• Ten coding tips for capturing patient risk and ensuring proper payment

    Correctly coding to capture patient risk is one key to succeeding in value-based payment programs, which frequently quantify risk through hierarchical condition categories (HCCs). Remembering these 10 tips can help ensure you’re getting proper credit for managing high-risk patients and keeping them as healthy as possible:

    1. Report diagnosis codes for active diagnoses each year: HCC codes reset annually, which means that each patient’s active diagnoses must be reported every year, regardless of how long the patient has had the condition, to be counted toward the patient’s overall risk. Annual wellness visits are a good time to do this.

    2. Be specific: Most unspecified diagnosis codes don’t risk adjust (e.g., ICD-10 code E11 for type 2 diabetes), so use the most specific code possible for each diagnosis (e.g., E11.22 for type 2 diabetes with diabetic chronic kidney disease).

    3. Address chronic conditions at least annually: Many chronic conditions are also HCCs, so try to address each chronic condition at least once a year and report that diagnosis code.

    4. Avoid symptom codes when possible: Symptom codes do not result in risk adjustments. If a specific diagnosis code can be used instead, do that.

    5. Report secondary diagnoses: Physicians often address conditions that risk adjust, even if they’re not the primary reason for the visit. Don't forget to code for the risk-adjusted secondary diagnosis if you addressed it or if it played a role in managing the other condition that prompted the visit.

    6. Code the complications as well as the condition: Complications of conditions such as diabetes usually increase patient risk scores, so be sure to code for the complications as well as the underlying condition.

    7. Address problems during Medicare wellness visits: A diagnosis code that risk adjusts can be used for a Medicare wellness visit if the condition is addressed during the visit (but it should not be the primary diagnosis for the visit).

    8. Avoid undocumented codes: Provide documentation for diagnoses. If a patient has a diagnosis that you are not documenting, it not only affects reimbursement in value-based care but also can affect patient outcomes.

    9. Use diagnosis code specificity tools: If your EHR has a diagnosis code calculator, make sure you use it to help you code to the highest level of specificity supported by documentation.

    10. Don’t use “history of” codes for active conditions: If a patient's condition is currently being treated, do not use “history of” codes for that condition. This includes chronic conditions such as diabetes and heart failure, along with cancers.

    Read the full FPM article: “How to Correctly Capture Patient Risk for Value-Based Care Programs.”

    Posted on Jul 22, 2021 by FPM Editors

    Disclaimer: The opinions and views expressed here are those of the authors and do not necessarily represent or reflect the opinions and views of the American Academy of Family Physicians. This blog is not intended to provide medical, financial, or legal advice. All comments are moderated and will be removed if they violate our Terms of Use.