Best Practices for Optimizing Patient Risk Adjustment Scores

Prospective provider education & training on RA methodologies and strategies is critical.

It is imperative that healthcare providers quickly learn to navigate the new order of Risk Adjustment payment methodologies to insure optimal reimbursement for their services. Optimizing Risk Adjustment Scores is vitally important for providers to thrive and excel under Value-Based performance reimbursement and Alterative Payment Methods for delivering healthcare services for at-risk populations.

To have a better understanding of where you currently stand with the HCC scores of your patients and your current coding practices, you need to review your QRUR report. The average patient has a Risk-Adjustment Score of 1.00. The healthiest patient is < 0.50 and the theoretically sickest patient is about 6.85. Do your scores accurately reflect the health of your patient population? Your spending budget for each patient is based on their HCC score. Keep in mind that your potential shared savings is also calculated by this score. Documentation and code selection to the highest appropriate specificity is crucial to capturing accurate HCC scoring.

It is vitally important to code all documented conditions that co-exist at the time of the patient’s face-to-face visit that effect, or may affect in the future, the patient’s acute/chronic care, acute/chronic treatment or acute/chronic management, e.g. Diabetes with ‘diabetic’ CKD, morbid obesity, drug or alcohol dependency.

Utilize concurrent, point-of-care, quick reference tools to recognize Risk Adjustment Factors.

EHRs are created by software engineers that are not clinically trained nor have a solid concept of clinical office flow or a provider’s medical decision making. EHRs add additional scrolling and clicking for risk adjustment queries; this is abrasive and time-consuming for clinicians.

Customized hard copy, quick reference tools are more efficient and transparent. Utilize quick reference tools created by clinicians to streamline your workflow and avoid unnecessary searching to optimize Risk Adjusting diagnosis selection. These tools serve as a quick easy reminder for risk adjusting factors, codes and scores. Having this constant reminder in the exam room will minimize the risk of missed HCC-RAF capture opportunities. Equip each exam room with quick reference tools for easy access. Time in the exam room should be spent with the patient, not the computer.

Retrospective audits and analytics to identify opportunities for Clinical Documentation Improvement.

Once you have robustly implemented HCC-RAF coding into your practice, do a retrospective audit. Documentation within the medical record should be noticeably improved. There will be an increase in the high level of specificity codes and a significant decrease in unspecified codes on your dx code reports.

Review your patient roster to identify patient populations that would be considered high risk patients or those that appear on your unspecified dx code report. Get these patients scheduled for an appointment so you can capture the appropriate HCC-RAF scores. The optimal opportunity is the Annual Wellness Visit. Not only will you capture updated diagnosis coding and clean up their problem list, you will also gather much of your quality measure and HEDIS requirements as well.

There will be many benefits to you practice, accurate HCC scores for your sicker patients, increased shared savings for your practice, better patient outcomes and utilization of resources resulting from improved documentation and diagnosis code selection.

Successful Health & Wellness Solutions, LLC has extensively researched the current CMS-HCC grouper model, version 22, to analyze which Risk-Adjustment Factors based on prevalence and weighting, that have the greatest potential impact for a primary care physician’s RAF weights. A quick reference guide for the most common, High-Value Risk-Adjustment Factors (by HCC, RAF score, ICD-10-CM codes and description of chronic condition) is included in the Successful Health & Wellness Solution’s Physician and Nurse manuals. Also, we have designed an ‘Annual Assessment Screen for Chronic Conditions Checklist’. We strongly encourage you and your clinical office staff to screen, capture, document and code High-Value, RAF-Chronic Conditions that will certainly impact your reimbursement going forward.

Successful Health & Wellness Solutions can provide the following products:

  • RAF Quick Reference Guide for the 95% (2 SDs) of RAF weights impacting primary care (family practice and internal medicine) based on disease prevalence and RAF score weight.
  • An indexed, High-Value Chronic Conditions highlighted for primary care, Master CMS-HCC manual containing about 9,000 conditions by HCC, RAF score, ICD-10-CM and condition description.