ICD-10 Coding & Risk Adjustment
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 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
- HPP’s ICD-10 Coding Guide booklet is intended to reduce the amount of time office personnel spend determining ICD-10 coding information. It can help ensure that your claims are processed in an accurate and timely manner. This booklet was updated in April 2021.
- CMS and Coding guidelines are available at https://www.cms.gov/files/document/2021-coding-guidelines-updated-12162020.pdf
Support & Help
If you have questions, please email Christina Rock, HPP’s Supervisor of Clinical Education at firstname.lastname@example.org.