Click row to cross-filter providers · right-click to drill through
Facility ↕
Patients ↕
Conditions ↕
Closed ↕
Compliance ↓
Avg RAF ↕
Gap $ ↕
Providers
All facilities
Payor Mix · Compliance
Medicare Adv.
84%
Medicare
79%
Commercial
71%
Medicaid
66%
Patients In View
12,486
All facilities
Patients w/ Open Gaps
6,842
▲ 4.1% MoM
Avg RAF / Patient
1.84
▲ 0.07 vs LY
Total Open Gap $
$2.71M
Across cohort
High-Risk (RAF ≥ 2.0)
3,748
30% of cohort
Patient Cohort · CY 2026
Click a patient to drill through to detail · right-click for more options
Status: All▾
✓All
Has Open Gaps
All Closed
Has Suspected
RAF: All▾
✓All
High (≥ 2.0)
Medium (1.0–1.99)
Low (< 1.0)
Program: All▾
✓All programs
Value-Based Care
Chronic Care Mgmt
Remote Pt. Monitoring
Not enrolled
Last Visit: All▾
✓All
Last 30 days
Last 90 days
Last 6 months
Last 12 months
Overdue (> 12 mo)
0 of 0 patients
Patient ↕
Age/Sex ↕
Payor ↕
Provider ↕
Facility ↕
Cond ↕
Open ↕
RAF ↕
Gap $ ↓
Last Visit ↕
Care Coord ↕
AI ↕
JN
Jodyne N. Pennycuick
PID 1213447729
F · 69 yrsPayor: Medicare Adv.Provider: Dr. Patel, R.Facility: West Medical CtrLast Encounter: Mar 18, 2026Care Coord: L. Martinez
2.14
Total RAF
$13.1k
Gap $
4 / 7
Closed
Active HCC Conditions
Click to view ICD-10 details & encounter history
HCC 158
Pressure ulcer of other site, stage 3
L89.893 · Skin · Chronic
1.069
$10.0k
Open
›
HCC 52
Alzheimer's disease, unspecified
G30.9 · Neurological · Chronic
0.346
$3.24k
Closed
›
HCC 111
COPD, unspecified
J44.9 · Respiratory · Chronic
0.335
$3.14k
Closed
›
HCC 85
Other heart failure
I50.89 · Cardiovascular · Chronic
0.331
$3.10k
Addressed
›
HCC 18
Diabetes type 2 with nephropathy
E11.21 · Endocrine · Chronic
0.250
$2.34k
Closed
›
—
Anxiety disorder, unspecified
F41.9 · Behavioral · Chronic (no HCC)
—
$0
Closed
›
HCC 22
Suspected: Morbid obesity (BMI 40+)
E66.01 · Endocrine · Suspected
0.210
$1.96k
Suspected
›
Risk Score · 6-Year Trend
Encounter Timeline
Mar 18
Annual Wellness Visit
Dr. Patel · 4 conditions attested
Feb 02
Follow-up · CHF
Dr. Williams · 1 condition addressed
Dec 14
Wound care consult
RN Garcia · documented
Nov 02
Lab review
A1C · BMP · Lipid panel
JN
Jodyne N. PennycuickPID 1213447729
F · 69Provider: Dr. Patel, R.Facility: West Med Ctr
5Findings
+1.42Potential RAF
$13.3kPotential $
Analyzed Apr 24, 2026 · Run #142
AI Summary
This patient shows 5 potential documentation opportunities. Prior-year CHF (HCC 85) has not been recaptured in 2026 despite active diuretic therapy. Current metformin and gabapentin prescriptions without a coded diabetes diagnosis suggest an unreported or under-specified condition, supported by two A1C results at or above 6.9. Sustained BMI readings over 40 across four visits support a morbid obesity code. One external claim from an outside cardiology group references atrial fibrillation not present in the CHN problem list.
Generated overnight by the local model from precomputed pattern matches. No live AI is called by this page. Proposed findings require provider review before any chart change.
Suspected Findings · CY 2026
Click a finding to expand evidence and actions
Confidence: All▾
✓All
High only
High + Medium
5 active · 0 disposed
Outside Sources
External claims & HIE, not in CHN chart
Atrial fibrillationI48.91 · HCC 96
Heartland Cardiology Assoc.Claim · Feb 2026
Peripheral vascular diseaseI73.9 · HCC 108
Regional HIE feedEncounter · Nov 2025
Osteoporosis w/ fracture hxM80.08 · HCC 169
St. Mary's Hospital dischargeInpatient · Sep 2025
Disposition History
Previously reviewed for this patient
Mar 02
Dismissed: Suspected hypothyroidism (E03.9)
Dr. Patel · Reviewed, labs within range
Jan 15
Added via ICE: Chronic kidney disease st. 3a (N18.31)