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Medicare Risk Adjustment
Our goal is to share a few points about your vital role,
as a provider, in recording your Medicare patient’s conditions and diseases.
This will not only strengthen the Medicare Advantage program but also assist
in the continuation of care and chronic disease management of members.
Diagnosis Coding is
Critical show/hide
- 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.
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How Does Medicare Risk
Adjustment Impact Providers? show/hide
- Increased accuracy of coding helps MHP identify your
patients who may benefit from disease management and other
medical support programs.
- More accurate medical status information can be used
to match health care needs with appropriate level of care.
- CMS outlines the responsibilities of physicians and
other health care providers to include:
- Reporting ICD-9-CM diagnostic codes, including secondary
diagnoses, to the highest level of specificity
- Maintaining accurate and complete medical record
documentation (ICD-9-CM codes submitted must be justified
with proper documentation)
- Reporting claims and encounter data in a timely
manner
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Conduct a Comprehensive
Medical Exam Early Each Calendar Year show/hide
- MHP encourages a comprehensive medical evaluation to
be performed every calendar year.
- This is the opportunity to record ALL known health conditions
for the patient.
- MHP’s Medicare patients should be contacted to arrange
an exam to revalidate ALL medical conditions.
- Arranging an appointment with the patient early each
calendar year will support CMS’ revalidation requirements.
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Tips for Improving Coding
Accuracy show/hide
- Evaluate whether ALL diagnosis codes for the encounter
are included in the claim transaction to MHP.
- If your billing system limits you to only 4 codes, consider
updating your system.
- MHP and CMS require complete diagnosis coding to appropriately
reflect a patient’s complete medical history.
- If you have not done so already, consider installing
an electronic medical records (EMR) system.
- Talk to CMS about medical coding training or check Web
sources for medical coding assistance.
- Medical records should be made available to MHP’s Risk
Adjustment Department for periodic review.
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What is Medicare Risk
Adjustment? show/hide
- 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.
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MHP depends on the proper submission of encounters and
claim transactions from providers to improve the accuracy of those submissions.
If we can assist you in this effort, please let us know.
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Resources
90 Most Common Diagnoses
Diabetic Coding Tips
Cardiovascular Coding Tips
ICD9 Codes with HCC Category
PCP Designation Form
CMS Guide
CMS Medicare Risk Adjustment
Contact MHP
For additional information call
314-214-8405 or
Email us.
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