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Medicare risk adjustment

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.


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

If you have questions after reviewing these resources, contact and put “CDI and coding guidelines” in the subject line.

The Importance of Accurate ICD-10 Coding

Diagnosis codes provide a standardized method to capture the health of the patient. The ICD-10 diagnosis codes vary in their levels of specificity to ensure that the health status and risk profiles of patients are correctly represented. Coding to the most accurate level of specificity facilitates proper payment, financial predictions, compliance with regulatory requirements, and patient access to health care services

While there are situations in which an unspecified code is the correct code for the patient, an unspecified code should only be selected when there is no clinical support for a more specific diagnosis. Clear documentation of the diagnosis as well as clinical support will capture the most accurate picture of the patient. Moreover, precise coding supports better patient care management by providing reliable data for clinical decision-making and population health analysis.

Consider using the CDC’s lookup tool to ensure that you choose the correct degree of specificity for your patient’s condition.

Chronic Conditions Codebook

Managing chronic conditions can slow the progression of disease, prevent or delay complications, reduce the risk of hospitalizations, ensure patients are receiving appropriate care to improve the control of chronic disease, and improve the overall health, wellbeing, and quality of life for patients.

Documenting chronic conditions is an important part of risk adjustment because CMS resets each member’s risk score on January 1 every year. Accurate coding ensures that previously documented HCCs (disease categories) are re-evaluated for consideration in the current year.

This Chronic Conditions Codebook is available to help your organization manage and document chronic diagnosis codes. These codes are displayed in:

  • the PEAR Comprehensive Visit Diagnosis Considerations to Address section of the CV forms
  • the monthly risk gap file that is being sent to some of our health system partners for their chronic condition point of care alerts within their EMR workflow
  • the calculation of your organization’s persistency rate¹ in the Risk Accuracy Performance Dashboard

To improve accurate coding of chronic conditions, you may want to consider whether your organization’s disease management workflows are capturing all diagnosis codes that are designated as chronic in the codebook.

The Healthcare Cost and Utilization project (HCUP) publishes the Chronic Condition Indicator Refined (CCIR) list annually. This is a list of diagnosis codes that are assigned a chronic indicator which distinguishes a condition as chronic or non-chronic.

As CMS identifies additional diagnosis codes for risk adjustment, our clinical team will conduct a review of the latest CCIR list, make a final determination on chronicity, and update the codebook as needed.

Download the latest Chronic Conditions Codebook.

¹Persistency rate: the rate of chronic conditions that have been submitted to the health plan by any provider last year and this year compared to the total chronic conditions submitted to the health plan last year