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Provider Manual

Risk Adjustment - Basics

Last Updated on June 17, 2019

Risk Adjustment & Hierarchical Condition Categories Documentation Basics

Provider documentation is required to support  diagnoses that map to Hierarchical Condition Category (HCC) codes.  The International Classification of Diseases–10 (ICD-10) guideline is the standard used to support diagnosis coding. The following information outlines documentation basics that may impact whether a diagnosis is a HCC or not. 

Every note should include the following:

  • Date of service
  • Patient name & date of birth on every page
  • Provider signature and credentials
  • Only industry standard abbreviations
  • Documentation of each medical condition being
    • Monitored/Managed
    • Evaluated
    • Assessed/addressed
    • Treated
    • Considered in your care of the patient
  • Be as specific as possible – use signs and symptoms if diagnosis is not clear

Document on each condition the patient has that influences your ability to evaluate or treat the patient.  This includes any of the following:

Pertinent Conditions

  • Document and code for any patient condition that is
    • Present but stable
    • Managed on therapy  
    • Requires observation
    • Requires referral to another provider for management
    • Influences your decision making in care of the patient
  • Avoid documenting “history of” when the condition currently exists
    • In ICD 10 coding language, “history of” means that the patient no longer has the condition, in which case it cannot be coded as an active disease

Chronic Conditions

Chronic conditions are conditions that the patient has and is expected to have as an ongoing health issue. 

  • Document chronic conditions annually, even when stable with treatment
  • Document that the condition is chronic
  • Document severity/stage of condition (i.e. stage IV chronic kidney disease/major depression)
  • Document associated conditions or  complications and relationship to  the underlying chronic condition (i.e. diabetic retinopathy, cirrhosis secondary to alcoholism)

Active status

Conditions that are present and unresolved or unlikely to resolve need to be documented at least annually.  CMS considers the condition resolved if not evaluated and coded at least once/calendar year, in which case the risk factor score for the member is lowered.

  • Forever codes – conditions that do not go away and patients are expected to have forever.
    • Amputation
    • Transplants
    • Alcoholism in remission
    • CHF (compensated)
  • Might be forever codes –
    • Ostomy
    • Cirrhosis
    • Diabetes
    • Hepatitis
    • Paraplegia/Quadriplegia – be specific

“History of” or “Past” Conditions

  • History of Cancer – appropriate diagnosis when the patient has successfully completed treatment for malignancy, does not have active disease or metastases and is not being treated for cancer
    • Cancer on a long term therapy (i.e. breast/prostate cancer on hormonal therapy) is active cancer, not “history of” cancer when the therapy is not prophylactic.
    • A patient with cancer who declines treatment is considered active cancer.
  • History of stroke vs CVA – A stroke is an acute event and should not be diagnosed once a patient is discharged from the hospital.
    • Document deficits and diagnose history of stroke or the specific deficits (i.e. hemiplegia secondary to CVA)

Conditions that require 2 codes billed together

  • Diabetic manifestations – nephropathy, neuropathy, etc. 
    • Document the causal relationship between the conditions using “secondary to” or “due to” statements and diagnose both conditions (i.e. neuropathy due to diabetes).
  • Hypertensive renal disease – document & code both the hypertension & the renal disease
  • Infections – document & code for both the type of infection & the organism
    • Example: UTI & E. Coli

 

Questions

Brenda Anderson
Revenue Management Educator
Security Health Plan 
Telephone: 715-221-9598

Shared email:   rf.shp.risk.adjustmnt@securityhealth.org