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ICD-10 Coding & Risk Adjustment

ICD-10-CM

ICD-10-CM is the standard transaction code set for diagnostic purposes under the Health Insurance Portability and Accountability Act (HIPAA). It is used to track health care statistics/disease burden, quality outcomes, mortality statistics and billing. The proper use of ICD-10-CM codes will result in fewer claim denials, less time with payers trying to justify increased clinical resources for the patient and a higher revenue stream. Therefore, it is vital to educate yourself and your staff on appropriate coding, which should result in appropriate payment.

ICD-10 Coding Impacts

  • Tracking public health conditions (complications, anatomical location)
  • Improving data for epidemiological research (severity of illness, co-morbidities)
  • Measuring outcomes and care provided to patients
  • Making clinical decisions
  • Identifying fraud and abuse
  • Designing payment systems/processing claims

Risk Adjustment

Risk adjustment is a modern payment model that uses both demographics and diagnoses to determine a risk score which predicts how costly the individuals care will be for the coming year. Risk adjustment models improve reimbursement and provide a better picture about patient populations.

Diagnosis codes from patient charts and using these illnesses (along with their comorbidities and complications) determine the ICD codes, which drives risk. Diagnosis codes are a good starting point for analyzing known conditions and speculating on potential risks. The more severe or complex a diagnosis, the higher the risk value that is assigned.

Risk adjustment assists in the financial forecasting of future medical need.

HPP’s Risk Adjustment Impact

  • Medicare Retrospective Chart Reviews performed by clinical coding team.
  • Chronic Care Management Program (CCMP) on NaviNet for Health Partners (Medicaid) members that meet the criteria.
  • Electronic Patient Assessment Solution Suite (ePASS) through Inovalon for selected Medicare members.
  • Provider Education
    • One-on-one trainings
    • Provider reports
    • Webinars on coding, documentation and risk adjustment

Resources

Support & Help

If you have questions, please email Christina Rock, HPP’s Supervisor of Clinical Education at crock@hpplans.com.