Coding Initiatives to Enhance Revenue and Capture Risk Score
Volume 3 of 10
When you mention goals to increase revenue it is typically perceived as “more patients to see and more work to do”. To be honest, the easiest way to enhance revenue and see financial growth is to talk to your provider group and gain a strategy to continually educate the providers regarding risk adjustment based on coding. Providers care for their patients, document the care, and most often are now applying the appropriate codes to reflect the reason for the visit. Most providers are probably doing a good job as they have become the coders, but a little education on coding in a method of risk adjustment will capture their care provided today, and the care they manage but do not include in the current coding practice. Do your providers, or do you as a provider, know about risk adjustment or what it means? Risk adjustment is CMS’s process of reimbursing Medicare plans based on the health status of their members. It was implemented to adjust payment with predicted healthcare costs of members based on their health status and demographics. The adjustments for predicted cost come from the risk adjustment data that is pulled from diagnosis codes submitted in claims and medical record documentation from the provider offices as well as hospital inpatient and outpatient settings.
Medicare relies on complete reporting of medical diagnoses to build an accurate health risk profile in each individual patient. The goal of the provider should be to capture each patient’s current and active diagnoses on at least an annual basis. One of the simplest ways to do this is by completing an Annual Wellness Visit. Medicare utilizes risk-adjustment data to determine care management programming resources for providing its members with patient centric and collaborative support for those with complex care needs.
Complete and accurate coding allows for more meaningful data exchange between Medicare and providers to: Identify potential new problems early; Reinforce self-care and prevention strategies; Coordinate care collaboratively; Avoid drug-drug/disease interactions; Improve the overall health care evaluation process; Improve office practice patterns and communication among the patients’ health care team.
Why is medical documentation and coding important to risk adjustment? Accurate risk adjustment payment relies on complete medical record documentation and diagnosis coding. CMS requires that all applicable diagnosis codes be reported and that all diagnoses be reported to the highest level of specificity and this must be substantiated by the medical record. A great example of this that I use all the time when teaching these initiatives is on diabetes. Most medical offices have numerous diabetic patients. If you looked at the record, you would find that most are assessed with the simplest Type I or Type II diabetes. With this code, there is no specificity or documentation of other disease manifestations that would increase the risk adjustment. Comorbidities such as retinopathy, neuropathy, chronic kidney disease, or insulin use will increase the risk score and payment, therefore they should be documented. Even an above the knee amputation done 10 years ago on a diabetic patient should be documented and coded. Remember, unless doing an audit, Medicare and insurance companies do not see your records. They see claims data and base their payment to the organization on this and the patients calculated risk score.
There are numerous helpful tips and guidelines on various disease states that will make your providers more efficient and help your coders from chasing down providers for revised documentation. Coders and providers should meet regularly to develop standard processes that will educate and lessen friction between these two groups. These simple steps will improve care, lower cost, and increase revenue.
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