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Best Practices for Successful Risk Adjustment Documentation and Coding in Value-based Care

If you’re still struggling to get a handle on risk adjustment documentation and coding, don’t worry-you’re not alone. 

With constantly evolving regulations, changing reimbursement models, and increasing pressure to deliver high-quality care while managing costs, it’s no wonder so many Medicare organizations find themselves overwhelmed. 

But fear not – we’ve compiled a list of best practices for successful risk adjustment documentation and coding that will help you stay on top of your game and ensure optimal patient outcomes. 

So grab a cup of coffee and read on…

Table of contents:

How are you gearing up with the new 2024 Advance Notice proposed payment updates?

CMS has released the 2024 Advance Notice with Proposed Payment Updates for the Medicare Advantage and Part D Prescription Drug Programs.

The Advance Notice proposes updates to MA payment growth rates and changes to the MA and Part D payment methodologies.

The proposed model includes restructuring condition categories using the International Classification of Diseases (ICD)-10 classification system (instead of the ICD-9 classification system).

In addition, the advance notice also updates underlying fee-for-service (FFS) data years (from 2014 diagnoses and 2015 expenditures to 2018 diagnoses and 2019 expenditures), as well as revisions focused on conditions that are subject to more coding variation.¹

Critical challenges when shifting risk adjustment vendor

There are a few critical challenges that must be considered when shifting risk adjustment vendors. 

1. The first is data migration:

All of the patient’s data must be transferred from the old vendor to the new one. This can be a complex and time-consuming process, depending on the size and complexity of the data set.

2. Another challenge is business continuity:

The new vendor must be able to provide the same level of service as the old one, without any interruptions or disruptions. This can be difficult to achieve, especially if there is a significant difference between the two vendors. 

3. Finally, cost management is a key concern:

The new vendor should be able to provide the same level of service at a lower cost than the old one. If not, it may not be worth making the switch.

Benefits of NLP- Powered risk adjustment documentation and coding solutions

The ICD-10-CM coding system is a complex and ever-changing one, and keeping up with the latest coding changes can be a challenge for even the most experienced coder. 

Fortunately, there are NLP-powered risk adjustment documentation and coding solutions that can help coders stay compliant with the latest coding guidelines.

These solutions use natural language processing (NLP) to automatically review clinical documentation and identify potential codes that may have been missed. This can help ensure that coded data is complete and accurate, which is critical for risk adjustment purposes. 

In addition, these solutions can provide real-time feedback to clinicians on their documentation, which can help improve documentation quality over time.

Overall, NLP-powered risk adjustment documentation and coding solutions can be a valuable tool for coders and clinicians alike. These solutions can help improve coding accuracy and completeness, while also providing feedback to clinicians on their documentation.

Best Practices for risk adjustment documentation and coding workflow

1. Use a reliable technology solution – Make sure you’re using risk adjustment chart review technology solutions that are accurate and up-to-date. This will help ensure that your risk adjustment codes are accurate.

2. Automate code review and audit verification – By automating the code review and audit process you can ensure all diagnoses, treatments, and procedures are accurate and complete.

3. Keep up with changes – Risk adjustment documentation and coding can change over time. Stay up-to-date on the latest guidelines to ensure that your codes are accurate.

Summing up

Overall,  best practices for successful risk adjustment documentation and coding in value-based care are essential to ensure that providers get paid accurately and on time. 

By following these best practices, healthcare organizations can improve their reimbursement rates while also ensuring the quality of care. 

Moreover, by utilizing NLP-powered retrospective risk adjustment chart review solutions, they will be able to stay ahead of the curve when it comes to compliance.

Reach out to our subject matter experts to get started with ICD-10-CM code review and audit technology solutions now!




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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.