Risk Adjustment Overview

Mandated by the Affordable Care Act, risk adjustment programs help control premium rates and ensure high-risk members get the care they need.

Risk adjustment uses information collected from medical records and claims to determine risk scores for patients; higher risk scores show a need for higher reimbursement rates for patients who have serious conditions. That's why it's important to properly document your patients' medical records and use codes to the highest level of specificity using ICD-10-CM.

Successful risk adjustment results in better health management for your patients. Accurate coding and thorough medical record documentation allows us to identify patients who could benefit from our Chronic Care and Complex Case Management programs. These programs, offered free of charge, focus on education and improving the health of our members.

We have risk adjustment programs for Commercial and Braven Medicare Advantage members.

We also have a risk adjustment program for Medicaid.

If you have questions about our risk adjustment programs, email RiskAdjustment@HorizonBlue.com.

Your Role in Risk Adjustment

You play a huge role in the overall success of risk adjustment. From entering specific codes at patient visits to submitting accurate claims and assisting with audits, risk adjustment involves all levels of staff in your office.

It's important that you follow these risk adjustment guidelines:

• Perform comprehensive, face-to-face annual wellness exams of your patients.
• Visit with patients who have chronic conditions at least once per year.
• Accurately code and document any condition that is monitored, evaluated, assessed or treated (MEAT) during every patient visit.
• Accurately enter diagnosis codes to the highest level of specificity.
• Thoroughly document all medical conditions (acute/chronic, status and history) in problem list, patient history, patient assessment/plan and claim.
• Enter medical record documentation in SOAP format: Subjective, Objective, Assessment and Plan.
• Report all coded conditions on the claim; you can submit up to 12 ICD-10-CM diagnoses on a claim.
• Timely submit requested medical records

These steps help capture an accurate picture of your patients' overall health and decrease the burdens on you and your staff for chart retrieval requests.

• Medical Record Requirements

  Medical Record Requests

  We request and review medical records at any time during the year as part of our risk adjustment efforts. Some quality programs, like Medicare Stars and HEDIS®, also request medical records.

  You must respond to our medical documentation requests and within the timeframe requested.

  We do not reimburse for medical record copies, postage and/or for any other miscellaneous costs associated with the retrieval of medical records.

  You can use HorizonDocs, accessed on NaviNet, to receive requests for medical records and securely send the requested documents in one place. To use HorizonDocs, you must have access to NaviNet and be signed up to use HorizonDocs. You can ONLY use HorizonDocs to send medical records when we request them.

  In support of our risk adjustment activities, your office may have received or will receive medical records requests from one of our contracted vendors:

  Cognisight	Gathers information and medical records for Initial Validation Audits (IVA).
  Episource	Gathers medical charts and assists with coding for patients enrolled in Medicare Braven Advantage and Commercial health plans offered by other Blue Cross and/or Blue Shield plans.
  Inovalon	Gathers medical charts and assists with coding for patients enrolled in Medicare Braven Advantage and Commercial health plans offered by other Blue Cross and/or Blue Shield plans. Provides in-home assessments related to risk adjustment for patients enrolled in Horizon Commercial and Braven Medicare Advantage plans.

  Medical Records Retention

  Follow these standards for maintaining patient medical records:

  Patient Population	Medical Record Retention Requirement
  Braven Health Medicare Advantage (MA) Members	Physicians and other health care professionals Maintain medical records for a minimum of 10 years.
  All Other (non-MA) Members	Physicians and other health care professionals Retain records for 7 years from the date of the most recent entry. Hospitals Discharge summary sheets: retain for 20 years after discharge. For adult patients: retain records for 10 years following the most recent discharge. For minor patients: retain records for 10 years following the most recent discharge, or until the patient is age 23 years, whichever is longer.

• Important Coding and Medical Record Documentation Information

  Follow these important tips when documenting conditions:

  • A condition only exists when it's documented.
  • Document and code status of all conditions at least once a year.
  • Diagnoses do not carry over from visit to visit or year to year.
  • A condition can be coded and reported as many times as a patient is monitored, evaluated, assessed and or treated (MEAT) for the condition. We accept up to 12 ICD-10-CM codes per claim.
  • Do not code for conditions that were previously treated and no longer exist.
  • Conditions can be coded when documentation states condition is being monitored and treated by a specialist.
  • Co-existing conditions can be coded when documentation states that the conditions affect the care, treatment or management of the patient. Examples include transplant status, amputation status, dialysis status and chemotherapy status.
  • Do not code unconfirmed diagnoses. Do not use probable, possible, suspected or working diagnosis.
  • Do not use arrows or symbols alone to indicate a diagnosis.
  • Be sure the diagnoses codes billed are consistent with medical record documentation.

• Guidelines and Resources to Help You Better Manage and Code Chronic Conditions

  Webinars on Coding

  Risk Adjustment Coding Checklist

  ICD-10-CM Clinical Documentation Improvement for Chronic Conditions

  Case Management Programs