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MA and FFS, whereas the primary goal of RADV audits is to address improper payments to MA organizations. The coding pattern difference adjustment does not absolve MA organizations of the longstanding obligation to ensure compliance with risk adjustment requirements. CMS has issued guidance regarding the longstanding requirements regarding the accuracy of risk adjustment data submitted to CMS, including the April 15, 2022, HPMS memorandum, “Reminder of Existing Obligation to Submit Accurate Risk Adjustment Data.” All diagnoses submitted for risk adjustment must meet CMS requirements that diagnoses are documented in the medical record as a result of a face-to-face visit and coded in accordance with the International Classification of Diseases, Clinical Modification (ICD-CM) guidelines for coding and reporting,11 which apply equally to diagnoses resulting from health risk assessments and chart reviews. In addition, organizations that submit risk adjustment data are required to certify as a condition of receiving monthly payment that the data submitted under 42 CFR 422.310 are accurate, complete, and truthful based on best knowledge, information, and belief ( see 42 CFR 422.504(l)). And if an organization receives information about inaccurate diagnoses, the organization must correct its data. The Part C/D Overpayment Rule, 42 CFR 422.326, implements the overpayment requirements of section 1128J(d) of the Act and “establishes that, if a Medicare Advantage insurer has received a payment increment for a beneficiary’s diagnosis and discovers that there is no basis for that payment in the underlying medical records, that is an overpayment that the insurer must correct by reporting it to CMS within sixty days for refund.” UnitedHealthcare Ins. Co. v. Becerra, 16 F.4th 867, 869, 870 (D.C. Cir. 2021) (upholding relevant portions of the C/D Overpayment Rule). We also appreciate the commenter’s suggestion that CMS exclude the use of diagnoses from chart reviews and health risk assessments for risk adjustment and will consider this and other suggestions as we evaluate risk adjustment changes in the future. Comment: A few commenters requested confirmation that CMS conducted the annual analysis of coding pattern differences and requested release of analyses with all underlying data. Response: Section 1853(a)(1)(C)(ii) of the Act requires the Secretary to “annually conduct an analysis of the differences” “. . . in coding patterns between Medicare Advantage plans and providers under part A and B to the extent that the Secretary has identified such differences” and to reflect such analysis in the risk scores. Further, the statute provides for a minimum coding pattern difference adjustment factor of 5.9 percent for 2019 and each year after. As required by the Act, CMS conducted the annual analysis of the differences in coding patterns between MA and FFS for CY 2026 and assessed the impact of these differences in coding patterns on MA risk scores. In accordance with section 1853(b)(1) of the Act, in the CY 2026 Advance Notice, CMS provided notice of proposed changes to the methodology used to calculate the risk and other factors used in adjusting rates, and we included an explanation of the changes being proposed in

11 Medicare Managed Care Manual Chapter 7 – Risk Adjustment, Section 120.