Medicare Risk Adjustment – A Brief Input

By Author: mohd Ishtiak
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Medicare Risk Adjustment is a term used to describe about the payment method authorized by Balanced Budget Act of 1997 & utilized by the Centers for Medicare & Medicaid Services (CMS) to make improvements in payment accuracy to Medicare Advantage Organizations. However, to make such methodology be effectively possible, the ICD-9 coding plays the big part of the process. ICD-9 coding determines the degree of severity of patient’s health condition through its numerical indexing of illness diagnosis, hospital procedures and other pertinent clinical data. From such system, Medicare risk adjustment can analyze and provide the appropriate allowable funds that is to be reimbursed to physicians and amount that can be covered during hospitalization.
Medicare Risk Adjustment – Trouble Issues

Medicare Risk Adjustment can cause a problem to CMS (Centers for Medicare and Medicaid Services) when the following errors are made during the data entry of patients are made:

• Less Diagnosis Codes – one or two diagnoses are entered in each encounter where it can have more than 5 usually
• Less Specification ...
... – the patient’s diagnosis is too general where it can still have specifics on the grading of disease condition, thus altering the amount of covered reimbursements
• Past Codes Only – clinical record codes of an individual must not only include the historical data but as well the present and related information
• Poor Submission – the provider doesn’t have a consistent data submission
• In addition, coding should be parallel to the patient’s real health status

Info on Hospital’s ICD-9 Coding

ICD-9 Coding or the International Classification of Diseases is a classification that codes and categories mortality documentations from death certificates starting from the years 1979 to 1998. It contains all human ailments, disease conditions and circumstances that cause death. The system has slight annual revisions on the classification but major updates are published every decade. From such, hospitals need to be up to date on its ICD system so as to comply with the dynamic standards.

Tips on Getting Proper ICD-9 Coding

Health care staffs are the ones that have the dominion over patient’s clinical files. From such, to avoid future complaints and future difficulties, a thorough data recording can assist the patient and the hospital in getting the exact coverage from insurances. The following tips are helpful to both patient and health care unit and as well favorable to the Centers for Medicare and Medicaid Services (CMS) :

• Full assessment on chronic health conditions annually
• Detailed documentation on all assessed illness per patient visit
• Complete, Proper and Legible Chart Documentation
• Code up to the highest specificity and document
• Complete utilization of the coding system
• Ensure documentation of physician’s signatories on clinical records

Clinical Documentation Improvement with MS-DRG

Hospitals that still don’t have any back-up system that can monitor daily transactions are more unaware of the revenues that should be filling in the savings and profits of the institution. One of the proposed programs that have been running already on other health care system is the MS-DRG. The system gives a big difference from the manual coding mechanics, rating and indexing of reimbursements. Also, it assists and furnishes documents on code alignment when on investigation under compliance audit and other regulatory requirements.

A good example of MS-DRG efficiency is the case of heart failure and shock. Basing from the old MS-DRG, the two conditions are coded as one with a payment rate of $5,113.34. However, in the new DRG system, heart failure and shock are now categorized into 3; MS-DRG 291: heart failure with major complications, DRG 292: heart failure with moderate complications and DRG 293: Heart failure no complications. The three subsections have varying price values which are as follows respectively, $6,246.74 for MS-DRG 291 up to $4,350.63 for DRG 293. In this situation, the program can easily place the proper grading and minimize the flipping of a hundreds of code pages just to find the corresponding disease or procedure numeric code.

Clinical Documentation Improvement – Decision Making

When submitting to a specific CDI, hospital head officials must be in charged in the decision making for installation of the program and all personnel including physicians must support the program system by putting more details on the procedures performed, managements, diagnostics and final diagnosis so as to form an exact alignment on the proposed system for coding. In the beginning, it may seem difficult but as everyone gets familiar on the program, every transaction will be done in a smooth and fast manner.