Podcast recap: Risk adjustment and improving quality

“Risk adjustment is key to telling the patient’s story,” said Cheryl Manchenton, RN, CCDS, CPHM, a senior inpatient consultant/project manager/quality services lead overseeing CDI at 3M Health Information Systems based in Salt Lake City, Utah, on the April 13, 2022, episode of the ACDIS Podcast.

According to Manchenton, risk adjustment is the answer to the question, “How do you explain or predict the likelihood of adverse events happening to your patient, whether it be a re-admission, a complication, or a mortality?” In measuring the patient population's demographics and history, risk adjustment shows who is at risk and how much they’re at risk for adverse events. Knowing these risk factors, Manchenton said, can help organizations improve the quality of care for their patient population.

Manchenton and Cassi Birnbaum, MS, RHIA, CPHQ, FAHIMA, senior enterprise director for HIM, CDI, and coding at CDI PeaceHealth based in Vancouver, Washington, suggested CDI professionals ask where their organizations want to shine to home in on a risk adjustment focus. The charge to focus on as many areas as possible is challenging and often unproductive, they said. Instead, Manchenton and Birnbaum recommended looking for commonalities and understanding basic methodology in those focus areas.

If a CDI program doesn’t have the staffing resources to tackle risk adjustment and quality reviews, Birnbaum suggested leveraging technology—particularly prioritization—to further the program’s reach. Instead of looking at every possible risk adjustment opportunity, her organization focused on those charts that would make a meaningful difference in capturing appropriate risk and quality measures.

“[It was a] change from one-and-done to doing a much deeper dive,” she said, “identifying everything that will make a difference.”

In addition to leveraging technology, Birnbaum also leaned on the quality team at her organization to understand the impact the CDI’s team efforts and focus those efforts even further. One of the big issues with capturing risk adjusting diagnoses is that CMS bases reimbursement only on the first 25 codes on the claim. If the risk adjusting diagnoses fall below that threshold, they won’t do any good in capturing appropriate risk and quality measures.

Through working with her quality team, Birnbaum was able to show that prior to the incorporation of the Elixhauser method and a few other measures, about 58.32% of risk adjustment diagnoses fell below the line with the 25 codes that could be captured. After such measures, however, only 0.63% of diagnoses were below the line.

“After we really leaned in and partnered with our quality team," Birnbaum said, “we were able to exceed our own expectations."

Editor’s Note: To listen to the full podcast episode, click here.