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Risk Adjustment Coding: A Crash Course for Coders & Providers

Date: 05/08/18

In current performance-based payment models, providers’ payments are closely tied to their patients’ outcomes. Without risk adjustment, providers in higher-risk populated areas would receive payment reductions that may not accurately reflect the quality of care they provide. Risk adjustment allows for more accurate comparisons across Tax Identification Numbers by removing the differences in health and other risk factors that affect measured outcomes not under the provider’s control.

– American Academy of Professional Coders (AAPC)

 

Risk Adjustment Coding is a statistical process that takes into account the underlying health status and health spending of enrollees in an insurance plan when looking at their healthcare outcomes or healthcare costs.

Your Role in Risk Adjustment

You play a critical role in ensuring the integrity and quality of the data used in calculating the overall health risk of patients. As a provider, you should:

  • Keep accurate health documentation on record.
  • Remember that ICD-10 coding supports actual patient health status.
  • Know that documentation and coding drives risk adjustment and premiums and improves HEDIS scores, which in turn improves quality incentive earnings.

Remember:

  • Accurate coding tells a complete story about each patient’s encounter.
  • If it’s not coded, the patient doesn’t have it.
  • Conditions that go undocumented usually also go untreated.

Understanding Risk Scores

Each member is assigned a risk score based on demographic and health status information. The risk is calculated to average expenditures. Here’s how it works:

  • Patients scored at 1 are expected to use average resources.
  • Patients scored less than 1 are expected to use fewer resources.
  • Patients scored greater than 1 are expected to use greater resources.

Example:

  • Average expenditure = $1,000
  • Female, age 57 = $500 = .5 Risk Factor
  • Condition A = $700 = .7 Risk Factor
  • Risk Score = .5 + .7 = 1.2 -> Member expected to use greater resources

The M.E.A.T. of the Matter

Conditions must exist at the time of the encounter and affect patient care or management and be documented in order to be coded as a diagnosis.

Remember:

  • Every condition addressed at the time of the encounter should be documented
  • Each condition relating to a code must show evaluation and/or treatment
  • A list of diagnoses is not acceptable as evidence that the diagnosis affected the patient management

As a provider, you should follow the MEAT Documentation Model:

  • Monitoring: Signs, symptoms, disease progression, disease regression, etc.
  • Evaluating: Test results, medication effectiveness, response to treatment
  • Assessing/Addressing: Ordering tests, discussion, review records, counseling
  • Treatment: Medications, therapies, other modalities

Documentation Best Practices

Documentation should include:

  • Patient’s name and date of service
  • All of the patient’s conditions, including co-existing conditions
  • Details to code each condition to the highest degree of specificity
  • Treatment and/or management for each condition
  • Physician’s signature, credentials and date

Remember:

  • Ensure the signature on the medical record is legible. Stamps are not permissible, per CMS.
  • For EHRs, confirm all electronic signature, date and time fields are completed. Include qualifying words like, “Authenticated by” or “Verified by.”

Specificity Best Practices

Be as specific as possible in your documentation. Pay attention to list headers, like “Past Medical History,” and avoid using “History Of” because that indicates a condition no longer exists. For example, if a chronic condition, like diabetes, is currently present in the patient, don’t use “History Of” because that indicates the patient no longer has diabetes.

Treatment or Management Best Practices

Per the CMS Participant Guide: “Physician should code all documented conditions that co-exist at the time of the encounter/visit that require or affect patient care treatment or management.” As a provider, you must document the details about how the condition(s) impact the patient’s care.

Want to learn more?

Check out our 10 tips for effective risk adjustment coding. You can also contact your dedicated Provider Consultant or call Provider Services at 1-866-595-8133 and ask to speak to a member of our Quality team for guidance.