Hierarchies are imposed among related condition categories. CCs are related clinically and with respect to cost. In the CMS model, those conditions that do affect risk adjustment (which are roughly 10,000 out of 70,000+ diagnoses) are grouped into approximately 1,300 diagnostic groups (DXG) that are then aggregated into condition categories (CC).
That’s because this payment model excludes diagnoses that are vague/nonspecific (e.g., symptoms), discretionary in medical treatment or coding (e.g., osteoarthritis), not medically significant (e.g., muscle strain), or transitory/definitively treated (e.g., appendicitis).
M.e.a.t. clinical documentation code#
Not every ICD-10-CM diagnosis code affects risk adjustment under the CMS model. This ultimately helps control the cost of care.įor the purposes of this article, we’ll focus on the Centers for Medicare & Medicaid Services’ (CMS) risk adjustment model. Strong documentation, combined with appropriate ICD-10-CM coding, provides a comprehensive view of the patient. In addition, patients may be omitted from beneficial care management, disease intervention, and other wellness programs if the coded data associated with their records is inaccurate or incomplete. That’s because documentation and coding are the primary means of communication between care teams. This is true under all payment models-not just risk-adjusted ones. Inadequate coding (i.e., missing codes or lack of specificity) also often leads to time-consuming onerous retrospective chart retrieval and reviews as well as compliance risks.įor patients, lack of appropriate ICD-10-CM diagnosis codes can result in poor coordination of care. If your coded data indicates subpar performance or that you haven’t met certain performance thresholds, you could be missing out on revenue. Why does coding matter for risk adjustment? If your documentation doesn’t support the ICD-10-CM codes you’ve assigned-or you omit certain codes because no documentation exists-your revenue under value-based contracts could suffer. Health plans, CMS, and other treating providers can’t connect the dots when there are only a few dots to connect, or worse yet, a blank page.
Without this narrative, the story is disjointed, confusing, or lost completely. When combined with demographic data and other details, the patient’s health status becomes clearer. Together, these codes create a narrative that includes important diagnostic information. The provider- through their documentation-tells the patient’s story using the ‘language’ of ICD-10-CM diagnosis codes. Why does provider documentation matter for risk adjustment? Here are five questions and answers to consider. The question is, are you-as the provider-telling the most important aspects of it, or are you missing critical details? We’re talking about the details that affect the patient’s health status and predict the resources required to care for them-two pieces of information that play a critical role in risk-adjusted payment models.
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