The Solution to Risk Adjustment: A Coder’s Perspective

The Solution to Risk Adjustment: A Coder’s Perspective    

Kameron Gifford, CPC

Over the last twelve years, I have worked with physicians to develop efficient billing practices, implement value added processes and improve the entire experience of care for their patients. What can this knowledge contribute to developing compliant, engaging and transparent risk adjustment programs? What can health plans learn from expert practice managers?

Use a Whole System Approach

In medicine, continuity of care can mean the difference between a positive and a negative outcome. We know that fragmented systems don’t work. So why has this become the standard for Medicare Advantage plans? Initial Health Risk assessments are outsourced to midlevel providers that perform a “home based” assessment or perhaps the patient is instructed to visit a website or to call an 800 number.  Then a few months later another company is contracted to “retrieve” medical records from the PCP who then forwards those records to a coder to code any “missing diagnoses”. This does not add any value for the patient. What will?

When patients enroll in a managed Medicare plan they are assigned (or pick) a PCP. This is who should be doing the initial health assessments. CMS encourages FFS providers to perform this type of exam by reimbursing the “Welcome to Medicare” exam with no cost share to the patient. If this is the “standard of care” for some beneficiaries, why not all?

Coding comes from documentation and therefore it is impossible to improve our coding without first improving our documentation. Knowing this, retrospective audits should be used as a tool for identifying deficiencies and a foundation from which specific educational programs can be built to support individual needs and learning styles.

Educate Everyone

In 2011, I began educating medical professionals in compliant HCC Coding and Documentation.  My mission was to teach the fundamental purpose and principles behind the methodology. Doctors are trained to take an enormous amount of information and condense all of this into a progress note. This abbreviated summary of events is then interpreted into ICD-9 and CPT Codes (which may or may not risk adjust) which will determine the amount of reimbursement for that particular service.

Currently plans are trying to interject change at the end of a process. Instead, by educating physicians, nurses, coders, administrators, medical assistants, and receptionists change can be implemented at the initial point of contact. If the medical assistant and nurse understand quality measures they will be able to accurately audit the chart before the physician ever walks in. Flags can be raised for patients who have not had their mammogram or who didn’t turn in their hemmoccult cards. Physicians who understand the 10 guiding principles of HCC will document to a higher a degree of specificity and use linking words. A coder with training in HCC Coding will know that you must use a buddy code when coding manifestations. This knowledge allows the coder to query the physician immediately when the case is still fresh on their mind.  The ability to audit in “real time” expedites the process of changing one’s behavior and the physician’s ability to adapt under these circumstances are amazing. The end result is a complete an accurate medical record which does add value to the patient.

Return on Investment

Education empowers. One of the greatest dilemmas in managed care is how to get physician buy in? By providing quality educational opportunities to not only physicians but to their office staff as well you will position yourself as a blessing instead of a burden. In the current environment of greater oversight, tighter regulations and changing reimbursement patterns providing something as simple as education builds relationships.

Empirical Risk Management tested this philosophy and the return on investment was incredible. 300 to 1. But, the greatest achievement of all was seeing the hunger for knowledge and the positive impact on human life that was reflected in patient centered whole system change.

For more information please visit our website: www.ermconsultinginc.com or by email: kgifford@ermconsultinginc.com