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Risk Adjustment Medical Coding

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Last-minute Checklist for RA Medical Coding Professionals

Risk adjustment medical coding professionals are quite aware of the need for having clear and concise medical records documentation before they are submitted as claims requests to Centers for Medicare & Medical Services (CMS) or Health and Human Services (HSS). And, proper medical record documentation, help, payers to gain correct reimbursements, whilst ensuring smooth revenue cycle management, and physicians to offer value-based care.

However, the individuals behind the risk adjustments are medical coders who perform the chart reviews and audits before the risk adjustment claim data submission deadlines.

In this article, we are presenting best practices of Risk adjustment documentation and coding for the CMS-Hierarchical Condition Category (HCC) and the Department of HHS-HCC models.

With both the models having different applications, one thing in common is the dependency on the International Classification of Diseases, Tenth Revision, Clinical Modification (ICD-10-CM) codes that are used to risk adjust patients as per their health conditions.

What are the best practices for Risk Adjustment Documentation and Coding?

  • Validation of medical record eligibility
  • Assignment of appropriate ICD-10-CM codes
  • Submission of ICD-10-CM codes to CMS or HHS for reporting

First, you will need to ensure the patient medical records include the patient identification number, validation of the provider who has to be a qualified physician and present for a face-to-face encounter, and verify the authenticity of medical records.

Next, to support an HCC, you need to ensure that the corresponding diagnosis must be mentioned in a health encounter.

The 2 important aspects of HCC coding are:

1. Analyze medical record documentation to mark those reportable conditions

2. Then, precisely assign ICD-10-CM codes to those conditions

In addition, the documentation in patient’s health records must support MEAT criteria i.e.

  • Monitoring
  • Evaluation
  • Assessment
  • Treatment

Some healthcare organizations use “TAMPER™”:

  • Treatment
  • Assessment
  • Monitor/Medicare
  • Plan
  • Evaluate
  • Referral

The above acronym is used by risk adjustment coders to identify reportable conditions.

A risk adjustment coding professional is recommended to accurately examine all sections of progress notes to determine whether the documentation of the chronic conditions meets the requirement of the risk adjustment models.

Moreover, the specificity of the clinical documentation is pivotal for risk adjustment coding professionals to determine whether the chronic condition is current and active.

Closing tips for Risk Adjustment coding professionals

NLP-Powered Solutions are helping risk adjustment medical coders to automate and streamline the patient chart review and audit process, whilst ensuring accurate documentation of HCC and ICD-10-CM codes based on MEAT criteria and federal coding guidelines.

Click to read the FY2023 release of ICD-10-CM.

Are you looking to add artificial intelligence to your Risk Adjustment Coding Workflow?

Contact us to reach an expert now!


American Health Information Management Association


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Disclaimer: All the information, views, and opinions expressed in this blog are inspired by Healthcare IT industry trends, guidelines, and their respective web sources and are aligned with the technology innovation, products, and solutions that RAAPID offers to the Risk adjustment market space in the US.