Risk Adjustment Coding

An actuarial tool used to predict health care cost.

A process involving diagnosis reporting to measure a patient’s health status. Diagnosis codes are used to adjust potential risks. Risk Adjustment is a method to evaluate and measure all patients on an equal scale – levels the playing field. Other factors includes age, race, socioeconomic status, gender. Risk Adjustment is used to forecast trends and future needs of patients.

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.

Risk Adjustment Coding Service

With years of proven HCC experience Codingwize is ready to handle your HCC coding to ensure your practice is receiving maximum reimbursement. By having accurate coding, you will receive an accurate risk adjustment factor (RAF) while reducing your potential revenue lose.