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High Risk Diagnosis Codes and Risk Adjustment

High risk diagnosis codes are like any other ICD-10 code containing a series of letters and numbers. The letter provides context for the nature of the diagnosis and the numbers further refine the injury or disease into subcategories which describe cause, manifestation, location, and severity.1 The more severe or complex a diagnosis, the higher the risk associated.

For example, in the M: Musculoskeletal system category, the following are considered high risk diagnosis codes due to their severity and complexity:2

  • M34.0 Progressive systemic sclerosis
  • M35.00 Sicca syndrome, unspecified
  • M36.0 Dermato(poly)myositis in neoplastic disease

Although there are high risk diagnosis codes in almost every nature of diagnosis, they most commonly appear in the following categories:2

  • D: Neoplasms, blood, and blood-forming organs
  • F: Mental and behavioral disorders
  • M: Musculoskeletal system
  • O: Pregnancy and childbirth
  • R: Abnormal clinical and lab findings
  • Z: Factors influencing health status and contact with health services
Low Risk and High Risk Arrows

As someone visits a doctor’s office or hospital throughout their life, they collect diagnosis codes. The diagnosis codes, in collaboration with demographics, determine the risk adjustment factor (RAF) score for that individual. The RAF score translates to how costly the individual’s care will be for that coming year.

Hospitals and health systems benefit from the RAF VueTM software because it provides instant insights into chronic code capture and recapture opportunities, quickly surfaces patients with the greatest treatment and financial impacts, automatically calculates reported and potential RAF scores, and generates reporting at the patient, provider, and reviewer level.

Need help evaluating or capturing accurate RAF scores? Interested in the RAF VueTM technology? UASI has helped clients across the country ensure accurate risk adjusted reimbursement. Contact us at to get started.