Book excerpt: Strong documentation equals accurate risk assessment

By Laurie L. Prescott, MSN, RN, CCDS, CDIP, CRC, and Sharme Brodie, RN, CCDS

The goal of the risk-adjustment model applied to Medicare Advantage plans is for Medicare to provide more accurate payments to the plan administrators to compensate for the care provided. Enrollees who have more complex needs likely require more services compared to those healthier patients requiring fewer services. CMS-Hierarchical Condition Category (HCC) codes compensate plans (insurers) commensurate with the risk score of the beneficiaries they enroll, instead of paying an average amount for Medicare beneficiaries. The plan must submit the qualifying diagnoses that affect the patient’s risk score. These submissions are subject to verification, much like the audit process inpatient acute care hospitals undergo with Recovery Auditor reviews.

aThe relationship between ICD-10-CM codes to CMS-HCCs is one-to-many—meaning a number of ICD-10-CM codes maps to one of CMS-HCC. Each CMS-HCC model category relates to a “rela­tive factor” or health risk score that is used to compute the patient’s risk-adjustment factor (RAF).

Not all ICD-10-CM codes maintain a value in the HCC model, however. Only those diagnoses that historically are related to high costs of care related to coordination, complication, or medications are included. CMS pro­vides an annual list of those diagnoses.

The CMS-HCC model is prospective in that it uses diagnosis information from a base year to predict costs or risks for the next year.

The higher the score, the more complicated the patient or the higher the expected costs to provide care. For example, CMS will use data pulled from calendar year 2018 to calculate the 2019 risk scores.

Documentation should reflect specificity within the code set to accurately capture a condition rather than relying on “unspecified” codes. As discussed elsewhere in this book, the “default” code is often unspecified, which can result from insufficient or imprecise documentation, like simple pneumonia without documenta­tion of the causal organism or etiology.

Physicians who provide care to Medicare Advantage patients, may better appreciate and understand the need for CDI efforts. The growing importance of diagnosis codes in the office setting represents an opportunity for improved collaboration between the community provider and healthcare organizations, since the hospital (inpatient setting) can also be a source of diagnoses to support HCC assignment. Targeting providers who accept Medicare Advantage beneficiaries could also be a way to engage providers in documentation improvement education, especially those related to the increased specificity associated with ICD-10-CM. Providers must also understand that the HCC model is used to risk adjust patients in some CMS quality programs, especially with those metrics associated with outcomes like 30-day mortality, so this collaboration could positively affect quality reporting and patient care.

Editor’s note: This article is an excerpt from The Essential Guide to Supporting Quality Care Measures Through Documentation Improvement.