Risk Adjustment Documentation & Coding, 2nd Edition

Risk-adjustment practices consider chronic diseases as predictors of future health care needs and expenses. Correct and detailed documentation and compliant diagnosis coding are critical for proper risk adjustment. The guidance provided comes directly from 2020 ICD-10-CM conventions and guidelines, the American Hospital Association’s Coding Clinic for ICD-10-CM and ICD-10-PCS, and from the Centers for Medicare & Medicaid Services or other federal sources current through October 1, 2019. This guidance is long-standing, and applies to everyone, not just risk-adjustment coders.

Features and Benefits

• Five chapters delivering an overview of risk adjustment, common administrative errors, best practices, and guidance for development of internal risk-adjustment coding policies.
• Two appendices offering mappings and tabular information of ICD-10-CM codes that risk-adjust to HCCs and RxHCCs.
• Advice/Alert Note highlights important information, exceptions to the rules, salient advice related to codes and diagnosis, such as federal guidance for coding and documentation from the 2020 ICD-10-CM Official Guidelines for Coding and Reporting, Federal Register, 2008 CMS Risk Adjustment Data Validation Participant Guide, or other federal regulatory guidance sources.
• Chapter Opener presents a general introduction and overview of the subject that may also cover some of the basic concepts and terminology necessary for understanding the topic. In most cases, the educational goals for the chapter are presented as well.
• Clinical Coding Examples illustrates a coding concept using a brief coding scenario or full reproduction of the documentation related to a medical encounter, with coded results directly presented in the chapter.
• Clinical Examples demonstrates a clinical documentation concept using excerpts from a real medical record, with discussion of the critical deficits in content.
• Coding Tip provides practical advice, recommendations, and/or helpful information and reporting instructions about codes associated with a specific diagnosis, such as advice from the American Hospital Association’s Coding Clinic for ICD-10-CM and ICD-10-PCS.
• Definitions of important and difficult terms are provided throughout the text at the bottom of the page in which the term appears, in order to negate the need for additional resources to learn the meaning of diagnostic, regulatory, or medical reimbursement terminology.
• Documentation Tip provides explanation of how ICD-10-CM classifies commonly documented phrases, as well as instructions on specificity requirements in coding, so that physicians can ensure the codes abstracted from their medical notes accurately reflect their patients’ condition.
• Example provides samples to further demonstrate or highlight content and concepts covered in the chapter.
• FYI provides additional information that may help readers to better understand or provide additional background information regarding a topic or content such as documentation or coding issues, either by providing an illustration of a concept or by further defining terminology, diagnostic scoring systems, or code lists.
• Sidebar provides derivative story related to the main concepts covered in a section(s) of a chapter