Risk Adjustment Documentation And Coding

Risk-adjustment practices consider chronic diseases as predictors of future health care needs and expenses. Correct and detailed documentation and compliant diagnosis coding are critical for proper risk adjustment. Risk Adjustment Documentation & Coding, 2nd Edition provides: Risk-adjustment parameters to improve documentation related to severity of illness and chronic diseases. Code abstraction guidelines and recommendations to improve diagnostic coding accuracy without causing financial harm to the practice or health facility. Chronic disease ICD-10-CM coding summaries for quick reference and study. The impact of risk-adjustment coding (hierarchical condition category (HCC) coding) on a practice should not be underestimated: More than 75 million Americans are enrolled in risk-adjusted insurance plans. This population represents more than 20% of those insured in the United States. Insurance risk pools under the Affordable Care Act include risk adjustment. CMS has proposed expanding audits on risk-adjustment coding. FEATURES AND BENEFITS Five chapters delivering an overview of risk adjustment, common administrative errors, best practices, and guidance for development of internal risk-adjustment coding policies. Ten chronic disease ICD-10-CM coding summaries for quick reference and study. Two appendices offering mappings and tabular information of ICD-10-CM codes that risk-adjust to HCCs and RxHCCs. Learning and design features: Vocabulary terms highlighted within the text and defined at the bottom of the page. "Advice/Alert Notes" that highlight important coding and documentation advice from federal regulatory sources. "Sidebars" that provide derivative story and additional information, such as "Coding Tips" that guide coders with practical advice from sources like AHA's Coding Clinic and cautionary notes about conflicts and exceptions "Clinical Examples" that underscore key documentation issues for risk adjustment "Clinical Coding Examples" that provide snippets or full encounter notes and codes to illustrate risk-adjustment coding and documentation concepts "Documentation tips" that highlight recommendations to physicians regarding what should be included in the medical record or how ICD-10-CM may classify specific terms "Examples" that explain difficult concepts and promote understanding of those concepts as they relate to a section "FYI" call outs that provide quick facts "Abstract & Code It!" exercises that test diagnosis abstraction and coding skills (exclusive to Chapter 4) Extensive end-of-chapter "Evaluate Your Understanding" sections that include multiple-choice questions, true-or false questions, audit and Internet-based exercises. Two downloadable course tests and slide presentations for each chapter. Exclusive content for academic educators: A test bank containing 100 questions and a mock risk-adjustment certification exam with 150 questions.

The Risk Adjustment Coding and HCC Guide brings together hard-to-find information about risk adjustment (RA) coding and hierarchical condition categories (HCCs) in a new comprehensive resource that explains this complex reimbursement methodology. Now your organization will have a guide that provides both the big picture and the fine detail needed to document, code, and report essential information so that accurate risk levels are assigned and appropriate reimbursement received.

"Risk-adjustment (RA) practices consider chronic diseases as predictors of future healthcare needs and expenses. Detailed documentation and compliant diagnosis coding are critical for proper RA. Risk Adjustment Documentation & Coding provides: RA parameters to improve documentation related to severity of illness and chronic diseases. Code abstraction designed to improve diagnostic coding accuracy without causing financial harm to the practice or health facility. The impact of RA coding-also called hierarchical condition category (HCC) coding-on a practice should not be underestimated: More than 75 million Americans are enrolled in risk-adjusted insurance plans. This population represents more than 20% of those insured in the United States. Insurance risk pools under the Affordable Care Act include risk adjustment. CMS has proposed expanding audits on RA coding. Meticulous diagnostic documentation and coding is key to accurate RA reporting. This book will help align the industry through an objective compilation and presentation of RA documentation and coding issues, guidance, and federal resources"--

