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Accurate Coding and Documentation Helps Improve Quality of Care and Patient Health Status

Date: 02/20/24

Risk Adjustment is used to predict how a person will use healthcare services and the costs of those services. The goal of Risk Adjustment is to improve patient health status. Complete and accurate documentation by the provider is vital to the accuracy and effectiveness of Risk Adjustment programs. Accurate capture of
health severity ensures that resources are available to meet the care needs of patients with complex medical problems.

ICD-10 diagnosis codes are the basis for Risk Adjustment Hierarchical Condition Categories (HCCs). The diagnosis for all active conditions must be assessed and reported at least once a year, every year, as long as they exist. This includes chronic conditions, even if stable. Arkansas Health & Wellness is required to report the health status, including HCC conditions of each beneficiary, to the Centers for Medicare and Medicaid Services (CMS).

Every HCC condition reported by Arkansas Health & Wellness must be validated by provider documentation in the patient’s medical record. Coding errors and documentation deficiencies can cause a patient’s health status profile to look healthier or sicker than they really are. To ensure compliance with CMS guidelines, providers should address all conditions present at the time of an encounter with the patient that requires treatment and/or affects care and
management. Encounter documentation must include the specific diagnosis in the assessment and the ICD-10 code that matches the assessed diagnosis. This information should be included on the claim for the date of service.

Provider partners can help achieve the goal of improved quality of care and improved patient health status by participating in one or more of the following initiatives.

  • Continuity of Care (CoC) Program — Arkansas Health & Wellness’ program increases visibility into patients’ existing medical conditions for chronic condition management
  • In-Office Assessment (IOA) Program — Vendor-led program supports early detection and ongoing annual assessment of chronic conditions for patients to help improve health outcomes
  • Clinical Documentation Improvement (CDI) Program — Arkansas Health & Wellness’ review of provider coding and documentation trends for education tailored to review findings
  • Medical Record Review Projects — Vendor works with providers and Arkansas Health & Wellness to retrieve medical records and accurately report members’ health statuses in compliance with CMS regulations

Providers’ attention to active conditions during an encounter, as well as complete clinical documentation, is key to improving the quality of patient care and overall health outcomes and ensuring accuracy of Risk Adjustment reporting.

Additional information about Risk Adjustment coding and documentation is available on the Arkansas Health & Wellness website under Provider Resources. Coding training is also available and can be tailored to your facility needs. Email questions or education requests to RiskAdjustment@ARHealthWellness.com.