solved. Some examples include a history of a myocardial
infarction (MI) or history of a cerebrovascular accident
In addition to analyzing the quality of clinical documentation,
organizations should define internal policies for risk adjustment
coding professionals. Internal policies and procedures work
to ensure compliance with HCC requirements and encourage
consistency across the risk adjustment team.
Organizational policies might address the following risk adjustment coding principles:
Chronic diseases should continue to be coded and reported on an ongoing basis if the patient receives treatment
and care for the condition.
All diagnoses that receive care and management during
the encounter should be reported.
Conditions that are no longer active and/or not being
treated should not be reported. This includes problem list
diagnoses that have been resolved.
Report history of and status codes when pertinent and/
or influential where there is an impact on current care or
Documentation can be found in any section of the patient
record for a face-to-face encounter. For instance, a diagnosis does not have to be in the assessment portion of a
SOAP (subjective, objective, assessment, and plan) note to
be eligible for abstraction and reporting.
Internal coding policies should be consistent with the ICD-
10-CM Official Guidelines for Coding and Reporting and the
American Hospital Association’s (AHA’s) Coding Clinic for
ICD-10-CM/PCS advice. Organizations should require that risk
adjustment coding professionals follow these guidelines. The
guidelines provide direction for many of the coding issues that
risk adjustment coding professionals struggle with. Table 1 on
page 47 provides examples of specific ICD-10-CM Official Coding Guidelines that are helpful in risk adjustment coding.
Though the same ICD-10-CM Official Guidelines for Coding
and Reporting and AHA’s Coding Clinic for ICD-10-CM/PCS
advice apply for both risk adjustment coding and traditional
coding, coding management strategies do vary. It can be a chal-
lenge to effectively manage and monitor both. A best practice
in all organizations—both payers and providers—is to promote
thorough diagnosis coding for every encounter. This includes
both acute conditions that support medical necessity for cur-
rent treatment and chronic conditions impacting care that sup-
port accurate HCC reporting.
Another best practice for payers and providers is to ensure that
all ICD-10-CM codes for the encounter are captured in the elec-
tronic health record (EHR) and are correctly passed to the prac-
tice management platform and submitted on a claim. While the
electronic claim forms may accommodate 12 diagnoses for the
professional 837P and 25 for the institutional 837I, some EHRs
cannot capture that many per encounter. Coding professionals
should ensure that the codes captured are in appropriate order,
identifying the principal diagnosis (or first-listed diagnosis for
physician services). Organizations should work with the EHR
vendor, the clearinghouse, IT support, and the health plan to
ensure the maximum reporting opportunities are available and
to avoid missing eligible HCC diagnoses. This will ultimately en-
sure that all relevant and valid HCCs are submitted to CMS.
Accurate risk adjustment coding requires additional skills be-
yond traditional coding. Risk adjustment coding training should
explicitly address the following topics:
Overview of the HCC/risk adjustment factor (RAF) meth-
Review of criteria to identify reportable conditions (e.g.,
MEAT or TAMPER™).
A refresher of the ICD-10-CM Official Guidelines for Cod-
ing and Reporting with a focus on risk adjustment coding
and where correct coding is most impactful in the appli-
cable HCC model.
Education for the appropriate interpretation and use of
AHA Coding Clinic advice.
Familiarity with clinical indicators (e.g., testing, treat-
ment, medications) for chronic conditions to recognize
the current nature and/or presentation of the condition.
Practice analyzing clinical documentation to recognize
when documentation meets criteria for assignment of
chronic secondary diagnosis codes.
Table 2: Characteristics of RADV Audits
CMS-RADV National Sample CMS-RADV Targeted Sample HHS-RADV
Annual participation for most plans Random sample of plans to participate All plans participate each year
Small sample size Up to 201-member sample per plan contract 200-member sample per plan contract
Calculate error rate with no fiscal impact Error rate is calculated and extrapolated
across the contract population
Results applied to risk adjustment fund
Can occur several years after the benefit year Can occur years after the benefit year Occurs each year auditing the previous benefit