Health Costs

How to Master Risk Coding for Generating Higher Reimbursements?

Abhinav Shashank
Fri 03 August 2018

Right from the day-to-day activities to advanced sciences, probability, evidence, and risks form a crucial component of decision-making. How a team has performed throughout a particular MLB season often tells a lot about their odds of winning the upcoming matches. The weather forecast is, more often than not, pretty accurate. Such examples of predictive analysis are disparate and widespread. However, our healthcare system has been one of the last sectors to adopt a suitable methodology to accumulate such factors. The good news is that the scenario is finally changing, albeit slowly.

The surge in demand for more accurate clinical documentation and risk-coding

For the major part of the decade, most providers and other healthcare professionals have considered Risk Adjustment Factor (RAF) and coding as the cornerstones for succeeding in the rapidly-evolving value-based environment. Ironically enough, several organizations still struggle to optimize their reimbursements in such a setup. While this can be accounted to lack of perspective in some cases, many others have not been able to utilize their people, resources, and technology efficiently.

According to a recent report by the Office of Inspector General, Department of Health and Human Services, 28% of MA records that they reviewed had at least one potential error. These errors included inactive or invalid identifiers for billing providers, missing data, inconsistent dates, among many others. Errors like this double up to denied claims, and ultimately, lower reimbursements. The bottom line here is, if a syndrome is not coded properly at the time of the encounter, risk-coding will never reap expected dividends.

How can healthcare organizations create an efficacious risk-coding model?

It is foremost to understand that building a concrete risk-coding model is not a one-time exercise. In fact, it is an unceasing process towards improved finances which requires technological, managerial, and leadership support.

It is paramount for healthcare organizations to equip their providers with robust engagement solutions and tools to assist them in documenting their diagnosis of patients. In fact, according to a survey, engaged physicians are as much as 26% more productive than their colleagues and play a crucial role in clinical documentation improvement. Improvements in clinical documentation promote better overall feedback, risk-coding, and chart reviews.

M.E.A.T. guidelines for effective coding- A classic use-case

M.E.A.T. (Monitoring, Evaluating, Assessing, Treatment) guidelines are a widely used clinical documentation methodology used for indicating the category of diagnosis, It is used by organizations in their bid to improve their clinical documentation. Adhering to these guidelines is often the first step for ACOs and other healthcare organizations participating in Medicare’s Hospital Value-Based Program (HVBP) or Medicare Advantage (MA) programs when it comes to documenting any medical record.

  • Monitor– Keep a tab on signs and symptoms of disease progression
  • Evaluate– Analyze test results and effectiveness of medication to understand how the patient is responding to the medication
  • Assess/Address– Attend to the situation through discussions, reviewing records, counseling, among others
  • Treat– Come up with the right drugs, therapies, and other modalities

Following such guidelines are paramount for establishing a proper channel for diagnosis and eliminating the chances of skipped conditions. Further, organizations should also come up with techniques to run analytics on codes that were wrongly documented to identify providers and conditions which can result in poor risk coding.

What should an organization expect from its physicians?

Organizations need concise and concrete strategies to determine patients’ risk-scores and measure the expected cost-factor associated with each patient. As a rule of thumb, accurate clinical-coding always precedes risk-coding.

Physicians should imbibe the feeling of focusing on the patient rather than the disease each time they see a patient. This is imperative for holistic clinical documentation at the time of an encounter. For instance, physicians should monitor and report on chronic conditions at least once each year, even if the patient is stable.

For exact risk-coding, considering demographic, behavioral, chronic, and past symptoms is a must. More often than not, more than one type of illness or potential illness determine the final risk, and the risk score is subject to change frequently. However, co-existing conditions can sometimes get lost in translation if the status of the previous diagnosis is unclear or an episode is documented using non-standard abbreviations or ambiguous language such as “probably,” “possibly,” et al.

The volume of documentation may not always be a measure of its effectualness. The focal point of clinical documentation should be on clarity and its concise nature. In healthcare, precision is indispensable. The more clear physicians are while documenting different symptoms, the more accurate risk-coding automatically gets. Therefore, physician engagement solutions should allow physicians to have access to complete patient health records so that they can identify disparities and plan interventions as and when required.

The partnership between providers and coders is an all-important one

AAPC defines medical coding as “the transformation of healthcare diagnosis, procedures, medical services, and equipment into universal medical alphanumeric codes.” Coders should have a meticulous understanding of human anatomy and medical terminology. Good coders are in great demand today since accurate diagnosis coding is not only a prerequisite for proper analysis of patient and financial data,  it also ensures precise risk adjustment which drives a significant portion of a hospital’s revenue.

Risk-models, by default, are prospective payment models, and it is vital to document everything, especially the chronic symptoms. Both the providers and the coders should be trained to address and differentiate between the minutest of details related to the coding process. A very common example is the use of “history of” term, which should strictly be used when a patient no longer has that condition. Few professionals end up putting health conditions that are currently monitored but not being treated under “historic” bracket rather than “current.” Such mistakes sometimes go unnoticed and affect RAF.

Coders are also integral to audit processes as medical coding is responsible for predicting the finances required for each patient. Additionally, claims files that are to be released to payers should go through a coder so that they can review it thoroughly. Once those files are reviewed, unnecessary or missing codes can accordingly be removed, modified, or added to the final list with the help of concerned providers.

The road ahead

The Bureau of Labor and Statistics expects a job outlook of medical coders and billers to grow by 13% between 2016 and 2026. Inclination towards value-based reimbursements will only fuel the rise of risk-adjusted payment models. While it has justifiably been hyped, there is still a lot of scope for improvement. Risk-coding substantially depends on how well-versed providers and coders are with ICD-10 and HCC models, along with their eye for detail. Organizations will need their physician-champions to work closely with coders. Quality health at the right price is probably a door away- a door that hasn’t been properly unlocked yet!


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