Which data are used to compute risk scores in Medicare risk adjustment?

• A. Risk-adjusted codes data
• B. Patient satisfaction surveys
• C. Pharmacy counts only
• D. Lab results only

Answer: (A)

Risk scores in Medicare risk adjustment come from health status information encoded in diagnosis codes in medical claims. These ICD-10-CM codes are grouped into conditions that drive costs, and each condition has a weight in the model. Demographic factors like age and sex are also used, but the main data source is the diagnosed conditions submitted in claims. This is why the data used are the risk-adjusted codes data. Patient satisfaction surveys do not reflect health status; pharmacy counts alone don’t capture diagnosed conditions, and lab results alone don’t provide a complete, standardized view of chronic disease burden across beneficiaries. So the data used to compute risk scores are the diagnosis codes captured in claims.