Medicare Risk Adjustment is the payment methodology mandated by the Balanced Budget Act of 1997 and used by the Centers for Medicare & Medicaid Services (CMS) to improve payment accuracy to Medicare Advantage organizations such as MHP;
CMS determines the risk for each member based on the ICD-9 diagnostic codes from a provider’s medical record;
Payments to MHP are adjusted (i.e. Risk Adjustment) and designed to more accurately cover a given member’s anticipated medical expenditures based on the health status of beneficiaries;
Diagnosis information is collected from provider-submitted encounter data sent to MHP in claim transactions;
Encounter data with all diagnosis codes are submitted by MHP to CMS, i.e. unlimited number of codes; and
MHP’s Medicare patients should be contacted to arrange an appointment early each calendar year for a comprehensive medical examination to resubstantiate all medical conditions and to support CMS’ validation requirements. This is the opportunity to record all known health conditions for the patient. MHP depends on the proper submission of encounters and claim transactions.
CMS relies on complete and accurate ICD-9-CM diagnostic codes, not the actual CPT codes;
All codes should be submitted at the highest level of specificity and include all appropriate secondary codes;
Claim submissions must be backed up by accurately maintained and documented medical records;
Medical records are subject to CMS validation and review at any time;
CMS requires a patient’s diagnosis codes to be re-substantiated every year; all codes are wiped out at the end of each year, even for chronic health conditions;
Increased accuracy of coding helps MHP identify your patients who may benefit from disease management and other medical support programs;
The claim transaction to MHP should be evaluated to determine whether ALL diagnosis codes are included for the encounter;
Providers should refer to their billing system to determine whether they limit the claim to reflect only four codes when the record contains more than four diagnoses;
MHP and CMS require complete diagnosis coding to appropriately reflect a patient’s complete medical history;
Medical records should be made available to MHP’s Risk Adjustment Department for periodic review;
CMS and other web sources provide additional medical coding assistance;
Electronic medical records (EMR) systems assist incoding accuracy of claims; and
More accurate medical status information can be used to match healthcare needs with appropriate level of care.
Accurately report ICD-9-CM diagnostic codes, including secondary diagnoses, to the highest level of specificity;
Maintain accurate and complete medical record documentation (ICD-9-CM codes submitted must be justified with proper documentation); and
Report claims and encounter data in a timely manner, generally within 30 days of the date of service or discharge from a hospital’s inpatient facilities.
Several resources are available for additional information regarding CMS Medicare Risk Adjustment. Contact your MHP Provider Relations Field Representative; visit provider.mercyhealthplans.com; visit CMS at http://www.csscoperations.com/new/usergroup/2008raps/2008-raps-participant-colorslides.pdf; contact MHP at 314-214-8405 or email MHP at mhpmedicarerisk@mercy.net.