Risk Adjustment Coding: What Providers Need To Know
Date: 08/09/17
Risk Adjustment is a predictive modeling process that takes into account the underlying health status and health spending of patients. It allows health plans to identify members with serious or chronic illnesses and assigns a risk factor score to those members based on a combination of their health conditions and other demographic factors.
Risk adjustment strategies can help health plans work collaboratively with providers to identify high-risk members to ensure that those members have all the tools and resources they need to better manage their health.
How does risk adjustment work?
A risk adjustment value is assigned to each diagnosis code, which are grouped into a hierarchical condition category (HCC). Your patients may be assigned to more than one category because the combination of risk factors and demographic information may overlap to represent more than one type of illness.
Why should providers care about risk adjustment coding?
Increased coding accuracy helps to identify patients who may achieve better outcomes through individualized support services such as Care Management. This ensures that your patients receive the appropriate level of care while supporting your efforts to coordinate their care. In addition, risk adjustment supports your practice in meeting the reporting requirements of ICD-10-CM codes, including records accuracy and timely reporting of claims and encounter data. Additionally, effective risk adjustment coding helps to streamline your claims process, which may result in faster reimbursement!
What’s the provider’s role?
The Centers for Medicare and Medicaid Services (CMS) requires that you include documentation supporting the submitted diagnosis in your patient’s medical record. This documentation must support the current presence of the diagnosed condition, and it must indicate your assessment and/or plan for managing the condition. By documenting this information, you help to ensure the integrity of the data used in calculating the overall health risk of your patients and contribute to improved care for those patients.
What’s the best practice model for documentation?
Each and every condition that is addressed at the time of the patient encounter should be documented. Each condition that relates to a code must reflect evaluation and/or treatment. A list of diagnoses is not acceptable as evidence that the diagnosis affected the patient management. The best practice is to follow the MEAT Documentation model. MEAT is an acronym used to describe the four factors that help you establish the presence of a diagnosis during an encounter in proper documentation:
- Monitor: signs, symptoms, disease progression, disease regression, etc.
- Evaluate: test results, medication effectiveness, response to treatment
- Assess/Address: ordering tests, discussion, review records, counseling
- Treat: medications, therapies, other modalities
Want to learn more?
To learn more about Risk Adjustment Coding and how it will benefit your practice, contact your local Provider Relations Consultant. If you need help finding the Provider Relations Consultant for your region, call Provider Services at 1-866-595-8133.