10 Tips For Effective Risk Adjustment Coding

Date: 11/07/17

Conditions that go undocumented usually also go untreated. This is just one of many reasons that thorough and accurate Risk Adjustment Coding is critical to patient care. Plus, comprehensive coding provides specialists and ancillary providers with insight into a patient’s complete health profile, and it helps to streamline your claims process, which may result in faster reimbursements.

Try these 10 tips for effective Risk Adjustment Coding:

1.   Include a legible signature with credentials: Ensure the signature on the medical record, such as chart notes and progress notes, is legible and includes the signee’s credentials.

2.    Complete all fields in the EHR: For EHRs, confirm all electronic signature, date, and time fields are completed. Include qualifying words like, “Authenticated by,” “Verified by,” or “Generated by.”

3.    Be specific in documentation: Make sure you document to the highest degree of specificity in the medical record.

4.    Use the right ICD-10 code: Assign the ICD-10 code that includes the highest degree of specificity.

5.    Use the right language: Include proper casual or link language to support the highest degree of specificity in diagnosis and coding.

6.    Verify the codes: Make sure that the billed diagnosis codes are consistent with the written description on the medical record.

7.    Follow the MEAT documentation standards: Include whether the diagnoses are being Monitored, Evaluated, Assessed/Addressed, and Treated (MEAT) in the documentation.

8.    Avoid “History Of”: If a chronic condition is currently present in a patient, do not use language such as “history of.” This term indicates that the condition is past condition and cannot be coded as an active disease.

9.    Document all conditions: Document all chronic conditions present in the patient during each visit.

10. Submit all chronic diagnoses codes annually: At least once per year, submit all chronic diagnosis codes based on documentation in a claim.

To learn more about Risk Adjustment Coding and how it benefits your practice, contact your local Provider Relations Consultant. If you need help finding the Provider Relations Consultant for your region, call Provider Services at 1-866-595-8133.