Risk Adjustment gives physicians a safety net

The physician’s time is split between desktop medicine (administration) and face-to-face medicine. More than two-thirds of desktop medicine is dedicated to clinical documentation.  

“I would wager that physicians got into the practice of medicine to spend more time with patients and less time with charts,” said Ren Mullinix, SWHR’s Risk Adjustment Vice President. “The Risk Adjustment team works to make clinical documentation easier and more understandable. The more we can have advancements and integrations in our support technologies, the more we can simplify desktop medicine so the physician can spend more time with their patients.”  

Mullinix said it’s “unfair and unrealistic” to think physicians can keep up with all the clinical documentation and compliance guidelines in the evolving value-based care landscape. The SWHR Risk Adjustment team helps create a safety net to protect physicians from errors in the clinical documentation process with coders that review patient charts. The team audits all Medicare and Medicare Advantage documents to ensure a 95% accuracy score or better, which is a national best practice.  

 

The coders use national clinical coding guidelines when reviewing charts to make sure diagnosis codes that make it onto a claim or encounter meet MEAT criteria – evidence that the disease is Monitored, Evaluated, Assessed or Treated. If it meets the MEAT criteria, then it’s a supported diagnosis code. If it doesn’t, that’s an opportunity for the Risk Adjustment team to provide feedback to physicians to drive more accurate and specific clinical documentation. 

Accurate and specific clinical documentation ensures that physicians and SWHR have an appropriate accounting of all the clinical risks associated with a patient’s disease burden. In turn, this helps SWHR predict healthcare utilization and drive better care. However, every year on Jan. 1, known patient chronic conditions are resolved from the perspective of the Centers for Medicare & Medicaid Services (CMS). If a patient has chronically diseased arteries on Dec. 31, on Jan. 1, the plaque and fatty material on their inner artery walls has cleared up. To ensure SWHR is capturing the complete clinical and financial risk associated for treating chronic conditions, the total complexity of the patient base has to be redocumented each year.  

If conditions aren’t captured correctly in the physician’s notes, then the condition doesn’t exist for CMS. That’s why it’s key to educate physician partners and to give them the tools to be successful. Risk Adjustment looks at physicians’ records from the last two years to see where they had coding opportunities and where there were coding successes.  

A common opportunity for improvement is to be more specific with a diagnosis when coding. For example, when a physician documents that a patient has chronic obstructive pulmonary disease (COPD), that’s more specific than simply stating asthma.  

“Accurate, specific diagnoses are the bedrock of everything we do,” Mullinix said. “If we don’t document the disease burden of patients, we wouldn’t know which patients are at risk for falls, a stroke or heart attack, and physicians wouldn’t be able to conduct the requisite interventions and longitudinal care.”  

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