Broadly speaking, risk adjustment is simply a way of making sure that there are sufficient funds to adequately take care of the healthcare needs of a certain population. It’s a predictive modeling methodology which attempts to determine the health care costs which will be incurred based on the diagnoses of the individuals in that population. Due to the high cost of healthcare provider fee-for-service payment/reimbursement models, there has been an increase in moving to value based models which rely on risk adjustment to ensure proper funding.
Hierarchical Code Classification (HCC) codes are mandated by the Department of Health and Human Services (HHS) and specifically used by payers managing risk adjustment insurance plans to identify and classify conditions and injuries affecting the patient’s health status.
The following four separate HCC models are updated regularly by CMS and are used for different programs:
CMS: Medicare Risk Adjustment plans
RX: Prescription (Part D) plans
ESRD: Medicare beneficiaries with end-stage renal disease
HHS: Affordable Care Act (ACA) (Obamacare) plans
It is important to keep in mind that because health plans are funded based on these HCC models and their associated risk adjustment factors, under-coding leads to underpayment and loss of revenue but over-coding leads to audit risk and compliance actions. It’s essential to understand the rules to ensure maximum funding without increasing the organization’s risk of an audit. For Medicare programs, CMS regularly conducts Risk Adjustment Data Validation (RADV) audits to verify the accuracy of diagnosis codes submitted and every payer organization that provides Medicare Advantage (Part C) coverage to Medicare beneficiaries is audited.
If you are not seeing a CCI edit when reporting an E/M code with a certain procedure, it may be that there is no edit. CMS does not have a CCI edit for every CPT code, however, there are still general coding rules that must be followed.
The use of Modifier 25 is one example ...
To determine the dosage, size, doses per package and how many billing units are in each package, refer to the NDC number.
Take a look at the following
J1071 - Injection, testosterone cypionate, 1mg
For example; using NCD # 0009-0085-10 there are 10 doses of 100 mL
(100 mg/mL = 1 mL and there are ...
As we begin returning back to work, we will all face a new normal. The COVID-19 pandemic has changed the face of business. While it has certainly been a challenge to keep up with the ever-changing regulations (that’s likely to continue for a little longer), exciting new opportunities have also been created, such as the expansion of telemedicine. There’s also the maze of government funding that needs to be navigated and an increased awareness of OSHA standards to implement.
The CDC has released additional information and coding guidance for reporting encounters related to the 2019 health care encounters and deaths related to e-cigarette, or vaping, product use associated lung injury (EVALI).
The update offers coding scenarios for general guidance, poisoning and toxicity, substance abuse and signs and symptoms.
ICD-10-CM Official Coding Guidelines - ...
On April 30, 2020, CMS announced additional sweeping changes to meet the challenges of providing adequate healthcare during this pandemic. These changes expand the March 31st changes. The article covers some of the key changes. See the official announcement in the references below.
Risk adjustment is simply a way of making sure that there are sufficient funds to adequately take care of the healthcare needs of a certain population. It’s a predictive modeling methodology based on the diagnoses of the individuals in that population. As payers move to value based models, they heavily rely on risk adjustment to ensure proper funding.
All healthcare providers who are currently participating in the MIPS portion of Medicare’s Quality Payment Program may want to participate in the new COVID-19 Clinical Trials improvement activity. Read more about it here.