Health care has quickly transformed from a fee-for-service payment model where providers are paid based on volume of services to various value-based payment methodologies. These new payment systems are focused on promoting quality of care and creating better outcomes. One of them is risk adjustment.
The goal of risk adjustment is to reward efficiency and high quality care for sicker patients. These patients require much more clinical and financial resources to treat. Health plans are paid more to cover the costs of providing care to these sick members. The severity of illness of a plan’s members is measured by the diagnosis codes that are submitted on claims received from their healthcare providers.

Providers are accustomed to documenting and coding from an E/M and CPT perspective. Changing the focus to diagnosis coding, which is the focus of risk adjustment requires some changes to what you are used to.

It is best to focus on these few key areas on best practices for risk adjustment:

  1. Make sure problem lists are kept up to date. The problem list should show the status of each condition. It should not be a long list of every condition experienced by the patient. Be sure the highest level of specificity known to the provider is captured in the diagnosis codes. These codes do not accurately show the true severity of illness of sicker patients.
  2. All problems need to be in the assessment. Problems assessed during the visit should be noted in the assessment portion and coded correctly.
  3. All diagnoses should be documented. Note all the diagnosis codes for the visit, don’t limit them. All diagnosis that were part of the provider’s medical decision making process should be documented.
  4. All chronic conditions documented at least once annually. The patient’s chronic conditions should be assessed during the encounter visit at least annually, and submitted on a claim. This includes status codes such as amputations, transplant status, etc.