In a risk-adjusted health plan, such as Medicare Advantage, funding for a patient’s care depends on the documented diagnoses. All current diagnoses must be identified to the highest level of specificity. Missing or incomplete documentation will lead to negative outcomes that will affect the medical practice and patient alike. This article details how risk adjustment coders play a vital role in ensuring the quality of clinical documentation.
Medical care is complex and variable. Clinical documentation must be precise and paint a picture of the patient’s status and treatment outcome. Documentation in the patient’s medical record must be evaluated for completeness and accuracy, as well as meet the requirements set by payers to obtain proper reimbursement for services. The documentation must speak for itself without inconsistencies or conflicting outcomes. Reporting all diagnoses is essential to establish the appropriate risk adjustment factor (RAF) for a patient, as the RAF score will determine the patient’s potential healthcare needs in the future. Each current year’s financial funding is allocated based on the previous year’s documented diagnoses.
Healthcare providers must make the Centers for Medicare & Medicaid Services (CMS) aware of all the patient’s conditions and illnesses. Lack of clarity results in insufficient medical documentation. Great effort must be made to ensure that all pertinent information from the visit, including anything used to abstract diagnoses, should be documented in the notes to reduce the frequency of coder queries. And all diagnosis codes documented and submitted on a claim must be supported by the healthcare providers’ clinical notes.
Most providers have an inherent knowledge of what should be documented based on clinical standards and do this reasonably well; however, there is often a gap between what’s necessary clinically and what’s needed to fulfill coding and medical necessity requirements. It’s up to you as a healthcare business professional to work with your provers to make sure they are aware of the details needed for accurate code selection and quality measure reporting purposes.
It’s also important to recognize and consider the significant difference between regular outpatient coding and risk adjustment coding. A physician office’s primary focus is typically the patient’s chief complaint. In contrast, risk adjustment coding emphasizes not only the chief complaint but also the patient’s chronic conditions because they affect the patient’s overall health status, resource requirements, and clinician’s decision-making surrounding the chief complaint. Failure to report a diagnosis skews the patient profile and negatively affects funding for the management of that missed diagnosis. This leads to limited resources for that patient’s care.
With the advent of electronic medical records (EMRs), many physicians assume that code selection is a simple process and that picking from a list is sufficient for accurate and compliant coding. Remember, providers are generally not coders and may not realize that there’s more to documentation than picking from an EMR pull-down menu to code a patient’s condition.
It takes a collaborative effort to make sure providers are not ignoring coding and documentation guidelines and that they’re reporting all applicable diagnosis codes for each visit. Education is key to making sure providers clearly document relationships between conditions so they are not lost when coding since coders cannot assume many cause-and-effect relationships when not well documented in the notes. Encourage providers to pay close attention to reports and diagnostic findings, as those reports are good sources of risk-adjusted diagnoses. Reporting those diagnoses is crucial to paint a complete clinical picture.
In the risk adjustment system, coders are not submitting codes for services rendered. Instead, they are identifying all current active diagnosis codes to their highest specificity so that each patient’s RAF score can be calculated correctly. Before submitting claims, the coder must...
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