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Risk Adjustment Program

Risk adjustment, a component of Medicare Advantage and the Affordable Care Act (ACA), helps align payments to health plans with the risk characteristics of people enrolled in each plan.

Accurate risk adjustment relies on comprehensive, face-to-face health assessments of patients. These assessments result in appropriate medical record documentation and diagnosis coding. The diagnosis codes are then submitted to the health plan on a claim and used to determine the level of risk associated with the patient.

Florida Blue has risk adjustment programs in place that align with our commitment to ensuring that quality of care is maintained through the physician-patient relationship. These programs help identify care and coding opportunities that can help prevent and/or detect conditions and encourage members to schedule health screenings, tests and vaccines.

Helpful Resources

1 Availity, LLC is a multi-payer joint venture company. For more information or to register, visit

Commercial Risk Adjustment

Coding Presentation

File Name Type Updated
Asthma PDF November 2022
Autoimmune PDF October 2021
Cancer PDF April 2023
CHF PDF October 2021
COPD PDF October 2021
Diabetes PDF October 2021
Heart Arrythmia PDF October 2021
HIV PDF October 2021
Major Depression and Bipolar Disorders PDF November 2023
Seizure Disorders PDF October 2021

Medicare Risk Adjustment

Coding Tips & Best Practices

File Name Type Updated
Medicare Advantage Coding Tips from the OIG Toolkit PDF Janaury 2024
Angina Pectoris PDF December 2023
Annual Wellness Visit PDF March 2024
Arthritis PDF May 2024
Chronic Kidney Disease PDF September 2023
Chronic Obstructive Pulmonary Disease PDF November 2023
CMS-HCC Model V28 Advance Announcement *new* PDF April 2023
CMS-HCC Model V28 Perinatal and Congenital Codes *new* PDF February 2024
Dementia PDF April 2023
ICD-10 PDF October 2022
ICD-10 (Best Documentation Practices) PDF October 2023
Lung Cancer PDF August 2023

Peripheral Vascular Disease

PDF July 2023
Sickle Cell Disease PDF June 2023

Behavioral, Vascular Health, COPD, Weight, Hypertension, and Chronic Kidney Disease (Testing, Coding, and Documentation Tip Sheet)

PDF May 2023