I have not seen an actual regulation regarding this, but the CMS guideline for risk adjustment is that any chronic or acute condition that qualifies under the HCC codes must be documented and evalutated at least one time each year to be included for risk adjustment. CMS clears out all the codes on the MedAdvantage patients risk adjustment at the beginning of every year, so in order to count those codes for the new year and get the proper risk adjustment, we teach the physicians to briefly evaluate each condition.
Originally Posted by vazquecj
Example: patient had an MI (myocardial infarction) in 2000. The physician in the course of evaluting the heart on this patient would document "old MI stable now no new symptoms" and assign dx code 412 which risk adjusts under HCC category code 83.
The Medicare Advantage plans receive money from CMS to pay claims to their contracted physicians based on the total RAF (risk adjustment factor) scores of all the patients in their plan. The more chronic or acute conditions a patient has, the higher the RAF score which means more dollars available to pay the doctors for treating the patients. We do not get any incentive from this, just money to pay physicians, usually at a higher rate than they would get from traditional Medicare. Hopefully this will keep fewer physicians from dropping out of Medicare altogether!
Arlene J. Smith, CPC, CEMC, COBGC
AAPC Tacoma WA Chapter
Past-President 2013 and 2011
Member Relations 2008
AAPC NAB 2007-2009