Don’t take chances with risk adjustment

June 9, 2017

As noted by Healthcare Financial Management late last year: “A health system’s financial success under payment contracts that include some sort of risk adjustment depends largely on the extent that its physicians can accurately and completely document and code their patients’ conditions and treatments.”

Risk adjustment is an ACA program designed to align payments received by insurers with the risk of the populations being managed. While models vary, all are based on diagnostic information that corresponds to Hierarchical Condition Categories, or HCCs (pre-defined condition categories that correlate to a collection of ICD-10 codes) to calculate risk.

The program represents a significant break with tradition, as risk adjustment relies on diagnoses and patient demographics to calculate the payment amount, focusing on how sick the patient is, rather than how often he or she interacted with the provider. As payments are linked directly to the documented conditions in the medical record, accurate reporting is critical to a provider’s bottom line.

In fact, as also pointed out in the article, the failure to document a single risk-adjusted condition for an individual plan member can translate to thousands of dollars in lost revenue. And, to the extent that the same omission occurs across a health system’s overall patient population, the financial impact on the health system could potentially amount to millions of dollars.

Thus, it is important that coders know not only how to code for risk adjustment but also where to find the needed information and where to look for documentation to support code assignment.

That’s why Elsevier now offers Risk Adjustment Coding and Documentation Boot Camp® Online. Incorporating training related to risk-based reimbursement models, ICD-10-CM diagnosis coding, HCCs and other key factors, this powerful eLearning is crucial to a provider’s financial success.

Don’t risk getting it wrong. Let us know what we can do to help put your coding CDI, HIM and other staff on the right track.