Payment systems and reimbursement are ever-changing in healthcare and the rules of yesterday may or may not work tomorrow. Medical practices continue to hear about the switch from volume to value, and health systems and large groups have contracts in which they share risk with a payer or ACO.  The purpose of learning about this is to communicate to the payer, “just how sick the patient is,” as one physician said to me.

It is critical for clinicians and administrators to understand risk adjusted diagnosis coding, when entering into shared saving contracts. Too often, the explanations are aimed at payers and not practices.

This guide is an introduction to risk adjusted diagnosis coding. After reading this guide, clinicians will be able to focus on the specificity in diagnosis coding that not only gets a claim paid, but also communicates to payers the acuity of their patient population. Using this guide, clinicians can communicate not only how sick the patient is, but the disease burden of their entire population of patients.

This guide is essential for all practices that are part of an ACO or that have risk-based contracts.

Table of Contents

• Purpose
• Fee-for-service
• What is risk adjustment
• Coding and reporting guidelines
• Assessment versus past medical history
• HCCs
• Transition of V24 to V28
• Social determinants of health
• Compliance issues
• Status Codes
• Reference

Essential resources 

• CMS RADV Medical Record Reviewer Guidance
• CMS 2013 Risk Adjustment 101 Participant Guide
• CMS 2008 RADVI Participant Guide

Additional resources

• HCC Diagnosis Coding page