The primary purpose of the Risk Adjustment Data Validation (RADV) program is to ensure the integrity and accuracy of risk-adjusted payments made to Medicare Advantage (MA) organizations. CMS requires MA organizations to submit diagnosis data to determine risk scores for their enrollees. The RADV audits verify that the diagnoses submitted for payment are supported by medical record documentation. This process confirms that the risk scores are accurate, and consequently, that the payments made based on those scores are appropriate. The program is a critical oversight function to protect the Medicare Trust Funds from improper payments.

B. RADV audits focus on the validity of submitted diagnosis codes, not the medical necessity of the care provided for those diagnoses.

C. RADV audits are conducted at the MA organization contract level, not to identify overpayments to individual physicians.

D. While diagnosis codes are part of E/M billing, the RADV program's specific focus is on risk adjustment data, not the accuracy of E/M levels.

1. Centers for Medicare & Medicaid Services (CMS). (n.d.). Risk Adjustment Data Validation (RADV). Official CMS.gov webpage. Retrieved from https://www.cms.gov/medicare/health-plans/medicareadvtgspecratestats/risk-adjustment-data-validation-radv. The page states, "The purpose of RADV is to verify enrollee diagnoses submitted by Medicare Advantage (MA) organizations for risk adjustment payment."

2. Department of Health and Human Services. (2021, November 26). Code of Federal Regulations, Title 42, § 422.310(e) Risk adjustment data validation. This regulation outlines the legal basis and requirements for the RADV program, specifying its role in validating data submitted for payment.