Risk adjustment is a method to offset the cost of providing health insurance for individuals--such as those with chronic health conditions--who represent a relatively high risk to insurers. Under risk adjustment, an insurer who enrolls a greater-than-average number of high-risk individuals receives compensation to make up for extra costs associated with those enrollees.In the absence of risk adjustment policies, insurers have a financial incentive to deny coverage to higher risk individuals, and to write exclusions into policies or impose unaffordable premiums for individuals with pre-existing medical conditions. Risk adjustment aims to make comprehensive insurance available to all individuals, regardless of risk, and to allow plans that insure sicker-than-average populations to charge similar average premiums as plans that insure relatively healthy populations.The risk adjustment model enacted under the Affordable Care Act (ACA, or "Obamacare") is budget neutral. Total payments to insurers do not increase. Rather, insurers covering a relatively greater number of healthy individuals must contribute to a risk adjustment pool that funds additional payments to those insurers covering a larger portion of high-risk individuals.Risk adjustment models typically use an individual's demographic data (age, sex, etc.) and diagnoses to determine a risk score. The risk score is a relative measure of the probable costs to insure the individual. To cite a simple example, an individual with diabetes will have a higher risk score (his or her predicted healthcare costs will be greater) than an otherwise statistically identical individual without diabetes. Older individuals typically have a higher risk score than younger individuals, and those individuals with a personal or family history of certain conditions may garner a higher risk score than individuals without such a history.There are several risk adjustment models. The Centers for Medicare & Medicaid Service (CMS) risk adjustment model uses the Hierarchical Condition Category (HCC) method to calculate risk scores. This method ranks diagnoses into categories that represent conditions with similar cost patterns. Higher categories represent higher predicted healthcare costs. For example, diabetes with complications is ranked "higher" (resulting in a higher risk score and thus greater expected healthcare costs) than diabetes without complications. An individual may be included in more than one HCC.Diagnoses are reported using ICD-10-CM codes Not every diagnosis will "risk adjust," or map to an HCC. Acute illness and injury are not reliably predictive of ongoing costs, as are long-term conditions such as diabetes, chronic obstructive pulmonary disease (COPD), chronic heart failure (CHF), multiple sclerosis (MS), and chronic hepatitis; however, some risk adjustment models may include severe conditions relevant to a young demographics (such as pregnancy) and congenital abnormalities.All risk adjustment models depend on complete and accurate reporting of patient data. CMS requires that a qualified healthcare provider identify all chronic conditions and severe diagnoses for each patient, to substantiate a "base year" health profile for those individuals. Documentation in the medical record must support the presence of the condition and indicate the provider's assessment and plan for management of the condition. This must occur at least once each calendar year for CMS to recognize that the individual continues to have the condition. This information is used to predict costs in the following year. As such, incorrect or non-specific diagnoses can affect not only patient care and outcomes, but also reimbursement for that care, going forward.

These guidelines have been approved by the four organizations that make up the Cooperating Parties for the ICD-10-CM: the American Hospital Association (AHA), the American Health Information Management Association (AHIMA), CMS, and NCHS. These guidelines are a set of rules that have been developed to accompany and complement the official conventions and instructions provided within the ICD-10-CM itself. The instructions and conventions of the classification take precedence over guidelines. These guidelines are based on the coding and sequencing instructions in the Tabular List and Alphabetic Index of ICD-10-CM, but provide additional instruction. Adherence to these guidelines when assigning ICD-10-CM diagnosis codes is required under the Health Insurance Portability and Accountability Act (HIPAA). The diagnosis codes (Tabular List and Alphabetic Index) have been adopted under HIPAA for all healthcare settings. A joint effort between the healthcare provider and the coder is essential to achieve complete and accurate documentation, code assignment, and reporting of diagnoses and procedures. These guidelines have been developed to assist both the healthcare provider and the coder in identifying those diagnoses that are to be reported. The importance of consistent, complete documentation in the medical record cannot be overemphasized. Without such documentation accurate coding cannot be achieved. The entire record should be reviewed to determine the specific reason for the encounter and the conditions treated.

A Hierarchical Condition Category (HCC) is defined as a risk adjustment model that is used to calculate risk scores to predict future healthcare costs. The Centers for Medicare and Medicaid Services' (CMS) CMS-HCC model is used to predict healthcare spending for Medicare Advantage Plan enrollees. The purpose of the scoring model is to adjust capitated payments made to beneficiaries in these plans based on the member's health. HCCs were initially implemented by CMS in 2000 and have been phased in over time. This article will focus on the CMS-HCC model.The model is based on diagnosis codes and includes 79 HCCs. Age, sex, disability, and living circumstances--such as whether the individual is living at home, in a nursing home, or in a long-term care facility--also play a part in the calculations of an HCC.

This book is designed to offer quick documentation tips for providers from a medical coder/auditor point of view. Medicare Risk Adjustment is driven by diagnoses. Specific and supportive documentation is very important not only for appropriate code selection but also to validate patient diagnoses. So what is it exactly that we look for when we are validating diagnoses? MEAT! We want to make sure that the diagnoses documented by the provider are Monitored, Evaluated, Addressed/Assessed, and Treated. Ultimately, specific and supportive documentation= appropriate coding = appropriate reimbursement.