Both pro-fee and facility coding becomes complex when RA (risk adjustment) considerations must be factored in. RAFs (risk adjustment factors) include a variety of things that make one patient more likely to need expensive or frequent medical care than the average patient. Demographics like age, sex, or ethnicity may be involved, as well as having a pre-existing chronic condition like diabetes or having a family history of ailments such as heart disease.

CMS uses the HCC (hierarchical condition category) method for determining risk scores for each patient. Diagnoses must be reported via ICD-10 CM coding, but not every single diagnosis actually “risk adjusts.” Chronic conditions are much more likely to need risk adjustment coding than acute conditions –– but there are exceptions with some models where pregnancy or congenital diseases may also risk adjust.

Additionally, risk adjustment cannot be properly done without accurate patient data to establish the base year (previous year) risk score, nor absent complete and accurate documentation of all medical care rendered. Thus, there is a large scope to the work that goes into preparing for and completing submission of CMS and other risk-adjusted claims.

We are experienced and ready to handle your HCC coding and data validation reviews to ensure your practice is receiving maximum reimbursement. We have the expertise to code and conduct a thorough retrospective review of your risk adjustment coding to ensure revenue optimizing and compliance.  By having accurate coding, you will receive an accurate risk adjustment factor (RAF) while reducing your medical loss ratio (MLR) calculations.