Get in the Know: Risk Adjustment 101

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Get in the Know Risk Adjustment
101 Speaker Nikki Taylor MBA, CPC, COC, CPMA,
CRC, AAPC Fellow
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Learning Objectives

• What is risk adjustment coding and how is it
  useful?
• Learn the ins and outs risk adjustment models,
  predictive modeling, and quality care
• Get to know documentation requirements and issues
• Nail down common diagnoses seen in risk
  adjustment coding
• Highlight helpful tools and resources to help
  ensure coding success

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Risk Adjustment Basics

• Risk Adjustment- calculates data elements to
  compare patient wellness levels
• RA models used to weigh patients equally
• All models use diagnosis codes
• Variables help pinpoint patients
• Higher medical costs
• Variables explain current trends
• Spending
• Predicting future needs
• Recognize resources
• Risk adjustment models adjust health plan revenue

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Risk Adjustment Basics, cont.

• Section 1343 of the Affordable Care Act (ACA)
• HHS created a risk adjustment model
• Using commercial claims data
• Improves HCCs to mirror conditions anticipated in
  a commercial risk adjustment group
• Hierarchal grouping similar to Medicare
  methodology
• HHS different set of HCCs

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Risk Adjustment Basics, cont.

• Evens out the playing field!
• Provides incentives for insurers to cover lower
  and higher risk individuals
• Healthy and sick are covered equally
• Stabilizes premiums
• Premiums reflect benefits and NOT health status

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Risk Adjustment Basics, cont.

• Patients
• Receive more affordable health insurance
• Improved quality care
• Targets patients for risk factor and disease
  prevention programs
• Healthcare Providers
• Performance based payment models
• Health Plans
• Monitor patient populations
• Improved quality care
• Improvements to data accuracy
• Accurate risk adjustment factor (RAF) scores

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Risk Adjustment Models

• Diagnosis-based program examples
• Health and Human Services Hierarchal Condition
  Category (HHS HCC-C)
• Commercial, Individual, and Small Group
• Blended HCC-C Model
• Medicaid Chronic Illness and Disability Payment
  Systems (CDPS)
• Medicare Hierarchal Condition Category Part C
  (Medicare HCC-C)
• Diagnosis Related Groups (DRG)- Inpatient
• Adjusted Clinical Groups (ACG)- Outpatient

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Download Full Slide here https//www.supercoder
.com/medical-coding-webinars/risk-adjustment-101
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Resources

• https//www.aafp.org
• https//www.cms.gov/Regulations-and-
  Guidance/Guidance/Transmittals/Downloads/R116MCM.p
  df
• https//www.codinginstitute.com/white-papers/conqu
  er-your-hcc- coding-selection?utm_sourceinstagra
  m- whitepaperutm_mediuminstagram-risk-adjustmen
  t-whitepaper- 110718utm_campaigntci-social
• https//www.ncbi.nlm.nih.gov/pmc/articles/PMC42142
  69/
• https//www.healthcare.gov
• https//www.cms.gov/CCIIO/Resources/Forms-Reports-
  and-Other- Resources/Downloads/RA-March-31-White-
  Paper-032416.pdf