medicare Advantage organizations should be paid appropriately for the health status of their members—not more because of unsupported diagnoses and not based on diagnosis data that cannot be validated.
This is why risk adjustment coding is about much more than identifying conditions that map to HCCs. The diagnosis has to be accurate, documented, coded correctly, and defensible if reviewed later.
How does a RADV audit work?
CMS defines the audit sample and identifies enrollees and HCCs for validation.
The plan retrieves and submits medical records intended to support the audited diagnoses and HCCs.
CMS validates the submitted records, abstracts diagnosis information, calculates payment errors, and issues audit results.
Under the current Payment Year 2024 audit instructions, the number of records that may be submitted for a sampled enrollee is tied to the number of audited HCCs. CMS permits a maximum number of medical records equal to twice the number of audited HCCs for that enrollee. This is a good example of why older rules of thumb—such as memorizing one fixed number of “best records”—should not replace the current CMS audit instructions.
What does CMS look for in the medical record?
The exact requirements depend on the audit year and applicable CMS instructions, but the core principle is consistent: the submitted medical record must be valid and must support the diagnosis being validated.
| Record element | Why it matters |
|---|---|
| Correct patient and date of service | The record must belong to the sampled enrollee and fall within the applicable data-collection period. |
| Appropriate provider and credentials | The encounter must meet CMS requirements for an acceptable provider type for the applicable audit. |
| Valid signature/authentication | CMS audit instructions include signature requirements and, in certain circumstances, attestation procedures. |
| Diagnosis documented in the record | The condition being used to support risk-adjusted payment must be supported by the medical record. |
| Appropriate coding | Diagnosis coding must follow the applicable ICD-10-CM coding and reporting rules. |
| Clear, nonconflicting documentation | Conflicting or ambiguous documentation can make support harder to establish and may require compliant clarification. |
What happens if a diagnosis is not supported?
If the submitted medical record does not support a diagnosis used in the audited risk score, the associated HCC may not validate. CMS then recalculates payment using the diagnoses and HCCs supported through the audit process.
An unsupported diagnosis can therefore create a payment error and potential overpayment recovery. CMS also notes that RADV audit findings are used to address improper payments to Medicare Advantage organizations.
This is why documentation accuracy matters in both directions. Missing a valid diagnosis can make the patient's documented disease burden incomplete, while reporting an unsupported diagnosis can create compliance and financial risk.
Why should a risk adjustment coder understand RADV?
RADV helps explain the compliance side of the CRC role. A risk adjustment coder is not simply trying to find every diagnosis that maps to an HCC. The coder needs to know whether the diagnosis is supported, whether the selected ICD-10-CM code is accurate, and whether the documentation would remain defensible if audited.
- Read the full medical record rather than only the problem list.
- Distinguish active disease from history or status.
- Use MEAT as a documentation-review framework without treating it as an automatic rule.
- Do not infer diagnoses from medications, labs, or other clinical clues alone.
- Verify ICD-10-CM codes and apply current guidelines.
- Recognize conflicting or incomplete documentation and follow compliant query or escalation procedures.
Read: Supported vs. Unsupported Diagnoses →
Read: What Is MEAT? →
What is happening with RADV audits now?
CMS has been actively expanding and accelerating Medicare Advantage RADV activity. In 2026, CMS published audit materials for multiple payment years and initiated Payment Year 2024 audits on August 28, 2026.
The current PY 2024 audit instructions describe sampling, medical-record submission, diagnosis-code abstraction, payment-error calculations, and a methodology for calculating extrapolated overpayments. The instructions also note ongoing litigation concerning the 2023 RADV final rule and state that CMS has not yet decided whether, for those PY 2024 audits, it will collect extrapolated overpayments or only overpayments associated with sampled enrollees.
RADV FAQ
Is RADV the same as an HCC audit?
RADV is a formal CMS Medicare Advantage risk adjustment audit program. It validates diagnoses and HCCs used in risk-adjusted payments by reviewing supporting medical records.
Does RADV audit CPT procedure codes?
The contract-specific MA RADV program is focused on validating diagnosis data used for risk adjustment, not on auditing CPT procedure coding as its central purpose.
Can an old problem-list diagnosis support an HCC?
Do not assume it can. The submitted medical record must satisfy the applicable CMS audit and coding requirements and support the diagnosis for the relevant data-collection period.
Why are signatures and credentials important?
CMS audit instructions include medical-record validity requirements involving the provider, credentials, and signature or authentication. A clinically meaningful note can still create audit problems if required record elements are missing.
What should a coder remember most about RADV?
Code what the documentation supports. Accurate risk adjustment coding should be defensible from the medical record, not driven by the financial value of an HCC.
Build audit-ready risk adjustment coding skills
MediCode Bootcamp’s CRC education uses documentation review and case-based coding to help students understand not only which code to select, but why the medical record supports—or does not support—the diagnosis.
Explore the Self-Paced CRC CourseView CRC Boot CampFree CRC Study ResourcesSources reviewed October 2026: CMS Medicare Advantage RADV Program; CMS RADV Documents and Data; PY 2024 MA RADV Audit Methods & Instructions. This guide was also shaped by the CRC course materials in the MediCode Bootcamp training library. Always verify current CMS instructions for the audit year involved.