The Function Nobody Built
Most retrospective risk adjustment programs follow a linear process: receive charts, review documentation, identify codes, submit to CMS. The process ends at submission. Once codes are sent, the program moves to the next batch. What happens to those codes after submission, whether they remain defensible as clinical conditions change and documentation evolves, is nobody’s job.
This creates a growing inventory of unmonitored submitted codes. A diagnosis submitted in 2024 based on that year’s documentation may no longer have adequate support in 2025 or 2026. The condition may have resolved. The provider may have stopped documenting active management. The member may have changed primary care physicians, and the new provider’s notes don’t reference the condition. The code sits in CMS’s system generating risk score credit for a diagnosis that no current clinical documentation supports.
When CMS audits that code, it evaluates it against current documentation standards. A code that was defensible when submitted may not be defensible when audited, particularly for conditions that require evidence of ongoing management. The gap between submission and audit is where defensibility erodes, and most programs have no process to monitor that erosion.
What Post-Submission Surveillance Does
Post-submission surveillance continuously evaluates the defensibility of previously submitted codes against evolving documentation. On a quarterly or semi-annual cycle, the system reviews the plan’s active HCC inventory and checks each code against the member’s most recent clinical documentation. Codes with strong current evidence are confirmed. Codes where documentation has weakened or disappeared are flagged for review, provider query, or proactive deletion.
This turns submitted codes from static inventory into dynamically managed assets. Instead of discovering that a three-year-old stroke code has no current neurological follow-up documentation during a RADV audit, the surveillance process identifies the gap during routine operations. The plan can either obtain updated documentation through provider outreach or remove the code before it becomes an audit liability.
The surveillance function also feeds provider education. When the system identifies patterns of documentation degradation (for example, a specific provider consistently stops documenting ongoing management for chronic conditions after the initial diagnosis), that information drives targeted outreach. The provider receives specific, actionable feedback rather than generic documentation training.
Why This Matters More Under V28 and Annual Audits
Two factors make post-submission surveillance more important now than at any point in risk adjustment history. First, V28 reduced the number of codes mapping to HCCs, which means each remaining code carries more relative weight. A single stale code has a larger proportional impact on risk scores and audit outcomes than it would have under V24. Second, CMS now audits all contracts annually. The probability that any given submitted code faces scrutiny increased dramatically. Codes that might have gone unexamined for years under periodic audits now face annual review potential.
The combination of higher per-code impact and higher audit probability makes unmonitored code inventories significantly riskier. Plans that submit codes and never revisit them are accumulating exposure with every passing quarter as documentation ages and conditions change.
Building the Missing Function
Retrospective Risk Adjustment Coding programs have invested in front-end capabilities: better AI, faster chart review, improved MEAT validation. The missing investment is on the back end, after codes are submitted. Post-submission surveillance that continuously evaluates code defensibility, flags documentation degradation, and triggers proactive remediation closes the gap between submission and audit. Plans that build this function are managing their entire code inventory as a living portfolio rather than treating submission as the end of the process. That portfolio management approach is what produces defensible results when CMS’s expanded audit workforce arrives.
