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How Providers Are Responsible for Risk Adjustment Records

What are some important factors to take into account when it comes to obtaining and documenting appropriate information for reimbursement as more credentialing services for providers move toward population health management systems and payment models? Risk adjustment, documentation, and quality are three aspects that work together to ensure appropriate population health-based payments. In-depth and precise documentation tends to support quality indicators and risk-adjusted payments in addition to making excellent clinical sense. Physicians must take the time to comprehend how the specificity of their ICD-10 code documentation relates to risk-adjusted payment techniques in order to secure proper compensation.

Providers are essential in ensuring the accuracy of the information needed to determine the members’ overall health risk. let’s see How Providers Are Responsible for Risk-Adjustment Records.

Risk Adjustment – Provider’s Role:

  • Comprehensive health status for each patient
  • Accurate and complete ICD-10-CM coding for every patient, every time
  • Medical record documentation sufficient to support ICD-10-CM coding
  • Coding to the highest level of specificity for claim submission
  • If it’s not coded… the patient doesn’t have it

Physicians with a medical billing company only obtain more appropriate remuneration in various risk-adjusted payment models (such as Medicare Advantage) when they accurately document diagnoses that fall into one or more hierarchical condition categories (HCC). HCCs stratify patient risk, enabling payers to anticipate the costs used to calculate capitated payments. Physicians’ per-member, per-month Medicare reimbursements the following year are impacted by the CMS-HCCs they report in the current year. Along with commercial capitated payment arrangements and CMS alternative payment models including shared-savings contracts and accountable care organisations, risk adjustment is a key component of contracts for Medicare Advantage plans.

Documentation should include:

  • Patient’s name and date of service (DOS) on each page
  • All of the patient’s conditions, including those co-existing
  • Details to code each condition to the highest degree of specificity
  • Treatment and/or management for each condition
  • Physician’s signature, credentials, and date

Consider these four tips during documentation:

· Try to be more specific

Consider type 2 diabetes mellitus as an example. Physicians who identify diabetic problems in their patients as a result of the disease will be compensated with risk-adjustment fees for caring for sicker patients. The diagnosis and the stage of chronic kidney disease (CKD) in people with Type 2 diabetes who also have diabetes must be supported by medical records. Physicians may earn an extra HCC and risk-adjusted reimbursement if a patient has end-stage renal disease and is in stages 4, 5, or 6 to reflect the anticipated resources required to care for a sicker patient. When applicable, documentation of “dependency on renal dialysis” is given weight in risk-adjusted payment models.

· Document all diagnoses and chronic conditions

Record all diagnoses and ongoing conditions that have an impact on the patient’s current therapy, medical decisions, or care. Some chronic illnesses run the danger of changing forever if properly recorded each year. Amputation of a lower extremity, atherosclerosis, COPD, drug and alcohol addiction, heart failure, HIV/AIDS, lupus/rheumatoid arthritis, major depression (document episode, severity, and remission status), some stomas and artificial openings, transplants, and chronic viral hepatitis B are all included (except renal). Physicians must not only document these conditions at least once a year, but also explain how they evaluate and treat them, in order to be given credit in a risk-adjusted payment model.

Coexisting or comorbid condition

Consider the example of hypertensive heart disease. To receive risk-adjustment credit, physicians must document that heart failure is due to hypertension. They must also specify the type of heart failure.

·The Medical record must support diagnosis

Resist the temptation to automatically regenerate a problem list or past medical history in a new electronic progress note. Take the time to validate each condition and update the record when additional or more specific diagnoses are made from test results, inpatient visits, specialist consult reports, or other provider visits since the last date of service. Risk-adjusted payments are ultimately a good thing for physicians.  You get more appropriate reimbursement for your sicker patients.

Importance of Documentation:

  • Assures all of the patient’s medical conditions are addressed
  • Improves communication between physicians, hospitals and other health care professionals
  • Supports proper claim payment, reducing denials
  • Used in research and education
  • Accurate coding of conditions is needed for appropriate Risk-Adjusted payment
  • Documentation is key… if not documented, it cannot be coded

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Jesse Handerson

I am a professional blogger at a renowned medical billing company. I used to write quality blogs and articles related to medical billing company and practice management etc.

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