Risk adjustment diagnosis codes are reported based on the medical conditions discussed during face-to-face encounters or hospital stays, when applicable, and should be addressed at least once a year. The Centers for Medicare & Medicaid Services (CMS) conducts risk adjustment data validation (RADV) to ensure documentation supports code submissions on claims to Health Alliance. Use these documentation tips to help support submitted codes.
Code current, ongoing, active and chronic conditions when documentation supports that:
- Condition is stable, unstable, or worsening
- Member is to continue current treatment plan
- Treatment plan is adjusted
- Member will be referred to a specialist
Example: Chronic atrial fibrillation, stable, no current episodes. Continue Xarelto 20mg and Metoprolol 50 mg daily.
Do not code unconfirmed conditions that are suspected, probable, or ruled out.
Example: I suspect rheumatoid arthritis. Labs ordered to check rheumatoid factor, refer to Rheumatology; follow up in one month.
Link etiology/manifestations and underlying conditions by specifying cause and effect relationship.
Example: Type 2 diabetes with associated CKD stage 3, stable, no change in meds.
- Code even those conditions being treated by another professional if you had to consider it as a component of your medical decision making.
Example: Patient with significant history of CHF, Type 2 DM & HTN here for swelling of the left foot. Assessment and Plan: Cellulitis of the left foot, start IV antibiotics immediately following in infusion room. CHF, Type 2 DM and HTN all stable on current meds with no changes. Follow up as needed.
International Classification of Disease, Tenth Revision, Clinical Modification (ICD-10-CM)
If you have any questions, email CodingCounts@healthalliance.org.