Medicare Risk AdjustmentClinical documentation improvements and general coding tips

What Is Risk Adjustment?

Risk adjustment is a process of collecting all diagnosis codes from patient charts and using the documented illnesses, comorbidities, and complications to determine a risk score. Risk scores are used to illustrate a need for higher reimbursement rates for patients who have more serious health conditions to manage.

What Is Clinical Documentation Improvement?

Clinical documentation improvement is a process used to improve documentation so that a patient’s clinical status is accurately represented in coded data.

Resources

For your reference, we have created a repository of top medical diagnoses and documentation challenges:

If you have questions after reviewing these resources, questions can be emailed to RADVsupport@ibx.com. Please put “CDI and coding guidelines” in the subject line.

Independence Blue Cross coding and documentation education materials are based on current guidelines, are to be used for reference only, and are not intended to replace the authoritative guidance of the ICD-10-CM Official Guidelines for Coding and Reporting as approved by the American Hospital Association (AHA), the American Health Information Management Association (AHIMA), Centers for Medicare and Medicaid Services (CMS), and the National Center for Health Statistics (NCHS). Clinical and coding decisions are to be made based on the following:

1. The independent judgment of the treating physician or qualified health care practitioner.
2. The best interests of the patient.
3. The clinical documentation as contained in the medical record.