Risk Adjustment

4 Steps to Increasing Risk Adjustment Coding Accuracy

For Medicare Advantage, ACA, and Medicaid plans, accurate risk adjustment plays a critical role in the overall success of a health plan. Without a risk score that reflects actual member diagnoses, you will most likely miss out on reimbursements and may not be providing the best patient care that you can.

Although risk adjustment is designed to incentivize payers to accept patients who have more than one chronic condition in addition to those who are predominantly healthy, incomplete and inaccurate documentation and coding do not accurately represent relevant patient diagnoses, negatively affecting CMS premium payment, compliance, and patient care.

One hundred percent accurate risk adjustment coding may seem impossible, but there are best practices to follow to ensure the process is as error-free as feasible, thereby creating accurate risk scores, the corresponding premium payment, while increasing patient care. These include establishing appropriate staffing, correctly identifying code gaps, performing thorough quality assurance, and implementing advanced technology.


High-Quality Staffing


Having an appropriate level of trained and certified coders for risk adjustment coding is essential. Maintaining quality coders requires regular and updated training, including targeted education for staff members who regularly make the same coding mistakes. Coders knowledgeable about the organization’s internal coding standards, ICD coding guidelines, and risk management are essential.

Instead of hiring seasonal coders, consider working with a reliable technology services company that employs their own trained coders. Your organization will work with the same coders year after year, ensuring they are intimately familiar with your organization’s coding needs. These risk adjustment teams are experienced in leading projects for Medicare, Commercial, and Medicaid health plans and utilize highly-customized strategies to achieve client goals.

Be sure that even if your technology services vendor uses off-shore coding, they store your data onshore to ensure information security. Also, opt for a company that has its own employees instead of subcontractors to verify the coders have the same training and certification. These additional resources can help with other parts of the coding process, including overflow and second-level reviews (2LR).


Closing Gaps


Part of identifying coding gaps includes ensuring the captured data is accurate. This process occurs by fixing common documentation errors, standardizing coding procedures, working with an organization to provide trained coders, and regularly using analytics software to identify 999, MAO-02, and 277 errors before submission to CMS. It may also include reviewing coding patterns and offering documented guidelines to providers on how to best fix any regular errors.


Regular Reviews


Having the resources in place to review completed risk adjustment coding can result in accurate reimbursement for health plans and prepare your organization for potential CMD RADV audits. These reviews should check for accuracy, detail, and consistency plus correctly documented medical records. A coding manager can conduct second-level reviews, which can be essential both for identifying coding errors and for serving as a final decision in the case of coder uncertainty.

If coding reviews show repetitive errors in any area, examine the causes of documentation gaps. Once identified, coders should be made aware of the errors to avoid similar problems in the future. One way to avoid increased errors is through utilizing coders who receive training and certification regularly and are part of a core group without high turnover. Such a team also should employ a process that escalates more complex queries to auditors to review and provide appropriate resolution.


Turning to Technology


In risk adjustment coding, analytics and workflow platforms such as epiAnalyst examine records to identify gaps in codes and help health plans recapture codes. The software prioritizes members with the highest HCC recapture opportunities based on the code value and ease of obtaining justification, among other factors. After identifying high-priority codes, the software can help to automate chase list generation and attestation letter production and mailing to close the HCC gaps.

Because technology requires training for increased accuracy, comprehensive coder training and multi-level auditing must be in place. Leveraging coders’ ability and providing them with the necessary resources is essential, and is especially true when applying a newer technology such as NLP to the coding process.


To learn more about how Episource’s trained team of coders and our epiAnalyst software can help make your organization’s risk adjustment coding more accurate, contact us today.


We simplify the management of member programs by making it radically more efficient, and increasing value to healthcare organizations and their members

Presentation @ RISE VBC: Effective Collaboration Strategies Between Payer & Provider