We used existing guidelines and best practices of diagnosis coding to
develop a dedicated Medicare Risk Adjustment webpage to assist our
providers in accurately coding and documenting diagnoses for our Medicare
Advantage members.
Risk adjustment
Risk adjustment is a process of collecting all diagnosis codes from patient
charts and using the documented illnesses, comorbidities, and complications to
determine a risk score. Risk scores are used to illustrate a need for higher
reimbursement rates for patients who have more serious health conditions to
manage.
Clinical documentation improvement
Clinical documentation improvement is a process used to improve
documentation so that a patient’s clinical status is accurately
represented in coded data.
Resources
For your reference, we have created a repository of top medical diagnoses
and documentation challenges:
Learn more
If you have questions after reviewing these resources, please email RADVsupport@ibx.com and put "CDI and coding guidelines" in
the subject line.
Independence Blue Cross coding and documentation
education materials are based on current guidelines, are to be used for
reference only, and are not intended to replace the authoritative guidance of
the ICD-10-CM Official Guidelines for Coding and Reporting as approved by the
American Hospital Association (AHA), the American Health Information Management
Association (AHIMA), Centers for Medicare & Medicaid Services (CMS), and
the National Center for Health Statistics (NCHS). Clinical and coding decisions
are to be made based on the following:
1. The independent judgment of the treating physician or qualified health care
practitioner.
2. The best interests of the patient.
3. The clinical documentation as contained in the medical record.