The Vital Role of Documentation and Coding in Risk Adjustment and Value-Based Payment Models

In the ever-evolving healthcare landscape, accurate documentation and coding are pivotal in ensuring quality care, appropriate reimbursement, and successful risk adjustment. Let’s delve into why these aspects are crucial for providers and payers.

Risk adjustment is the process of accounting for the health status of patients when determining payment. It aims to level the playing field by adjusting reimbursement based on the severity of illness. Here’s why documentation and coding matter:

• Accurate Diagnosis Capture: Properly documented diagnoses allow coders to assign the most specific and relevant codes. These codes drive risk scores, which directly impact reimbursement. Incomplete or vague documentation can lead to underreporting of conditions, affecting risk scores and financial outcomes.
• Hierarchical Condition Categories (HCCs): HCCs are the building blocks of risk adjustment. Each HCC corresponds to specific diagnoses and conditions. Accurate coding ensures that all relevant HCCs are captured, reflecting the true health status of patients.
• Clinical Documentation Improvement (CDI): CDI programs bridge the gap between clinical language and coding. By enhancing documentation quality, CDI specialists ensure that all relevant conditions are captured, leading to more accurate risk scores.

While understanding the importance of documentation and coding is crucial, implementing best practices ensures optimal results. Here are some strategies to enhance documentation accuracy and efficiency:

• Documenting Diagnoses to the Highest Level of Specificity: Providers should include as much detail as possible during the evaluation. Examples include, but are not limited to, location, laterality, recurrence, severity, chronicity, underlying causes, and complications. This allows coders to assign the most appropriate diagnosis code that accurately reflects the patient’s severity of illness.
• Documenting an Assessment and Plan for Each Diagnosis: Each diagnosis addressed during a patient visit should have supporting documentation that explains the provider’s medical decision-making and management plan. Examples of supporting documentation can be easily remembered in the form of the acronym “TAMPER”: treatment, assessment, monitoring, plan, evaluation, and referral.
• Addressing and Documenting Chronic Conditions Once Per Calendar Year at a Minimum: The Centers for Medicare & Medicaid Services (CMS) encourages providers to address chronic conditions during a face-to-face visit and document them at least once every calendar year. This includes conditions that are stable and asymptomatic. Conditions not addressed or documented for an entire year will be assumed to have been resolved and will not factor into the patient’s overall perceived risk.

Documentation and coding bridge clinical care and financial sustainability in the dynamic healthcare landscape. By prioritizing accuracy, providers and payers can achieve better outcomes, enhance patient care, and thrive in value-based payment models.

Remember: Every code tells a story—make sure it’s complete and accurate.

Disclaimer: This blog post provides general information and should not be considered professional advice. Always consult with experts in the field for specific guidance.

Martha Tokos MHI, CPC, CRC, CDIP, CCDS‑O
EVP, Clinical Documentation Integrity