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Risk Adjustment

Risk Adjustment


Slide 1:

Welcome to the Results and Recognition Quality Programs of 2021. My name is Andrina Charles and I’m one of the Clinical Quality Improvement Liaisons, also known as a CQIL. In this webinar we will discuss Risk Adjustment and the importance of coding.

Slide 2:

Today we will discuss:

  • What Risk Adjustment is and the process
  • Medical Record Retrieval & Coding
  • Provider Coding Education
  • Hierarchical Condition Categories and common errors
  • Best Practices

Before we dive in, just a little disclaimer that us CQILs are not certified coders nor are we Risk Adjustment Specialists. We do not ever tell Network Providers how to code because you all code according to the services you render and the documentation in the medical record must support any codes used. This purpose of this presentation is to relay information to you in an effort to stress the importance of coding. If you have any questions related to the content, there will be an email for the Risk Adjustment department provided at the conclusion.

Slide 3:

What is Risk Adjustment?

It’s the process where health plans are equitably reimbursed based on the expected cost to care for their member population and thepurpose of this system is to adequately cover the costs of care by providing covered benefits for enrollees, including those with complex conditions. So essentially, risk adjustment ensures that insurers receive appropriate revenue for the healthcare costs of the population they are insuring.

Providers have an important role to play in risk adjustment, too. According to the AAPC, which is the Advancing the Business of Healthcare, an engaged partnership between the provider and the health plan is vital to bringing valuable benefits to enrollees. For instance, insurers may use premiums and risk adjustment payments to offer its members enrollment in exercise programs, case or disease management, transportation to medical appointments, and other services. The health plan uses diagnosis codes that providers submit on claims to identify what types of programs are needed, and more specifically who needs them.

So for the Providers, Risk Adjustment simply means that the documentation should capture the patient’s full health story, including all of the conditions that may affect how they’re managed and/or treated. All current and co-existing diagnoses should be documented during every encounter and submitted to the highest level of specificity. In addition, all relevant conditions must be captured on an annual basis year over year.

Slide 4:

Let’s walk through the Risk Adjustment process.

A patient visits a healthcare provider either in person or virtually.

The provider documents all relevant medical conditions in the patient’s medical record and claims are submitted to support what was completed during the visit, which would include the diagnoses codes as well as quality codes.

The plan receives the codes and are able to predict risk scores for financial purposes. The plan also submits claims to the regulatory bodies such as the Centers for Medicare & Medicaid Services (known as CMS) as well as the state.

Now for the regulatory action, based on applicable risk adjustment model, risk scores and reimbursements are calculated. The plan data is reviewed and audit plan encounter submissions are completed.

Slide 5:

Medical Record retrieval, known as MRR, and Coding ensures Horizon knows and understands the full health status of our members and allows Horizon to identify provider educational opportunities centered around improved coding and documentation.

The benefits of this include:

Providing feedback to providers on any missed diagnosis codes that weren’t included on claims (and that would be an underpayment risk) as well as unsupported diagnosis codes included on claims (that would be an overpayment risk).

This process may identify provider billing issues such as EMR diagnosis code restrictions and another benefit is complete and accurate clinical diagnosis to drive comprehensive care and improve clinical outcomes.

At some point in the future there will be a shift focusing on documentation improvement and billing of diagnosis codes which would reduce the need to retrieve such a high volume of medical records.

Slide 6:

We’re going to review a couple of helpful acronyms to help capture the full health status of a patient.

It’s very important that providers document the patient’s full health history as previously mentioned.

MEAT is an acronym used to describe four factors that help providers with proper documentation to establish the presence of a diagnosis during an encounter.

M is for managed or monitoring, E is for evaluated, A is assessed and T is treated

The TAMPER approach involves reviewing the chart for acceptable documentation & evidence and pulling it all together to tell a comprehensive and accurate story about the patient for ongoing and future care. This acronym stands for:

Treatment, Assessment, Monitoring or Medicate, Plan, Evaluate and Referral

Slide 7:

HCC stands for Hierarchical Condition Categories and these are sets of medical codes that are linked to specific clinical diagnoses and each HCC represents multiple diagnoses with similar clinical complexity and expected annual care costs. So these diagnoses have been assigned a value for risk adjustment.

HCC models rely on the reported ICD-10 codes to establish the patient’s health status annually. So thorough clinical documentation and complete diagnosis coding are crucial to accurate HCC reporting.

Slide 8:

We will now review a few situations where an audit has shown inaccuracies in reporting which leads to an incorrect HCC.

The first one is HCC 74, which is the Disorder of the Immune Mechanism.

Diagnosis codes D84.9 or D89.9, these codes should not be reported for immunosuppression resulting from use of drugs to treat autoimmune conditions such as rheumatoid arthritis, multiple sclerosis or inflammatory bowel disease.

For the reporting of immunodeficiency conditions, documentation must specify the type of immunosuppression such as:

Primary, which is defined by an inherent absence or quantitative deficiency of cellular, humoral, or both components that provide immunity and then Secondary, which is acquired and defined by loss or qualitative deficiency in cellular, or humoral immune components that occur as a result of a disease process or its therapy.

Slide 9:

The next HCC is 132, which is Unstable Angina and Other Acute Ischemic Heart Disease.

