The Medicare Risk Adjustment model has been around for 13 years now and coders and providers are still struggling to understand it. Understanding how the model works and the payment methodology is one thing but there is more of a need to understand how to document and code the diagnoses in the ICD-9 book to the highest level of specificity. The diagnoses and how to document and code them is nothing new in regards to this model. The ICD codes and their descriptions have been around since the ICD book came out in the 50's. The problem lies in that the providers have not had any specific training on what diagnoses there are to choose from in the ICD-9 book and how to document them to the highest level of specificity. On the same note the coders or billers generally are not thoroughly trained in ICD code assignment and when to query the provider for a more specific diagnosis. Being more specific in your documentation and code assignment of the diagnoses applies across the board to every patient regardless of their insurance. However, the payment methodology for the Risk Adjustment HCC model, Hierarchical Condition Categories, applies to Medicare Advantage Plans.
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