Medical practices can get paid more for Medical Advantage claims by accurately reporting patient risk—but the main way insurers evaluate risk is through your diagnosis codes. And if your practice isn’t performing ICD-10-CM self-audits, you could be underrepresenting your risk and shorting your practice significant income without even knowing it.
Background: Risk adjustment is a modern payment model, which uses both demographics and diagnoses to determine a risk score. That risk score subsequently predicts how costly the individual care will be for the coming year. All risk adjustment models use ICD-10-CM codes to evaluate the potential patient-level risks. In other words, your income under risk adjustment models is based almost exclusively on your ICD-10-CM coding.
Your best bet to ensure that you’re collecting maximum reimbursement under risk adjustment plans is to review your ICD-10-CM codes in great detail, and the best way to do that is by performing a diagnosis coding self-audit.
Take these steps to ensure that you’re properly self-auditing your ICD-10-CM codes to maximize your risk adjustment payments.
Grasp What a Self-Audit Means
Many medical practices are familiar with self-auditing their procedure codes (CPT and HCPCS codes), but not as many offices review their diagnosis codes. When you perform a self-audit, you’ll pull a sample of charts from each provider in your practice and confirm that all of the codes are reported accurately and to the highest level of specificity.
You can either perform a prospective or retrospective audit. During prospective audits, you’ll pull the charts before actually submitting your claims, allowing you to catch issues prior to claims processing. If you perform a retrospective audit, you’re reviewing the claims and the remittance advice to see what you billed, what was paid, and if you coded the claims accurately. There are pluses and minuses to each method, and it’s up to your practice to determine which will work best for you.
Pinpoint What You’re Looking for
It’s one thing to review charts and compare the codes against the diagnoses referenced in the medical notes, but it’s another to confirm that the diagnosis codes are specific enough for risk adjustment payment models. Check these pointers to evaluate your documentation for specificity:
- Using general ICD-10-CM codes will not allow you to collect under risk adjustment models. For instance, if a patient has diabetes, you can’t simply select a random diabetes code on a claim, because the message it sends the insurer is that the patient has stable diabetes, putting them at low risk. Instead, you’ll report the most specific code from the E08-E13 code series, pinpointing whether it’s type 1, type 2, or other. You should also note any complications or manifestations affecting a body system, along with underlying conditions like malnutrition (E40-E46) or Cushing’s Syndrome (E24.-).
. - Report additional codes to reflect any cause and effect relationships. When you’re performing your self-audit, look for additional codes that show the payer the risks that come from the patient’s condition. Using the diabetes example above, you can add additional codes to show the risks the patient faces from diabetes, such as gastroparesis secondary to diabetes, macular edema, or retinopathy. Drill down another level after that to identify the site of any diabetic ulcers (L97.1-L97.9) or the stage of related chronic kidney disease (N18.1-N18.6).
. - Don’t forget Z codes. The ICD-10-CM Z codes tell insurers more about why you saw a patient, and provide extra details that show further risk. In the case of diabetes, you might add Z79.4 to reflect long-term insulin use, or Z79.84 to show payers that the patient is on oral hypoglycemic drugs.
. - Avoid terms like “history of” if the condition is active. A history of certain conditions can show risk, but not as strongly as an active condition, so never report a “history of” code when the patient is actively experiencing the condition. For instance, if a patient has a history of colon cancer, you may report a code from the Z85.03 range, but if they’re actively being treated for colon cancer, you’ll instead report the appropriate code from the C18-C21 range.
. - Make sure documentation supports codes. During your self-audit, you should be confirming that the ICD-10-CM codes are specific and tell a story, but that story should be fully reflected in that documentation as well. For instance, if you are reporting an ICD-10-CM code for lung cancer that has spread to the liver, the documentation shouldn’t simply say “lung cancer.” You must ensure that your records show the full breadth of the patient’s condition.
. - Remember the commonly overlooked diagnoses. If a patient is dealing with certain conditions like kidney failure or HIV, their risk may be considered higher no matter what, and so you should always report these codes on your claims when appropriate. Commonly overlooked diagnoses include renal dialysis (Z99.2), HIV status (B20), major organ transplant (Z94.-), and obesity (E66 or Z68.4-).
Create Your Audit Schedule, Plan
Your practice should evaluate how often you’ll be auditing. Although some practices have an annual audit program, this frequency may not allow you to catch issues quickly enough to move the needle on your risk adjustment payments. By the time a year has passed, you could have lost thousands if your coding wasn’t accurate enough.
Instead, you should audit your diagnosis codes at least quarterly at first. If you discover any issues, perform a training session to let the providers know what you found and how they can improve. Then, once you see that you’re no longer finding problems during your self-audits, you can lower the frequency.
Want to know more about risk adjustment coding? Check out the 60-minute online training, Risk Adjustment Tactics to Boost Code Levels & Increase Pay. During this session, coding expert Leslie Boles, BA, CCS, CPC, CPMA, CHC, CPC-I, CRC will share everything you need to know about collecting under risk adjustment payment models. Sign up today!
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