# Risk Adjustment Documentation



## em2177 (Nov 4, 2008)

Can anyone tell me if it is proper to conduct chart audits in SNF facilities for the purpose of Risk Adjustment. I have a couple of PCP's that visit patients at SNF facilities but I am not sure if it will be proper to audit those charts.  
Thanks,
Elizabeth M. CPC


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## pmital (Nov 25, 2008)

I believe SNF facility documentation is unacceptable for risk adjustment coding, but documentation by physicans of patient visits there is an exception.


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## jeyasri_sundar@yahoo.com (Sep 15, 2022)

I am new coder, like to know basics documentation requirement for risk adjustment codes. (any links or documentation will be helpful)


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## TThivierge (Dec 3, 2022)

Hi Jeyasri
I read the book _Risk Adjustment Documentation and Codin_g by Sheri Poe Bernard by AMA .Excellent resource and also reading the the_ Healthcare Business_ journal has good articles. But things I know about risk adjustment coding is when the provider gives you clear detailed dx codes ensure use the dx matches because amost dx have risk adjustmnt codes linked with  DRG codes for inpatient reimbursements. Also if pt has particular  medical problems ensure add on end of claim proper supported Z dx codes listed since in medical documentation.Add this in med record  Smoking current or past HO dx Z87 or F17 or Z72  especially if pt. has heart or respiratory conditions. DRg for these disease are such as:  Quadriplegias G82or G81,  Long term drug use block Z79 for DM , Cancer, or Cardiac patients and Residual Weakness one side of body after stroke dx I69 and Amputations block Z89 , Cardiac Pacemakers Z95, HIV B20, Kidney Dialysis and BMI dx Z68 and E66 together on same claim from notes in record.  Be familiar with the Chronic  Conditions  listed in medical documentation of the pt. They are DM, COPD, Depression,RA Arthritis, MS, Parkinson Ds., CHF, Hemipholia  D66 and Atrial Fibril. Some ds that do not risk adjust are Anemia, Glasglow Coma Scales, IBS, R symptoms dx codes used for heart attack , BMI less than 30% do not risk adjust, and Mental Retardation and dx R06.03

Here are some elderly patient illness tracked by CMS and Medicare.... HLD, CKD, Hypothyrodism,DJD or Osteoarth, HTN, DM, COPD, Depression, Heart Ds.
Also if someone has Forever Ds add it on the claim too if in documentation

Errors to watch on medical record are missing signatures and credentials, correct dates of service, wrong data, be aware of cloning notes, miss list of dx assessments, describe treatment given, labs or xray orders and reason or medical necessity, evidence of MEAT or SOAP guide used in documentation, do not code illness no longer have unless it is history code in which provider should date when pt last had it. Provider not create own medical abbreviations but follow standards set, medical coders should follow sequencing rules with  Dx and CPT codes, understand Excludes 1 Rules and integral coding.    Unspec. dx can be used for inpatient admissions whereas Unspecfic dx  should not be used for outpatient settings. However sometimes unsec dx are used in outpatient settings because cannot be helped. The providers clear documentation will help you assign proper dx. codes which is the key to Risk Adjustment.
Oh yes another thing to remember the dx combination codes such as: UTI dx N39.0 add infection code B95-B97, DM E11 with manifestation codes of nerve damage or eye problems,, Cardiac Arrest I46 differ types give the reason, CHF I50 and HTN I11.9 code together if listed, BMI% and Z68 with matching percentage, CHKD and Anemia,  Osteomyelitis dx M86 with dx infection of dx B95-B97. 
Well I hope I helped you understand the Risk Adjustment  coding a bit more.
Lady T


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## TThivierge (Dec 3, 2022)

Hi Jeyarsi,
Here are some of the *Lifetime Long Patient Conditions list or Forever Diseas*e I have seen over the years can be diseases patient cannot get rid of because there is no cure or a traumatic illness in which changes patients lives forever. The Forever Ds list contains......Alcoholism , Substance Abuses, AIDs, HIV, Amputations, Paralysis, CP =Cerebral Palsy, Dementia & Alzheimer's Ds, Autism, MS, Major Depression, Mental Retardation or Intellec. Challenged, Transplants of Organs, Migraines, Herpes sex ds, SCI or TBI=Traumatic Brain Injury, Asthma, Muscular Dystrophy, Sickle Cell, Lupus, ESRD, Parkinson Ds. or Huntings Ds.

Let me add Cancer Ds. are considered cured if not returned after 5 years. I was shocked to see Alcoholism, Depression, and Substance Abuse on Forever List but it seems these patients always battle these diseases. Hey do you know the organs can live without? Pancreas, one kidney, limbs, eyes, genitals appendix, and one lung, eyeballs, ears, part of intestines.
Anyway just trying to help and I hope I did  
Lady T


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