Risk Adjustment Coding
What is Risk Adjustment?
An actuarial tool used to predict health care cost
A process involving diagnosis reporting to measure a patient’s health status
Diagnosis codes are used to adjust potential risks
Risk Adjustment is a method to evaluate and measure all patients on a equal
scale – levels the playing field
Other factors (age, race, socioeconomic status, gender)
Used to forecast trends and future needs of patients
Predictive Analysis – review of current and past medical conditions to predict
future costs
Affects payment and quality
Risk Adjustment Models
CDPS – Chronic Illness and Disability Payment System (Medicaid)
HCC – Hierarchical Co-Existing Conditions (Medicare)
Health and Human Services HCC Model (ACA)
DRG – Diagnosis Related Groups – Inpatient
ACG – Adjusted Clinical Groups – Outpatient
Medicare HCC Model
Hierarchies or groups of conditions
A value is assigned to each diagnosis in the model called a risk adjustment
factor (RAF)
Not all diagnosis codes carry a value
Trump list
Approved Provider list (face to face encounters)
79 HCC Categories
HCC Risk Adjustment 101
Medicaid CDPS Model
18 Major disease categories
Hierarchies – trumped diagnoses
Level of risk – very high, medium, low, extra low
Personal history of, family history
Similar coding rules as those of HCCs
Capture all current diagnoses and all known statuses
Timing of risk adjustment calculation
Retrospective
Past claims adjusted to show actual experience
Concurrent
Benchmarking model, outcome is already known – current time period, used to
change payment arrangements, more accurate than prospective
Prospective
Current claims (diagnoses) used to predict the future
Predictive Modeling
Quality of Care
Definition of predictive modeling – An analytical review of know data elements
to establish a hypothesis related to the future health care needs of a patient
with varying certainty
Predictive modeling software
CMS Star Ratings
HEDIS
Case management, Disease management, Utilization management
Predictive Analysis software tool
Predictive Analysis software tool
Predictive Analysis software tool
Risk Adjustment and Financials
Health plans are funded based on Risk Adjustment Factors
Under coding leads to underpayment and loss of revenue
Over coding leads to audit risk and compliance actions
Example taken from AAPC:
Audit risk and compliance
CMS conducts RADV audits to verify the accuracy of diagnosis codes
submitted
Medical record must support the diagnosis codes
Provider signature must be valid
Provider credentials are reviewed (MD, DO, PA, NP, LCSW,OT, PT, etc)
Prospective assessments
In-home annual wellness visit
Completed by MD, PA, or NP
Data shared with PCP and care coordinator
Gap closure
Diagnosis Documentation & Coding
Report all diagnosis codes that are part of the MDM for each visit
Cause and effect needs to be documented in order to be coded
Rule out diagnosis codes do not count for risk adjustment (except in-patient)
Previously treated, no longer existing diagnoses are not coded
Evidence of Treatment (TAMPER) to code condition
Treatment
Assessment
Monitoring or Medicate
Plan
Evaluate
Referral
Coding from medical record
Coding diagnoses from Review of Systems
Do not code patient stated conditions without provider verification
Coding diagnoses from Exam
Valid diagnoses as recorded by provider in this section shall be coded
Coding diagnoses from Assessment and Plan
Generally these diagnoses should always be coded unless they are historical
Past medical history
Current vs history must be clear
When codes are historical in nature – code history of….
If a condition no longer exists it is not coded
Code for all diagnoses
Coders may sometimes confuse diagnosis reporting with the selection of
E&M level
When choosing the E&M level, diagnosis codes should only be counted
toward the level of service when they are documented as to how they were
evaluated or addressed
ICD coding guidelines instruct coders to include all comorbidities for each
encounter
Diagnosis specificity
Documentation must be specific
Code to the highest specificity possible at all times
Comorbidities – cause and effect must be clearly documented to be coded
Modifying factors should be clearly documented
Chronic vs Acute
Commonly under diagnosed conditions
Hypertension
Diabetes
Health status codes
Certain health status codes are very important to assess, document and
code at least annually using the highest level of specificity
Patients undergoing dialysis
Lower limb amputation status
Asymptomatic HIV status
Ostomy (specific site)
Commonly coded diagnoses in Risk
Adjustment Models
Basic concepts and diseases
Related progression and comorbidities
Understand clinical documentation more clearly
Oncology reminders
Malignancies should only be documented when patient has evidence of
current disease. If the disease has been eradicated through surgical
intervention, radiation or chemotherapy code the history of code
Patients who do not receive definitive treatment should still be coded as
active disease
Patients who have successfully completed treatment should be coded with a
history of code
Stroke coding
A stroke (CVA) is an acute event, it should not be coded as active for an
extended period of time
Once the patient is discharged, it should be coded as a history of CVA
with or without residual effects
Residual effects should be coded every time they are assessed
Hemiparesis must be documented as due to CVA to be coded as such
Potential for guidelines to change with ICD10
Use additional codes to identify the presence of
Alcohol abuse, dependence
Tobacco use
Hypertension
Angina
Angina
Chronic Condition, may or may not be related to MI
Notice how documented, NOS, unstable, etc.
