Risk Adjustment

Summary

The Zus Risk Adjustment Coding module surfaces opportunities for accurate, complete diagnosis coding by identifying both previously documented chronic conditions that must be recaptured and suspected conditions that may have been overlooked in prior documentation.

The module supports provider organizations and value-based care teams by linking diagnoses directly to clinical evidence, enabling coders and clinicians to act with confidence. By surfacing these gaps prospectively, care teams can address coding opportunities during regular patient encounters rather than retrospectively, leading to higher reimbursement accuracy and improved clinical documentation.

Risk Adjustment Coding is especially important for Medicare Advantage and other value-based contracts, where payment is tied to accurately capturing the clinical complexity of patients.

Overview Card

When Zus receives data about a patient’s medical history through EHRs, HIEs (e.g., CommonWell, Carequality, Surescripts), and claims files it analyzes the data to identify Recapture, Suspect, and Net New opportunities. These are displayed in the Risk Capture view of the ZAP.

These gaps are summarized on the Risk Capture Card of the Overview. The Risk Capture Card Includes:

• Type: Whether the risk gap is a Recapture, Suspect, or Net New gap.
• Condition: The suspected or previously documented HCC Category.
• Last Diagnosis Date: The last date that the condition was diagnosed.
• Status: Displays the current workflow state (e.g., Open, Pending, Accepted for Review, Dismissed)

To view the risk adjustment gaps in further detail, click All Risk Capture to navigate to the Risk Adjustment page.

Risk Adjustment Table

The Risk Adjustment Table displays a list of Suspect, Recapture, and Net New conditions identified through EHR and HIE data sources. Each row represents a coding opportunity associated with a specific patient condition. Users can filter, sort, and interact with the list to efficiently manage risk gaps.

Table Columns

• HCC: Displays the name of the risk gap's Hierarchical Condition Category.
• Type: The diagnosis type. Shows whether the opportunity is a:
  • Suspect: Not documented this year or within the recapture window, but evidence suggests the condition exists. Suspects come from Zus or from a payer gap file (see How Suspects Are Found below).
    • Suspect Confidence Levels: High confidence, medium confidence, or low confidence based on the supporting clinical evidence
  • Recapture: Previously documented and needs to be captured again this year.
  • Net New: Diagnosed for the first time during the measurement period, and not in the recapture period.
• Status: Shows the current workflow state of the opportunity (e.g., Open, Pending, Accepted for Review, Dismissed).
• Confidence Level: Confidence level of the suspect based upon the evidence supporting the gap
• Contract Year Dropdown: Select contractual year.

How Suspects Are Found

Zus generates suspects on two schedules:

• Automatically as new evidence comes in. Zus gathers certain FHIR resources as they change and generates suspects from them in near-real time. Zus doesn't extract quoted passages from clinical documents automatically.
• Ad hoc or ahead of upcoming appointments. Zus can generate suspects for a group of patients on demand, or automatically before upcoming appointments. It reviews the patient's full record, including clinical documents and medication history, for conditions that are likely present but not yet coded. Each suspect comes with an ICD-10-CM code and citations to its supporting documents, and every citation is checked against its source document.

How Scores Are Calculated

• HCC model: Gaps and scores use the CMS-HCC v28 model.
• Confidence: Each suspect has a confidence level from 1 to 5, displayed as Low (1-3), Medium (4), or High (5). It reflects how strong the evidence in the record is. A provider still needs to evaluate and document every suspect before it's coded.
• RAF scores: Zus calculates three Risk Adjustment Factor (RAF) scores per patient per calendar year:
  • Potential: All HCCs from gaps that haven't been dismissed
  • Expected: HCCs for gaps with an encounter diagnosis in the current measurement period
  • Actual: Only HCCs from closed gaps (acknowledged by the payer)
• Recapture settings: Your organization can set how many years back recapture looks, and whether it uses claims only or also encounter diagnoses from clinical data.

For the full method, see Risk Adjustment in the technical docs.

Viewing and Managing Gaps

Clicking on any condition in the Risk Adjustment Table opens a side drawer on the right-hand side of the screen. The side drawer displays detailed information about the selected Suspect, Recapture, or Net New opportunity and allows users to review evidence, update the condition’s Status, and add notes.

Gap Workflow

• Header: Displays the condition name, diagnosis type (Suspect, Net New, or Recapture)
• Detail: Lists the HCC code, data source (Zus, Payer File, Claim), the date the opportunity was opened, confidence level, and the matching ICD-10 code.
• Status: Users can update the status to Open, Pending, Accepted for Review, or Dismissed. Multiple workflow tags (e.g., “Sent to provider for review,” “Accepted by provider”) may be applied

Clinical Evidence

Beneath the Status section of the side drawer, coders can access Evidence Summary.

The Evidence Summary is a concise, aggregated view of all clinical evidence supporting the identified Risk Gap, including relevant labs, diagnoses, and other supporting data used to substantiate the opportunity.

• You are able to copy the evidence to your clipboard, or to the gap note by clicking in the upper right hand corner.

The Clinical Evidence section displays the underlying data that led to the creation of the Suspect, Recapture, or Net New opportunity. Clicking on the evidence card will take you to more detailed information, including the Source Document if applicable. Evidence can include:

• Encounter notes and summaries
• Labs
• Medications (e.g., furosemide 40 MG Oral Tablet)
• Doc Refs such as C-CDAs and PDF documents including imaging or specialist reports (e.g., Echocardiogram reports)

Network Query Requirements and Constraints

Customers are welcome to run their own records through Zus’s Risk Adjustment Recapture and Suspecting logic at any time. However, all requests to CommonWell, Carequality, and Surescripts must be for the purpose of Treating a patient.

In practice, that means that your users and your Zus subscriptions can request records for the following reasons:

• To chart prep for an appointment
• To stratify a population and identify patients rising in risk or in need of urgent engagement
• To identify patients with open care gaps
• Based on Zus’s standard intelligent refresh triggers as defined here

If you have purchased the Risk Adjustment add-on, Zus will automatically enrich records you retrieve with indicators for HCCs, suspect and recaptured condition indicators, and RAF scores. You are free to use these records for risk adjustment and other secondary Payment and Operations activities.

Customers may not initiate requests to the networks purely to support reporting and audit requirements, e.g.:

• End-of-year retrospective risk adjustment and evidence capture
• Quarterly or annual quality reporting and evidence capture (e.g., eCQM, HEDIS)