RAF Score & HCC Calculator

A Risk Adjustment Factor (RAF) score calculator with Hierarchical Condition Category (HCC) capture from encounter documentation, purpose-built for Medicare Advantage risk adjustment workflows. The skill analyzes clinical notes to identify HCC-eligible diagnoses, maps ICD-10 codes to HCC categories using the CMS-HCC risk adjustment model, and calculates expected RAF scores for individual patients and panel-level projections.

Quick Install

npx skills add Open-Medica/open-medical-skills --skill raf-score-calculator

What It Does

• HCC condition identification: Scans encounter documentation and problem lists to identify diagnoses that map to HCC categories, flagging conditions that are documented but not coded and conditions that are coded but lack supporting documentation
• ICD-10 to HCC mapping: Applies the current CMS-HCC risk adjustment model (V28) to translate ICD-10-CM diagnosis codes into their corresponding HCC categories, including hierarchical exclusions where higher-severity HCCs supersede lower ones
• RAF score calculation: Computes individual patient RAF scores incorporating demographic factors (age, sex, Medicaid dual eligibility, institutional status), new enrollee status, and the additive risk coefficients for each captured HCC
• Recapture gap analysis: Compares current-year HCC capture against prior-year conditions to identify chronic conditions (diabetes with complications, CKD, heart failure, COPD) that require annual re-documentation and recoding to maintain accurate risk scores
• Panel-level analytics: Aggregates RAF scores across a patient panel to project expected revenue, identify high-risk patients due for annual wellness visits, and quantify the financial impact of documentation improvement initiatives

Clinical Use Cases