New ICD 10 combination codes
Use additional codes to identify related factors:
History of tobacco smoke
Tobacco dependence
Tobacco use
Artificial openings
Important status factor and should be coded on every appropriate encounter
Affects patient care decisions
Risk for infection
Requires additional monitoring
Ensure the opening is still current as they may be temporary
Amputations
Amputations must be coded at least annually
If not coded, no credit is given in risk adjustment
BMI and Obesity
BMI reading may be reported by any clinician
BMI codes should never be primary diagnosis
BMI measures in pediatrics (2-20) are based on a percentile
Coders should only code the BMI when documented in the chart, do not
calculate
Obesity must be reported by treating provider not by other clinicians
Morbid obesity is risk adjusted
Chronic Kidney Disease (CKD)
Decrease in function of the kidneys
Increased risk for people with hypertension, diabetes; possibly also hereditary
Coders may not assign a diagnosis or staging based on review of lab data
Treating provider must document the diagnosis with which of 6 stages
If provider documentation is between stages (i.e. I-II, coder should choose lower stage)
If documentation uses mild, moderate or severe coders may assign appropriate stage
Code for dialysis when appropriate
Congestive Heart Failure
CHF – heart cannot pump enough blood (damaged weakened heart muscle)
Acute, chronic, acute on chronic or unspecified
Systolic, diastolic or unspecified
Use additional codes:
Heart failure due to hypertension
Heart failure following surgery
Heart failure due to hypertension with CKD
Chronic Obstructive Pulmonary Disease
(COPD)
Often referred to as COPD, emphysema, chronic bronchitis, obstructive
asthma
Permanent condition usually progressively worsens
Document and code patients receiving oxygen therapy
Acute on Chronic
Acute exacerbation
Code related factors:
Exposure to environmental smoke
Tobacco use
Tobacco dependence
Diabetes
Type 1 – body does not make insulin
Type 2 – body does not make enough insulin or unable to use body made
insulin
Most common disease under documented and often miscoded
Complications must clearly be stated with cause and effect (except gangrene)
Diabetes with neuropathy
Diabetes and neuropathy (cannot be assumed to be related)
Code all known manifestations as a separate code
ICD10 does away with controlled versus uncontrolled
Asthma
Inflammatory disease of the airways
Intrinsic or extrinsic (ICD10 does away with this)
Obstructive (COPD)
Comorbidity (allergy, etc)
5th digit identifies (unspecified, exacerbation, etc)
Code related factors:
Exposure to environmental smoke
Tobacco use
Tobacco dependence
Hypertension
Chronic elevated blood pressure, making the heart work harder than normal
< 140/90 controlled
Primary or secondary
Other complications, stroke, MI, heart failure, peripheral arterial disease, CKD
Benign, malignant, unspecified is no longer coded with ICD10
Hypertensive heart disease
cause and effect documented (combo code used)
Cause and effect not documented (code conditions separately)
Myocardial Infarction (MI)
Heart Attack
Diagnosis of Old MI is important for risk adjustment models, as it carries
implications for ongoing monitoring and treatment
May be listed on past problem list
New ICD 10 guidelines: MI is considered current < 4 weeks old
Use additional codes to identify:
History of tobacco use
Tobacco dependence
Dementia
Dementia is a serious loss in the overall cognitive ability beyond normal aging
expectations
Under age 65 determined early onset
Code first the underlying physiological condition if appropriate
With or without behavioral disturbances
Hepatitis
Inflammation of the liver
Acute vs chronic
Hepatitis A, B, C, D, E
Hepatitis C and new treatment regimen (Sovaldi/Harvoni)
Challenges with provider coding
Providers have not been trained in coding
Providers are unaware of coding guidelines
In many environments, providers have no incentive to code and submit ALL
diagnosis codes
Time constraints
Errors are rarely corrected
Itasca Medical Care (IMCare) specific risk
adjustment scenarios
In-Network At-Risk providers
100% share in the gain or loss of profits
Accurate coding affects provider payments and settlement outcomes
