Otolaryngology Coding Alert

Risk Adjustment:

Understand How Risk Can Inform Visit Complexity

Published on Tue Dec 14, 2021

There’s more to risk adjustment beyond reimbursement, experts say.

If you want to improve your otolaryngology practice’s reimbursement, risk adjustment and Clinical Documentation Improvement (CDI) are two initiatives that may be able to help you.

During the risk adjustment process, payers predict healthcare costs based on the health status of a person. When your providers see patients with high risk scores, the amount of time spent with the patient and resources required to deliver appropriate care create greater costs that affect your practice’s bottom line.

Read on to learn how to apply risk adjustment and CDI to your ENT practice.

Calculating Risk Scores Has Different Financial and Treatment Outcomes

By calculating demographics and the patient’s health condition, health plans give each person a number, or risk score, that’s used to determine the estimated healthcare costs of that person. Health plan organizations will insure members with expected lower healthcare costs to offset the costs of members with higher anticipated costs.

Insurance companies determine the risk scores for their members using a Hierarchical Condition Categories (HCCs) list, which is a list of diagnoses that have values assigned to them to calculate the risk adjustment. The HCC codes are coded into ICD-10-CM codes and sorted into disease processes or diagnosis groups of body systems. Following the initial sorting, the groups are divided further into condition categories that are based on similar costs. Additionally, depending on the demographics and diagnoses, or HCCs, each program enrollee receives a risk score or risk adjustment factor (RAF). That number resets on January 1 each year.

When patients come into your otolaryngology practice — whether they’re new or established, high-, medium-, or low-risk — your providers should capture as much information as possible to determine the complexity of the patient. By knowing how to document and report the complexity of the patient, your practice will be able to receive accurate reimbursement for the services delivered.

But financials are only part of risk adjustment. “It’s not all about reimbursement. Reimbursement’s a huge piece of it — we can’t underplay that, but [the coding is] a part of patient care and really measuring those patient outcomes in the interventions that we’re doing,” says Colleen Gianatasio, CPC, CPC-P, CPMA, CRC, CPC-I, CCS, CCDS-O, Director of Ambulatory CDQI for Mount Sinai Health Care Partners, during a presentation at the recent RISKCON conference.

Changing the Complexity of Your Patient’s Conditions

As an ENT coder, one of the key words you need to be aware of in the documentation is “chronic.” This word relating to the conditions your providers see will make the condition risk-adjusted. For example, J31- (Chronic rhinitis, nasopharyngitis and pharyngitis) will be risk-adjusted. However, rhinitis unspecified without “chronic,” coded to J00 (Acute nasopharyngitis (common cold)) in the documentation, carries the expectation that the patient will feel better in seven to 10 days. Your practice won’t necessarily see a patient with acute rhinitis year after year, unlike a patient with chronic rhinitis, who will be returning for follow-up visits each year.

Scenario: A patient with hyperlipidemia, coronary artery disease, benign prostatic hypertrophy (BPH), and chronic pharyngitis comes into your practice for a follow-up appointment. The patient’s conditions remain stable/unchanged, and there are no associated symptoms. The provider documented that the patient admitted to being a former smoker, reviewed and updated the patient’s medication list, and verified that the patient was compliant with the medication regimen.

In this scenario, while the statuses of the patient’s chronic conditions remain stable, the fact they have multiple chronic conditions makes them a more complex patient with a higher risk score, and you must document this fully. “We’re creating. We’re coders; we are builders; we are healthcare analysts; there are people behind the data that we provide, so it’s so important, it’s imperative that we get this right,” says Gianatasio.

This means, in addition to the applicable E/M visit code, you’ll use ICD-10-CM codes J31.2 (Chronic pharyngitis), E78.5 (Hyperlipidemia, unspecified), I25.10 (Atherosclerotic heart disease of native coronary artery without angina pectoris), and N40.0 (Benign prostatic hyperplasia without lower urinary tract symptoms) to document the patient’s chronic conditions. Lastly, you want to include Z87.891 (Personal history of nicotine dependence) to indicate the patient is a former smoker.

Use CDI to Write the Patient’s Whole Medical Story

CDI allows your practice to receive correct reimbursement and deliver proper care to your patients. When your providers include as much information as possible that pertains to the patient’s condition, you’re better suited to paint the complete clinical picture. A low-risk patient may come in only for a prescription refill and occupy just 15 minutes of the physician’s time, but a more complex patient, such as the one described in the scenario above, may require more time with the provider to ensure proper care.

Additionally, suggesting your providers use “patient is here for a follow up of” instead of “history of” when documenting the reason for the visit, “makes it sound more current and … going back to the ICD-10 guidelines, we want to code all documented conditions that coexist at the time of the encounter or the visit and require or affect patient care or treatment or management,” says Gianatasio. Even if the physician documents the patient’s visit as a follow up for their chronic pharyngitis and records the treatment plan as continuing their existing prescription, the physician is still treating a more complex patient. This simple documentation adjustment will help your practice receive proper reimbursement.