Strengthen Your Diagnosis Coding for Risk Adjustment

By Serine A. Haugsness, CPC

The concept of risk adjustment was “born” upon passage of the Balanced Budget Act of 1997 and refined by the Beneficiary Improvement Act of 2000, which mandated that the Centers for Medicare & Medicaid Services (CMS) implement risk adjustment for Medicare Advantage organizations (MAOs) in 2004 and achieve 100 percent risk-adjusted payments by 2007. To achieve this, CMS uses the CMS-Hierarchical Condition Category (HCC) model. Risk adjustment has also been adopted by a number of states using other models, such as the Chronic Illness Disability Payment System (CDPS), Episode Risk Groups (ERGs), Diagnostic Cost Group (DCG), and others—mainly because state populations are more diverse than the rather narrow group of Medicare-eligible patients.

Why Should a Coder Care About Risk Adjustment?

CMS requires accurate and complete diagnosis coding, and for all coding to be done in accordance with official guidelines and CMS regulations. If that’s not a good enough reason, think of your patients.

Great documentation and accurate diagnosis data provides information for care management activities, trends in chronic illness among populations, and increased communication among specialists treating the same patient. Conversely, poor documentation and diagnosis coding can lead to missed diagnoses (and lack of treatment), poor communication among treating physicians (leading to duplicate or contradictory treatment), and even incorrect diagnoses (like coding a “rule-out” as a confirmed condition). Incorrect diagnoses can follow a patient for the rest of his or her life and potentially exclude him or her from obtaining life or health insurance in the future.

How Can a Coder Keep Risk Adjustment Models Straight?

Here’s the best news: You don’t have to!

Coding supports all risk adjustment models while documentation and guidelines support coding; but because payment generally revolves around CPT® and HCPCS Level II coding, ICD-9-CM coding tends to be put on the back burner. CMS recognizes this and encourages MAOs to educate coders, physicians, and facilities about the need for correct and complete diagnosis information.

Here’s more good news: Becoming a better diagnosis coder NOW will help you in the transition to ICD-10-CM. The ICD-10-CM guidelines are similar to those for ICD-9-CM, so take advantage of the one-year delay to become a great diagnosis coder.

Here’s how:

  1. Read the Official ICD-9-CM Guidelines for Coding and Reporting.
  2. Skip the cheat sheets. Use the alphabetic index AND tabular listing every time (even if you THINK you know the code), and follow all of the listed rules.
  3. If you need clarification, go to the American Hospital Association’s AHA Coding Clinic for ICD-9-CM.
  4. Learn or brush up on anatomy and physiology (A&P) to help you understand when something doesn’t make sense for the condition you’re coding. This will also help you determine when you need to ask the physician to provide more clarity about the condition.

How Can Coders Help Providers Document Dx Better?

Providers who document well are a coder’s dream. Here are some things you can do to make that dream come true:

Make sure all of the required technical elements are present in every progress note. If required elements are not present, the auditor doesn’t have to go any further and can fail the note on a technicality. Required elements include:

  • A legible signature with credentials
  • Patient name on each page
  • Date of service is evident
  • Note is complete and legible (meaning someone coming in and auditing this note would not have to ask questions). You don’t want to fail an audit because the note cannot be deciphered.

Print out a few progress notes from your electronic health record (EHR). In many cases, the note you see when you’re coding from the EHR is not the same as the note the auditor sees printed out from your EHR. Audit some notes from the printed version or whatever version you provide to those who request medical records. Look for contradictory information and laundry lists of codes dating back to when the patient was in utero not supported in the documentation on that date of service. Use that information to provide feedback to physicians, managers, compliance officers, or whoever else might need to know in your organization.

Stress descriptive documentation. The Official ICD-9-CM Guidelines for Coding and Reporting, section IV.K, instructs, “Code all documented conditions that coexist at the time of the encounter/visit, and require or affect patient care treatment or management.” Remind physicians that simply listing a condition in the progress note is not necessarily sufficient to support that the condition is current. The progress note must support the diagnoses by showing evidence they were monitored, addressed, assessed, treated, or evaluated. Providing this information not only allows you to capture the diagnosis codes, it can help support medical necessity by showing what, how, and why the listed conditions affected the provider’s medical decision-making during that encounter.

Pay attention also to generic diagnoses such as chronic obstructive pulmonary disease (COPD), congestive heart failure (CHF), pain, and others. Providers are creatures of habit and may default to a generic diagnosis when a more descriptive diagnosis may be more appropriate.

Introduce providers to the golden rule: “Document for others what you would have them document for you.” Remember that every patient they see has probably been seen by another provider at some point and will probably see another provider some time in the future. Just like receiving good documentation with a solid history from the patient’s previous provider is helpful in diagnosing and treating the patient now, their good documentation will help another provider give great patient care in the future.

History versus current condition. When a physician documents “history of,” he or she might mean a condition that is chronic and is being treated, but causing no symptoms. Unfortunately, “history of” to a coder (and an auditor) means the condition no longer exists.

On the other end of the spectrum, many providers will document “breast cancer” to describe a patient who had a mastectomy in 1979 and has had no evidence of recurrence. It would be incorrect to code 174.9 Malignant neoplasm of breast (female), unspecified because there is no evidence of current disease.

Teach providers to document the timing of the disease process clearly so there is no question as to whether it is historical or current.

Rule-outs are dangerous! Rule-outs, probable, or possible diagnoses are not to be coded per outpatient rules. To avoid confusion and give coders something to code, providers should document the symptoms or reason the test is being ordered.

Remind your providers that CODERS MAY NEVER ASSUME. Everything coded needs to be spelled out and supported in the progress note for that date of service. Just because the provider knows the patient has a leg ulcer and that leg ulcer was caused by diabetes does not mean the coder can code it. Causality must be documented clearly in every note on every date of service (for example: “diabetic ulcer on the patient’s right heel”).

Give positive feedback when providers get it right! Providers tend to be high achievers. They are often motivated to provide excellent patient care by making their records complete and meaningful. We all like to receive credit for a job well done.

Serine A. Haugsness, CPC, is a coding analyst at Buckeye Community Health Plan, with risk adjustment and coding education as a primary responsibility. She holds an associate degree in medical billing and coding and has over 11 years of health care experience. Serine is pursuing a bachelor’s degree in health care management.


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