Wiki risk adjustment records review

[kshama1920]

Hi,
We got request to review our pediatric charts from amerigroup. It is to capture proper ICD 9 coding. They are doing review for state medicaid program for risk adjustment compliance. Does anybody have an idea what to expect and why this audit? Please reply if you have any experience with this.

 

[martinni1974]

When a commercial payer administers a medicare or medicaid plan on behalf of CMS the plan is funded through reimbursement of HCC codes which the plan bills to CMS. HCC codes are selected by severity and specificity of chronic conditions as well as acute conditions. An HCC is selected very similiar to the way a DRG is selected. The model is based on a collective asessment of risk and severity of the patients conditions. Documentation is key for the payer to arrive at an overall annual HCC to report up to CMS. Providers bill CPT or DRG to the payer and the payer bills CMS an HCC.

An audit for this purpose is to capture the highest severity of conditions your provider documented in the progress note. Coders that work for the payer will abstract this info and assign the pertinent HCC. Overall your provider will have a risk score based on their documentation. The higher the risk score the more they are reimbursed (the sicker a patient is the more CMS will pay the plan to manage the member) documentation specificity such as manifestations of chronic conditions and well documented personal and family history drive up the risk score.

Other elements are captured as well such as HEDIS and STARS metrics which reflect quality of care. Preventive services such as immunizations and routine screenings are also tracked.

 

[kshama1920]

Thanks!

Your reply and information is very helpful, I wondered why this review. Thanks for taking time to reply.
Have a nice day!