Risk Adjustment Coding Suite

End multi-vendor management headaches: AI-enabled coding automation with compliance and submission tools, all through Edifecs.

Value-based care has two core objectives: reduced cost and improved risk adjustment. With Edifecs, unify your risk adjustment operations. Our approach, from coding to submissions, helps organizations of all sizes create a risk-maturity scale, improve revenue integrity and compliance, and not just shift to value-based care, but thrive under it. The Edifecs Risk Adjustment coding suite delivers an automated, SaaS-based tech platform encompassing retrospective and pre-submission coding, compliance and audit support, and submissions. Experience the benefit of over 25 years of health information technology leadership and industry leading NLP technology ensuring plan, provider, coder, and member satisfaction.

Risk Adjustment Coding Suite Infographic


Retrospective Review

  • Our technology combines natural language processing (NLP) and analytics to extract valuable insights into healthcare datafrom unstructured data in medical charts, allowing for performance improvements across the board:
  • 5X increase in coder productivity
  • 20-30% increase in risk capture
  • 40% decrease in costs
  • All member charts that contain no coding errors are eliminated from the queue, ensuring coding time is focused only where needed, eliminating wasted efforts

Perform automated retrospective chart reviews with coding software that identifies conditions that are documented in the chart, but not captured, and presents the suggested code alongside the supporting documentation for review.

Audit Safeguards

  • Redaction logic identifies codes that lack sufficient evidence and automatically flags them to ensure compliant and accurate submissions that protect against future audits
  • QA functionality allows for “third pass” code reviews, customizable queues, and code intensity, condition, and population targeting
  • Chart linking ensures that submitted codes are attached to the relevant clinical evidence

Rectify codes that may lack sufficient evidence or are improperly coded to submit to CMS with confidence, with the built-in capabilities for “third pass” quality assurance, custom condition targeting, internal audit support, and redaction logic.

Best-in-Class NLP Engine

  • Understands the complexities of clinical language -- including grammar, syntax, context, and intent
  • Applies proprietary algorithms and logic to identify a set of patients or features that align to the model’s purpose, like uncovering areas to add, remove, or modify HCC codes at cascading degrees of confidence
  • Provides the greatest depth and breadth of industry standard terminology support, including SNOMED, ICD-10, RxNorm, and LOINC
  • Creates a universal clinical source of truth through a comprehensive patient profile that unites structured data elements to the newfound clinical information

Convert unstructured data - like physician notes entered in an EHR - into a structured extraction of clinically meaningful intelligence that can be systematically processed by machine to derive predictive insights.

Risk Analytics

  • Identify risk-centric care gaps and find missed RAF opportunity with ACA, MA, Medicaid, and other value-based care populations
  • Enjoy granular operational insights on providers, coders, members, and more to drive internal expertise with performance management
  • Identify areas for additional risk adjustment education and training to further optimize outcomes

Understand the impact of your risk adjustment program with analytics that evaluate populations, utilization, and health statuses to summarize provider and practice performance based on Annual Wellness Visits, recapture of chronic conditions, and documentation compliance.