Q&A | Coding

A deeper dive into risk-adjustment coding

Q&A | Coding

A deeper dive into risk-adjustment coding

Question: We are familiar with risk-adjustment coding because our accountable care organization (ACO) physicians are paid based on the health ‘risk’ of patients versus receipt of a fee for providing service. Are there some common coding pitfalls we should have on our radar? How can we make improvements to current practices and processes?

Answer: Know your patient population and disease- specific coding nuances. The assignment of risk adjustment and hierarchical condition categories (HCC) varies depending if the patient is a Medicare patient or covered as part of the Affordable Care Act. Here are key factors for various diagnoses.

Diabetes. There are various diabetes codes that map to different HCCs for both patient populations. There also are copious coding errors seen with diabetes for all patient types. However, certain body mass index (BMI) codes only add to a risk score if the patient is a Medicare patient. ACA patient risk scores, at this time, are not affected by a very high or low BMI.

Cancer. There are several distinct HCCs for various kinds of cancer and each HCC category has a different weight assigned to it. Metastatic cancer is more heavily weighted than some other cancers. The same is true for non-Hodgkin’s lymphoma. Not all cancers are equal in risk-adjustment coding, so it is critical that provider documentation is very specific and detailed.

Neoplasms. A coder’s thorough understanding of the coding guidelines for neoplasms is also important. There are many, and they can be challenging, so having a coder on staff who has significant coding experience in oncology can make quite an impact.

Status post codes. Often, status post code diagnoses are overlooked. Because they can have an impact on risk-adjustment scores, it is important to check the status post codes as well as the assessment and/or plan, which are typically where coders check for diagnoses. Many of these diagnoses are often found only on the physical exam and not in the assessment and/or plan, which is why they are sometimes overlooked. Toe-, foot-, ankle-, above- and below-the-knee amputations all map to an HCC. If the patient currently has a tracheostomy, gastrostomy, ileostomy or colostomy, be certain not to miss them because they also have an impact on patient risk scores as well.

The following strategies can be helpful in improving risk-adjustment coding.

Audits. Everyone is anxious when they hear the word ‘audit’ but conducting one can make a huge difference in risk-adjustment coding. Start with a coding audit. Determine what codes are being billed, and whether any unspecified codes are being used when perhaps a more specific one could lead to an increased risk score. Often simple patterns and trends emerge that can easily be fixed with one education session. The benefit is a significant increase in the risk-adjustment score. To get started on an audit, use the examples in this article to see improvements to practices and processes.

Flags. With the electronic health record, there are ways to ‘flag’ diagnoses and codes that are HCCs. Flagging these items helps the coder and provider to be more aware of what to look for and makes the HCC diagnoses jump off the page.

Documentation audit. Ensure providers are documenting as specifically as they can. If a patient is documented as having ‘diabetes’ but is on various medications that treat common diabetic manifestations, perhaps there is a documentation opportunity available that has not been captured. If chronic kidney disease (CKD) is documented, query the provider to determine the stage of kidney disease because higher stages of CKD map to an HCC. Do not miss an opportunity to denote a specific coding that could mean additional payment for the ACO. 

About the Authors

Kim Felix

holds the RHIA, CCS certifications and is vice president of education and training, Intellis.


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