You submitted your RADV audit response. Every sampled member-year includes complete medical records. MEAT criteria is documented. Diagnoses are clearly stated. You expect high validation rates.
Six months later, CMS’s validation results arrive. Your overturn rate is 22%. Diagnoses you thought were bulletproof got rejected. The rejection reasons surprise you.
CMS isn’t just validating whether documentation exists anymore. They’re evaluating whether documentation tells a clinically coherent story. Here’s what’s getting HCCs overturned in 2026 that wouldn’t have failed audits in 2023.
The Copy-Forward Documentation Rejection
You submitted documentation showing diabetes with nephropathy coded across multiple encounters. Each note includes “diabetes with diabetic nephropathy” in the assessment.
CMS rejected it. Their rationale: Every encounter uses identical language. “Diabetes with diabetic nephropathy” appears word-for-word in March, June, September, and December notes. There’s no variation, no progression documentation, no clinical detail specific to each encounter.
This pattern indicates template-driven documentation, not active clinical evaluation. CMS’s position: If the provider was actually evaluating nephropathy at each visit, documentation would vary based on current clinical status. Identical copy-forward language suggests the diagnosis is being perpetuated without evaluation.
What would have passed: Documentation showing nephropathy evaluation with visit-specific details. “GFR today 42, stable from last quarter. Continue ACE inhibitor. Patient reports good medication adherence” in March. “GFR 38, declining from 42 last quarter. Increased protein in urine. Referring to nephrology for medication adjustment” in June. This shows active management, not copy-forward.
The Addendum Timing Suspicion
You submitted documentation that includes provider addendums clarifying diagnosis specificity. The original note from the encounter mentioned “CKD.” An addendum dated three weeks later specifies “CKD stage 4.”
CMS rejected it. Their rationale: The addendum was added after your retrospective coding vendor reviewed the chart. The addendum timing suggests documentation enhancement prompted by coding review, not clinical recollection.
This is new in 2026. CMS is scrutinizing addendum dates and comparing them to your coding workflow timestamps. When addendums systematically follow coding reviews by days or weeks, CMS views them skeptically.
What would have passed: Documentation completed during or immediately after the encounter. Or addendums that include clinical detail explaining why additional information is being added. “Upon review of recent lab results, patient’s GFR of 22 confirms stage 4 CKD. Updated assessment to reflect current staging.”
The Single-Source Diagnosis Problem
You submitted documentation for diabetic nephropathy. The only mention appears in the annual wellness visit. The patient saw endocrinology twice and had three primary care sick visits during the year. None of those encounters mention nephropathy.
CMS rejected it. Their rationale: If nephropathy is real and clinically significant, why does it only appear in the wellness visit? The pattern suggests opportunistic coding during comprehensive encounters rather than ongoing condition management.
What would have passed: Documentation showing the condition acknowledged across multiple encounter types. Even if detailed evaluation only happens at specialist visits, primary care notes should reference the condition. “Known diabetic nephropathy, managed by nephrology, patient adherent to ACE inhibitor.”
The Severity Without Treatment Contradiction
You submitted documentation for CHF with reduced ejection fraction (HCC 85). The echocardiogram shows EF 30%. The diagnosis is clearly stated.
CMS rejected it. Their rationale: Despite documented severe CHF, the patient isn’t on guideline-directed medical therapy. No beta blocker. No ACE inhibitor or ARB. No diuretic. No cardiology follow-up.
CMS’s position: If CHF is severe enough to code at the highest severity level, treatment should reflect that severity. Absence of appropriate treatment calls into question whether the diagnosis is current and clinically relevant.
What would have passed: Documentation showing either appropriate treatment for the severity coded, or clinical documentation explaining why guideline therapy isn’t being used. “Patient has severe CHF with EF 30% but cannot tolerate ACE inhibitors due to hyperkalemia. Manages with diuretics only.”
The Lab Value Without Clinical Context Issue
You submitted documentation for CKD stage 4 based on GFR of 25. The lab value is documented. The diagnosis is stated.
CMS rejected it. Their rationale: The lab value appears in isolation without clinical context. No prior GFR values for comparison. No documentation of symptoms. No treatment plan. No discussion of progression or stability.
A single lab value without clinical story isn’t adequate documentation in 2026 audits. CMS wants to see that the provider used the lab value to inform clinical decision-making.
What would have passed: Documentation showing clinical context. “GFR declined from 32 six months ago to 25 today, indicating progression of CKD. Patient reports increasing fatigue. Adjusted medications to avoid nephrotoxic agents. Educated on dietary modifications. Will monitor monthly and refer to nephrology if continues to decline.”
The Specialist Note Without PCP Awareness Gap
You submitted specialist documentation showing detailed evaluation of diabetic complications. The endocrinology note clearly documents diabetic nephropathy with complete clinical detail.
The patient’s primary care provider notes from the same year make no mention of nephropathy. PCP continues to code diabetes without complications.
CMS rejected it. Their rationale: If the specialist identified and documented nephropathy, why didn’t the PCP incorporate this into their assessment? The disconnect suggests either the specialist diagnosis wasn’t communicated, wasn’t accepted, or wasn’t real.
What would have passed: Documentation showing coordination between specialist and PCP. PCP notes acknowledging specialist findings. “Per recent endocrinology evaluation, patient has diabetic nephropathy. Continuing ACE inhibitor. Will monitor GFR quarterly.”
The Resolved Condition Perpetuation
You submitted documentation for COPD coded across all four quarters. Each note lists COPD in the problem list.
CMS rejected third and fourth quarter. Their rationale: First and second quarter notes document active COPD with symptoms, treatment adjustments, and clinical evaluation. Third and fourth quarter notes show COPD in problem list but no symptoms documented, no exacerbations, patient never mentioned respiratory issues, no COPD medications prescribed or refilled.
CMS’s position: Just appearing in the problem list isn’t adequate. If the condition isn’t being actively managed or causing clinical impact, it shouldn’t be coded.
What would have passed: Documentation showing ongoing clinical relevance even for stable conditions. “COPD stable, patient adherent to inhaled corticosteroids, no exacerbations this quarter, pulmonary function stable, continue current regimen.”
What Actually Works
Surviving 2026 RADV audits requires documentation that tells clinically coherent stories, not just contains required elements.
Avoid copy-forward documentation by ensuring visit-specific clinical detail. Complete documentation during or immediately after encounters, not in addendums weeks later. Show conditions documented across multiple encounter types, not just wellness visits. Ensure treatment aligns with coded severity. Provide clinical context for lab values, not just the values themselves. Demonstrate PCP awareness of specialist findings. Document ongoing clinical relevance for chronic conditions.
The organizations with high validation rates in 2026 audits are the ones whose documentation reads like active patient care, not coding optimization.
