Risk Adjustment

The process of Risk Adjustment relies on providers to perform accurate medical record documentation and coding practices to capture the complete health status of each individual patient annually. Diagnoses do not carry forward to the following year and must be assessed and reported every year.

The risk adjustment data you give us, including clinical documentation and diagnosis codes, must be accurate and complete. Below is a checklist for your use when documenting. We also offer Coding Tips for various specific conditions.

Checklist

  • Medical records must support all conditions coded on the claims or encounters you submit using clear, complete and specific language.
  • Code all conditions that co-exist at the time of the member visit and require or affect member care, treatment or management.
  • Never use a diagnosis code for a “probable” or “questionable” diagnosis. Code only to the highest degree of certainty for the encounter/visit. Include information such as symptoms, signs, abnormal test results and or other reasons for the visit.
  • Specify if conditions are chronic or acute in the medical record and in coding. Only choose diagnosis code(s) that fully describe the member’s condition and pertinent history at the time of the visit. Do not code conditions that no longer exist.
  • Always carry the diagnosis code all the way through to the correct digit for specificity. A code is invalid if it has not been coded to the full number of characters required for that code, including the 7th character, where applicable. (Where place holders exist, X must be used for the code to be valid.)
  • Check the diagnosis code against the member’s gender.
  • Sign chart entries with credentials.
  • All claims and/or encounters submitted to us for risk adjustment consideration are subject to federal and/or MediGold internal audit. Audits may come from CMS,or we may select certain medical records to review to determine if the documentation and coding are complete and accurate. Please provide any requested medical records, including all available medical documentation for the services rendered to the member, in a timely manner.

Coding Tips

Proper Documentation and Coding

Angina Documentation and Coding

Documentation for Major Depression (MDD)

Updated 03/2018