If Coronary Artery Disease is documented in the medical records without any evidence of a clinical syndrome of angina being addressed, an Atherosclerotic heart disease of native coronary artery with unstable angina pectoris cannot be reported.

Medical record documentation for an Acute Coronary Syndrome and/or Unstable Angina and other correlated conditions must specify a definitive diagnosis, along with supportive evidence that may include the underlying disease and associated symptoms.

Slide 10:

The next common error is HCC 142, which is Specified Arrhythmias.

To correctly report an arrhythmia condition as Unspecified atrial fibrillation or Supraventricular tachycardia, documentation must include a definitive diagnosis of the type of arrhythmia being addressed.

We need to avoid contradictory documentation for which the final diagnosis does not support the evaluation and the treating clinician in the medical record should be clear.

Diagnosis code I48.91 or I47.1 can be captured when the documentation contains the specific type of arrhythmia and should always be reported at the highest level of disease specificity documented by the treating physician.

Slide 11:

HCC 2, which is Septicemia, Sepsis, Systemic Inflammatory Response Syndrome/Shock.

Report diagnosis A41.9 of Sepsis when documentation specifically addressed the quality of care the patient is receiving and includes an underlying system infection, treatment of condition with medications, and tests such as blood cultures.

ICD-10-CM guideline section I states the term urosepsis is a nonspecific term and does not have a code in ICD-10. It’s not to be considered synonymous with sepsis. If a provider uses the term urosepsis he/she should be questioned for clarification.

Slide 12:

HCC 8 Metastatic Cancer

If this is a valid patient diagnosis, the documentation should specifically indicate both the primary and the secondary malignant sites and include supportive evidence that the primary site has metastasized even though it was removed and the secondary malignancy is active.

We need to specify the histology and/or behavior of the neoplasm, if known, as benign, primary malignant, secondary malignant, in situ or uncertain.

Per ICD-10 guidelines, only multiple myeloma and leukemia conditions can be categorized as "in remission." Other types of cancer are identified as "active," "current" or "history of."

Slide 13:

HCC 42 Peritonitis/Gastrointestinal Perforation/Necrotizing Enterocolitis

When reporting a peritonitis condition determine its underlying cause and treatment as well as if the documentation includes pertinent information regarding body fluids. The treatment usually involves antibiotics, medication for pain and drainage of fluid when necessary.

Gastrointestinal Perforation is usually associated with Crohn’s disease and malignancy. When reporting this, document the specific treatment and nature of the disease process that caused the perforation.

Slide 14:

HCC 42 - Necrotizing Enterocolitis

This is a serious condition that occurs when inflammation, infection, or ischemia lead to intestinal necrosis and while it’s most commonly seen in premature infants, the condition can occur in term infants, infants outside of the newborn period, as well as in adults.

When reporting this condition the age of the patient needs to be determined and the specific treatment depends upon the nature of the disease and should be documented.

Coders should carefully review the documentation for proper code abstraction and should know how to differentiate disease processes.

Slide 15:

HCC 82 Drug Dependence

Code F13.20 when documentation clearly indicates dependence of a current prescribed drug the patient is actively taking.

Documentation of drug dependence solely in the past medical history should not be linked to a current medication or drug without dependence documented in the patient’s assessment and plan, within the medical record.

Proper documentation should include the: Pattern of harmful usage, Current state, and the relationship to any identified mental, behavioral or physical disorder.

If documented drug use is not treated or noted as affecting patients health, do not code for drug dependence.

Slide 16:

Ok, this is the last example we’ll review, which is HCC 88 plus 59 – I’m sorry, and 59, which is Major Depressive Disorder and Bipolar Disorders.

When documenting this, a record must contain information regarding the Episode, Severity, and State of remission.

The Provider should document if depression is well controlled with medication or active therapy, should note results of a depression screening and if suicide risk was assessed.

When documenting bipolar disorder, the provider should report: Whether the current episode is hypomanic, maniac, depressed or mixed, the Severity, as well as the State of remission.

Slide 17:

Before we conclude let’s take a look at some Best Practices.

Every visit should be treated as if it’s the only opportunity you have to capture a patient’s health history and status in the year, regardless of reason for the visit.

Fully document all applicable conditions for each patient you treat by including the appropriate ICD-10 codes on every claim submission and document all current and co-existing diagnoses during every encounter and submit to the highest level of specificity. All relevant conditions must be captured on an annual basis year over year.

In addition to submitting ICD 10 codes, ensure you also submit quality codes to close HEDIS gaps in care.

Adopt technologies like electronic health records or voice translation software to improve accuracy and efficiency.

Engage clinicians to accurately capture primary conditions and present co-morbidities, particularly in more complex cases.

Involve coders and office staff to ensure the use of coding best practices.

Standardize coding processes to minimize disruptions to the billing workflow.

Slide 18:

So that is the conclusion of this presentation. If you have any questions, please feel free to e-mail the Risk Adjustment team at the email you see noted here.

Again, my name is Andrina Chares, I’m one of the CQILs. Thank-you for listening and enjoy the rest of your day.

Calling all Coders & Office Managers! Information on coding, risk adjustment, common HCC errors and best practices.