Risk adjustment is not a new concept. It a process used by Centers for Medicare and Medicaid Services (CMS) to predict healthcare costs based on the relative risk of enrollees within a health plan to protect against potential effects of adverse selection. Medicaid began using risk adjustment modeling in 1996 and Medicare Advantage plans have been using the risk adjustment model since 2004. Although, it’s not a new model, our current clinical documentation practices are based on the intensity of each individual service (CPT, HCPC codes) with less emphasis on diagnostic specificity. As the healthcare landscape continues to shift, documentation and coding will increasingly drive reimbursement, quality measures, and medical home models.
At the end of this two hour session, participants will be able to: Compare the current model versus the future model of outlining patient risk; explain why clinical documentation is critical from the compliance, reimbursement and patient care perspectives; and identify the most common clinical documentation issues.
Important NACHC Library Content Note: This technical assistance resource was developed prior to the August 2017 release of the Health Center Compliance Manual by the Health Resources and Services Administration’s (HRSA) Bureau of Primary Health Care (BPHC). The BPHC Compliance Manual, issued August 2017, indicates where PINS, PALs and other program guidance are now superseded or subsumed by the BPHC Compliance Manual.
This project was supported by the Health Resources and Services Administration (HRSA) of the U.S. Department of Health and Human Services (HHS).