Medicare Risk Adjustment & HCC Clinical Documentation

Medicare Risk Adjustment & HCC Clinical Documentation Overview: Coding Guidelines & Substantiation

Risk adjustment is a method to offset the cost of providing health insurance for individualsâ€”such as those with chronic health conditionsâ€”who represent a relatively high risk to insurers. Under risk adjustment, an insurer who enrolls a greater-than-average number of high-risk individuals receives compensation to make up for extra costs associated with those enrollees.In the absence of risk adjustment policies, insurers have a financial incentive to deny coverage to higher risk individuals, and to write exclusions into policies or impose unaffordable premiums for individuals with pre-existing medical conditions. Risk adjustment aims to make comprehensive insurance available to all individuals, regardless of risk, and to allow plans that insure sicker-than-average populations to charge similar average premiums as plans that insure relatively healthy populations.The risk adjustment model enacted under the Affordable Care Act (ACA, or â€œObamacareâ€) is budget neutral. Total payments to insurers do not increase. Rather, insurers covering a relatively greater number of healthy individuals must contribute to a risk adjustment pool that funds additional payments to those insurers covering a larger portion of high-risk individuals.Risk adjustment models typically use an individualâ€™s demographic data (age, sex, etc.) and diagnoses to determine a risk score. The risk score is a relative measure of the probable costs to insure the individual. To cite a simple example, an individual with diabetes will have a higher risk score (his or her predicted healthcare costs will be greater) than an otherwise statistically identical individual without diabetes. Older individuals typically have a higher risk score than younger individuals, and those individuals with a personal or family history of certain conditions may garner a higher risk score than individuals without such a history.There are several risk adjustment models. The Centers for Medicare & Medicaid Service (CMS) risk adjustment model uses the Hierarchical Condition Category (HCC) method to calculate risk scores. This method ranks diagnoses into categories that represent conditions with similar cost patterns. Higher categories represent higher predicted healthcare costs. For example, diabetes with complications is ranked â€œhigherâ€ (resulting in a higher risk score and thus greater expected healthcare costs) than diabetes without complications. An individual may be included in more than one HCC.Diagnoses are reported using ICD-10-CM codes Not every diagnosis will â€œrisk adjust,â€ or map to an HCC. Acute illness and injury are not reliably predictive of ongoing costs, as are long-term conditions such as diabetes, chronic obstructive pulmonary disease (COPD), chronic heart failure (CHF), multiple sclerosis (MS), and chronic hepatitis; however, some risk adjustment models may include severe conditions relevant to a young demographics (such as pregnancy) and congenital abnormalities.All risk adjustment models depend on complete and accurate reporting of patient data. CMS requires that a qualified healthcare provider identify all chronic conditions and severe diagnoses for each patient, to substantiate a â€œbase yearâ€ health profile for those individuals. Documentation in the medical record must support the presence of the condition and indicate the providerâ€™s assessment and plan for management of the condition. This must occur at least once each calendar year for CMS to recognize that the individual continues to have the condition. This information is used to predict costs in the following year. As such, incorrect or non-specific diagnoses can affect not only patient care and outcomes, but also reimbursement for that care, going forward.
Country USA
Manufacturer Independently published
Binding Paperback
EANs 9781799242635
ReleaseDate 0000-00-00

Country	USA
Manufacturer	Independently published
Binding	Paperback
EANs	9781799242635
ReleaseDate	0000-00-00

Medicare Risk Adjustment & HCC Clinical Documentation Overview: Coding Guidelines & Substantiation

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