Get in the Know: Risk Adjustment 101

Speaker: Nikki Taylor

MBA, CPC®, COC™, CPMA®, CRC™, AAPC Fellow

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 Learning Objectives

• What is risk adjustment coding and how is it useful?

• Learn the ins and outs risk adjustment models, predictive
modeling, and quality care
• Get to know documentation requirements andissues
• Nail down common diagnoses seen in risk adjustment
coding
• Highlight helpful tools and resources to help ensurecoding
success

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Risk Adjustment Basics

• Risk Adjustment- calculates data elements to compare patientwellness levels

• RAmodels used to weigh patientsequally
• All models use diagnosis codes
• Variables help pinpoint patients
• Higher medical costs
• Variables explain current trends
• Spending
• Predicting future needs
• Recognize resources
• Risk adjustment models adjust health plan revenue

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Risk Adjustment Basics, cont.

• Section 1343 of the Affordable Care Act(ACA)

• HHScreated a risk adjustment model
• Using commercial claims data
• Improves HCCsto mirror conditions anticipated in a commercial risk adjustment group
• Hierarchal grouping similar to Medicaremethodology
• HHSdifferent set of HCCs

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Risk Adjustment Basics, cont.

• Evens out the playing field!

• Provides incentives for insurers to cover lower and higherrisk
individuals
• Healthy and sick are covered equally
• Stabilizes premiums
• Premiums reflect benefits and NOThealth status

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Risk Adjustment Basics, cont.

• Patients
• Receive more affordable health insurance
• Improved quality care
• Targets patients for risk factor and disease preventionprograms
• Healthcare Providers
• Performance based payment models
• Health Plans
• Monitor patient populations
• Improved quality care
• Improvements to dataaccuracy
• Accurate risk adjustment factor (RAF)scores
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Risk Adjustment Models

• Diagnosis-based program examples:

• Health and Human Services Hierarchal Condition Category (HHSHCC-C)
• Commercial, Individual, and Small Group
• Blended HCC-CModel
• Medicaid Chronic Illness and Disability Payment Systems(CDPS)
• Medicare Hierarchal Condition Category Part C(MedicareHCC-C)
• Diagnosis Related Groups (DRG)- Inpatient
• Adjusted Clinical Groups (ACG)- Outpatient

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 Download Full Slide here
https://www.supercoder.com/medical-coding-webinars/risk-
adjustment-101

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Resources

• https://www.aafp.org
• https://www.cms.gov/Regulations-and-
Guidance/Guidance/Transmittals/Downloads/R116MCM.pdf
• https://www.codinginstitute.com/white-papers/conquer-your-hcc-
coding-selection?utm_source=instagram-
whitepaper&utm_medium=instagram-risk-adjustment-whitepaper-
110718&utm_campaign=tci-social
• https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4214269/
• https://www.healthcare.gov
• https://www.cms.gov/CCIIO/Resources/Forms-Reports-and-Other-
Resources/Downloads/RA-March-31-White-Paper-032416.pdf
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