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Problem Lists Pose a Problem for Risk Adjustment Reporting... The Solution: Include Pertinent Problems in the Assessment and Treatment Plan

Date: 03/18/25

Risk adjustment is a tool used to predict the likely use and cost of healthcare based on an individual’s healthcare needs, which are contingent on risk factors such as age, gender, community status, and severity of health conditions.

Health plans are required to report the health status of each beneficiary to the Centers for Medicare and Medicaid Services (CMS) for risk adjustment purposes. Reporting accuracy can only be achieved through complete and detailed documentation and diagnosis coding accuracy from the provider.

While a properly maintained problem list can help a provider quickly identify conditions that may impact the current episode of care, a list of diagnoses or problems documented within a patient’s medical record cannot stand alone and may lead to missed reporting opportunities.

Reporting issues can be minimized when support of ongoing chronic condition diagnoses from the problem list is documented in another section of the medical record. Include evidence of current review in the assessment and treatment plan.

Providers can help ensure that resources are available to meet patients’ future healthcare needs by following risk adjustment documentation and coding best practices.

  • All conditions that require treatment or affect patient care should be documented in the assessment with the current treatment plan and a summary of any counseling provided.
    • The condition diagnosis must be specifically stated with evidence the condition was Monitored, Evaluated, Assessed, and/or Treated (MEAT).
    • Use adjectives such as “stable, “controlled, or “improving” to describe the condition status at the time of the encounter.
    • Link current medication to the condition it is used to treat.
  • Assess and report chronic conditions at least once per year, every year, for as long as the condition exists.
    • Review the problem list at each visit and update as needed.
    • Report status codes when appropriate (e.g., amputation, ostomy, presence of artificial organ, etc.)
    • Do not report an active diagnosis for conditions that have resolved and are no longer present.
  • The rendering provider’s authenticated signature with credentials and date signed must be present on the encounter record.
  • Include the appropriate ICD-10 diagnosis code(s) on the claim for the encounter.

To request additional risk adjustment coding insight or you have any questions regarding risk adjustment, please email the Risk Adjustment team at RiskAdjustment@ARHealthWellness.com.