If you operate a Medicare Advantage plan, precise risk adjustment is critical to receiving accurate payments and remaining financially viable. Risk adjustment helps ensure health plans receive adequate compensation based on the health status and expected costs of their enrollees. As such, proper documentation and coding are essential. This article explores useful strategies for enhancing documentation and coding practices to optimize risk adjustment under the CMS-HCC model.
Understanding Risk Adjustment
First, let’s quickly review how risk adjustment works under Medicare Advantage. The Center for Medicare and Medicaid Services (CMS) collects diagnosis data from plans to assign risk scores to enrollees based on demographics, medical conditions, and expected healthcare costs. Plans then receive capitated payments from CMS scaled to those risk scores. Higher MRA scores mean higher payments.
The CMS-HCC risk adjustment model relies on the International Classification of Diseases (ICD) diagnosis codes submitted by plans to determine risk scores. More documented conditions generally mean higher scores and increased reimbursement for the sickest patients. This makes comprehensive documentation and coding vital for appropriate payments.
Improving Documentation
Complete medical record documentation offers the foundation for accurate coding. Here are helpful tips for improving documentation related to risk adjustment:
- Capture detailed patient histories with specific descriptions of current and active conditions. Avoid vague terminology when possible.
- Include status updates on existing diagnoses at each encounter. Specify if conditions are stable, worsening, or improving.
- Record exhaustive physical exam findings documenting all observed abnormalities.
- Clearly link diagnoses to supporting clinical evidence in the medical record.
- Implement documentation improvement initiatives and staff training focused on risk adjustment capture.
Optimizing Coding
With enhanced documentation, plans can then assign precise ICD codes reflective of their enrollees’ health status. Follow these coding best practices:
- Code all documented conditions that meet official ICD guidelines for assignment. Err on inclusion when uncertain.
- Emphasize coding specificity by assigning codes for subtypes and severity when applicable.
- Review all domains in the medical record to avoid missing eligible diagnoses.
- Use concurrent code auditing to ensure all justified codes are captured initially.
- Provide regular ICD coding education and feedback for all clinical staff involved.
By instilling robust documentation and coding protocols, plans can significantly improve risk adjustment accuracy. This in turn helps confirm reimbursements adequately cover true patient costs for financially sound Medicare Advantage management.
Establishing an Ecosystem for Risk Adjustment Success
While strong documentation and coding provide the pillar for accurate risk adjustment, plans need an entire supportive ecosystem to realize maximum and sustainable success. Critical components of this ecosystem include:
- Comprehensive Data Analytics: Leverage technology and data science to deeply analyze patient records, identify documentation improvement areas, model potential risk score optimization opportunities, and track risk adjustment related KPIs.
- Integrated Care Coordination: Promote data sharing and collaboration between health plan departments and provider groups to foster a unified view of patient needs.
- Targeted Provider Engagement: Educate and incentivize providers on documentation and coding best practices through in-person training, online resources, data benchmarking, and auditing feedback loops.
- Patient Risk Assessment: Perform health assessments early and often to capture all conditions. Make documentation processes patient focused.
By cultivating a supportive environment that puts risk adjustment at the enterprise forefront, plans can transform disjointed coding activities into connected, optimized processes. And the results will speak for themselves with improved risk score accuracy and properly aligned reimbursement.
