4 Key Areas to Risk Adjustment Documentation

4 Key Areas to Risk Adjustment Documentation

Healthcare is quickly transforming from a fee-for-service payment model where providers are paid based on volume of services to various quality-based payment methodologies. These new payment systems are focused on promoting quality of care and creating better outcomes. One of these new payment methodologies is risk adjustment.
The goal of risk adjustment is to reward efficiency and high quality care for sicker patients. These patients require much more clinical and financial resources to treat. Health plans are paid more to cover the costs of providing care to these sicker members. The severity of illness of a plan’s members is measured by the diagnosis codes that are submitted on claims received from their healthcare providers during face to face visits.
Providers are accustomed to documenting and coding from an E/M and CPT© perspective. Changing the focus to diagnosis coding which is the focus of risk adjustment requires some changes to what they are used to.
When educating your providers on best practices for risk adjustment documentation, it is best to focus on just a few key areas.

  1. Make sure problem lists are kept up to date. The problem list should show the status of each condition (e.g., active, chronic, or resolved). It should not be a laundry list of every condition the patient has ever experienced. When updating the problem list make sure the highest level of specificity known to the provider is captured in the diagnosis codes. Be careful that problem lists don’t contain only default unspecified codes. These codes do not accurately show the true severity of illness of sicker patients
  2. All problems need to be in the assessment. All problems that are assessed during the visit should be noted in the assessment portion of the record and coded accordingly. Don’t limit the diagnosis codes on the claim to only what brought the patient into the office that day
  3. All diagnosis should be documented. All diagnosis that were part of the provider’s medical decision making process should be documented. An example of this would be a patient who is being treated with a medication that might affect the treatment of the current presenting issue. If it effects how the current condition is treated, it should be documented and coded
  4. All chronic conditions documented at least once annually. All of the patient’s chronic conditions should be assessed during a face-to-face encounter at least  annually, and submitted on a claim. This includes status codes such as amputations, transplant status, ostomies etc.

There is great value for providers in the office setting to employ coders in their office. Show your value as a professional coder by educating your providers on what they can do to ensure accurate reimbursement. Many more changes in healthcare reimbursement are approaching in upcoming years as we see look forward to the implementation of MACRA and MIPS. Working with your providers now on proper documentation and coding will ensure their success in the transition that is to come.

What is Macra

Colleen Gianatasio

About Has 10 Posts

Colleen Gianatasio, CPC, CPC-P, CPMA, CPC-I, CRC, CCS, CCDS-O, has over 20 years' of experience in the health insurance field, including customer service, claims, quality, and coding. As director of ambulatory CDQI at Mount Sinai Health Partners, her primary responsibilities are provider engagement and CDI for accurate coding and reimbursement. Gianatasio specializes in developing innovative coding curriculum and instruction to support compliance with federal guidelines and appropriate reimbursement processes. She is a certified AAPC instructor and enjoys teaching a variety of coding, documentation, and auditing classes. She serves as president-elect of the AAPC National Advisory Board.

No Responses to “4 Key Areas to Risk Adjustment Documentation”

  1. Brenda J McAlpin says:

    I love this article! Finally, some one sums the whole thing up! Thank You!

  2. Lee says:

    So, if the provider documents a condition in the assessment, but does not mention it anywhere else in the record or give an MDM, can we still code directly from the assessment?