CMS Expands RADV Audits for 2025: What PCPs Need to Know

In a major shift for Medicare Advantage oversight, CMS has announced the expansion of its Risk Adjustment Data Validation (RADV) audits. Starting in 2025, all eligible MA contracts will be audited annually, with a renewed focus on documentation integrity and payment accuracy. This includes retrospective audits for 2018–2024.

What’s Changing?

CMS’s May 2025 press release outlines a more aggressive audit strategy:

“Beginning immediately, CMS will audit all eligible Medicare Advantage contracts for each payment year in all newly initiated audits…”
“CMS confirms that any diagnoses submitted by an MAO for risk adjustment are supported in the enrollees' medical records. If diagnoses are unsupported… CMS may collect overpayments.”
— CMS.gov Press Release

Documentation Standards: No More “Chart-Only” Diagnoses

To pass CMS audits, documentation must meet stricter standards:

• Diagnoses must be linked to clinical care—not just listed in the chart.

• Provider-authored notes are required. Coders cannot validate diagnoses without direct documentation from a qualified clinician.

• Templates and workflows must be updated to reflect new audit criteria.

• Unsupported codes may trigger payment clawbacks, even if previously accepted.

What This Means for Primary Care

Primary care teams play a central role in risk adjustment—and now face greater responsibility:

• Annual Wellness Visits and HRAs must include actionable documentation.

• Prospective risk workflows should flag unsupported diagnoses before submission.

• Audit prep should include mock RADV reviews, especially for high-risk HCCs.

• Education is critical: Providers must understand that documentation drives payment integrity, not just coding.

Common High-Risk HCCs to Watch

While CMS doesn’t label HCCs as “high-risk,” these categories often trigger audit scrutiny due to their impact on risk scores and documentation complexity:

• HCC 18/37: Diabetes with chronic complications

• HCC 85/226: Congestive Heart Failure

• HCC 96/238: Specified Heart Arrhythmias

• HCC 108: Vascular Disease

• HCC 111/280: Chronic Obstructive Pulmonary Disease

• HCC 12/23: Prostate Cancer

• HCC 12/23: Breast Cancer

• HCC 158/381: Pressure Ulcers

• HCC 47/114: Severe Hematological Disorders

• HCC 136/326: End-Stage Renal Disease

These often require:

• Clear linkage to clinical care

• Provider-authored documentation

• Evidence of treatment, monitoring, or follow-up

How We’re Supporting You

At ProTrust Billing Partners, we’re updating our audit logic, provider education, and reporting workflows to align with CMS’s expanded RADV criteria. Our goal is to help PCPs:

• Document with confidence

• Avoid compliance pitfalls

• Capture risk accurately and ethically

Need help refining your documentation or preparing for audits? Reach out—we’re here to support your success.