A Note from the ACDIS Director: Risk Adjustment is the new mantra for CDI, and we’ve got you covered with a new boot camp

By: Brian Murphy 

One size does NOT fit all when it comes to health insurance. Beneficiaries range from the extremely healthy 65-year-old—the poster child for “65 is the new 45”—to a 65-year old suffering from COPD from a lifetime of smoking, cancer, and a hereditary condition such as Type 1 diabetes. The result is often a huge disparity in the amount paid out for the care of these two patients.  

The insurance market has adapted to these wide disparities with the concept of risk adjustment. Certain payers like Medicare Advantage now offer plans with options for coverage based off demographics and health status of the beneficiary. Risk adjustment applies not just to healthcare reimbursement, but also quality monitors such as 30-day mortality measures, 30-day readmissions, and Medicare spending per beneficiary. Healthcare organizations must be aware of how documentation supports risk adjustment and educate providers of the importance of complete and thorough capture of their patient’s health status to support accurate code assignment representing the potential risk their patients possess.

One size does also not fit all when it comes to educating CDI specialists and coding professionals involved in risk adjustment. To meet this need we’ve launched a brand new boot camp: The Risk Adjustment Documentation and Coding Boot Camp. This boot camp offers CDI and coding professionals involved with risk adjustment concrete strategies to make real differences in accurate payment and quality monitors.

This class is a first for HCPro: A true joint development between our CDI and coding educators to cover what is truly a marriage of skillsets. Risk adjustment requires coding and CDI professionals to work together as one team to ensure the capture of the most appropriate risk score for each patient. The Risk Adjustment Documentation and Coding Boot Camp reviews both inpatient and outpatient coding guidelines and their application to the CMS-Hierarchical Condition Category methodology, and includes detailed instruction on the individual HCCs and identification of opportunities for improved documentation. Clinical scenarios are used to demonstrate concepts and validate learning.

“CDI specialists are the logical intermediary since their role already includes documentation improvement for hospital inpatient services,” says Shannon McCall, RHIA, CCS, CCS-P, CPC, CPC-I, CEMC, CCDS, director of HIM/coding for HCPro. “To add to their already versatile role, risk adjustment documentation is right in their wheelhouse.”

“I see many CDI programs working to expand into the outpatient arena and there appears to be a struggle to find their identity or focus for their record reviews. Knowledge of principles of risk adjustment can provide that focus,” adds Laurie Prescott, MSN, RN, CCDS, CDIP, director of CDI education for HCPro. “Documentation for outpatient services and primary care is a slightly different beast than the more familiar territory of acute inpatient care for most CDI professionals. This different focus requires a melding of two skill sets that of CDI and that of coding professionals to succeed.”

Risk adjustment documentation is based on records from hospital inpatient, hospital outpatient, and provider services. Although CDI is firmly rooted in inpatient services, as more and more hospital systems purchase physician practices their focus and review scope increases. The arms reach wider to ensure documentation on the whole is optimized not just for inpatients but in all settings related to the hospital system to obtain accurate reimbursement. “The CDI team is already clarifying diagnoses like specific manifestations of diabetes mellitus and possibly the significance of pathology reports for metastatic cancer, so why not multi-purpose the focus to extend to conditions that may affect risk adjustment scores?” Prescott says. 

Coding professionals apply the coding guidelines to assure accurate code assignment. They often must prioritize these diagnoses in an inpatient setting. However, the importance of capturing vague or missing diagnoses has not traditionally been stressed in the outpatient setting since payment is based principally on CPT codes. Because diagnosis codes are used to calculate a patient’s risk score it is important to apply the principles of concurrent review and documentation improvement in the outpatient and professional services arenas as well, McCall notes.

Both CDI and coding professionals can assist providers in creating documentation that is complete and thorough to support the concepts of risk adjustment.

“We must document in a manner that allows capture of the patient’s true health status to assure that both the healthy robust 70-year-old woman and the fragile, compromised 70-year-old man are well differentiated within the risk adjustment model. Again this requires efforts from both CDI and coding professionals,” Prescott says, noting that this class also benefits payers who must be proficient in recognizing accurate versus inaccurate code assignment for patients covered under their risk adjusted plans.

Our first class is taking place in July and more are offered this fall. We hope to see you in Boot Camp!

To learn more about the Risk Adjustment Documentation and Coding Boot Camp or to register, click here.