As more providers shift toward population health management systems and payment models, what are some key considerations when it comes to capturing and documenting accurate information for reimbursement? When it comes to accurate population health-based payments, three factors go hand-in-hand: Risk adjustment, documentation, and quality. Thorough and specific documentation not only makes good clinical sense, but it also tends to support quality measures and risk-adjusted payments. To ensure appropriate reimbursement, physicians must make time to understand how their documentation specificity for ICD-10 codes translates to risk-adjusted payment methodologies.
Providers play a critical role in helping to ensure the integrity of the data used in calculating the overall health risk of members.
· Comprehensive health status for each patient
· Accurate and complete ICD-10-CM coding for every patient, every time
· Medical record documentation sufficient to support ICD-10-CM coding
· Coding to the highest level of specificity for claim submission
· If it’s not coded… the patient doesn’t have it
In many risk-adjusted payment models (e.g., Medicare Advantage), physicians receive more appropriate reimbursement only when they correctly document diagnoses that fall into one or more hierarchical condition categories (HCC). HCCs stratify patient risk, allowing payers to predict the costs on which capitated payments are based. CMS-HCCs that physicians document in the current year affects their per-member-per-month Medicare payments the following year. Risk adjustment plays an important role not only in Medicare Advantage plan contracts but also in commercial capitated payment arrangements and CMS alternative payment models, such as shared-savings contracts and accountable care organizations.
· Patient’s name and date of service (DOS) on each page
· All of the patient’s conditions, including those co-existing
· Details to code each condition to the highest degree of specificity
· Treatment and/or management for each condition
· Physician’s signature, credentials, and date
Take the example of type 2 diabetes mellitus. When patients have diabetic complications, physicians who document these complications as an effect of diabetes will receive risk-adjustment payment for taking care of a sicker patient. In the case of Type 2 diabetes with diabetic chronic kidney disease (CKD), physician documentation must support the diagnosis as well as the stage of CKD. If stage 4, 5, or 6 (end-stage renal disease), physicians may receive an additional HCC and risk-adjusted reimbursement to reflect the anticipated resources necessary to care for a sicker patient. Documenting ‘dependence on renal dialysis,’ when appropriate, also carries weight in risk-adjusted payment models.
Document all diagnoses and chronic conditions that affect the patient’s current care, current medical-decision making, or current treatment management. Some chronic conditions will risk adjusting in perpetuity when documented correctly every year. It includes amputation of a lower extremity; atherosclerosis; chronic viral hepatitis B; COPD; drug and alcohol dependencies; heart failure; HIV/AIDS; lupus/rheumatoid arthritis; major depression (document episode, severity, and remission status); some stomas and artificial openings; and transplants (except renal). To receive credit in a risk-adjusted payment model, physicians must not only document these conditions at least once a year but also describe how they assess and treat them.
Consider the example of hypertensive heart disease. To receive risk-adjustment credit, physicians must document that heart failure is due to hypertension. They must also specify the type of heart failure.
Resist the temptation to automatically regenerate a problem list or past medical history in a new electronic progress note. Take the time to validate each condition and update the record when additional or more specific diagnoses are made from test results, inpatient visits, specialist consult reports, or other provider visits since the last date of service. Risk-adjusted payments are ultimately a good thing for physicians. You get more appropriate reimbursement for your sicker patients.
· Assures all of the patient’s medical conditions are addressed
· Improves communication between physicians, hospitals and other health care professionals
· Supports proper claim payment, reducing denials
· Used in research and education
· Accurate coding of conditions is needed for appropriate Risk-Adjusted payment
· Documentation is key… if not documented, it cannot be coded