ICD-10-CM

ICD-10-CM is the standard transaction code set for diagnostic purposes under the Health Insurance Portability and Accountability Act (HIPAA). It is used to track health care statistics/disease burden, quality outcomes, mortality statistics and billing. The proper use of ICD-10-CM codes will result in fewer claim denials, less time with payers trying to justify increased clinical resources for the patient and a higher revenue stream. Therefore, it is vital to educate yourself and your staff on appropriate coding, which should result in appropriate payment.

ICD-10 Coding Impacts

• Tracking public health conditions (complications, anatomical location)
• Improving data for epidemiological research (severity of illness, co-morbidities)
• Measuring outcomes and care provided to patients
• Making clinical decisions
• Identifying fraud and abuse
• Designing payment systems/processing claims

Risk Adjustment

Risk adjustment is a modern payment model that uses both demographics and diagnoses to determine a risk score which predicts how costly the individuals care will be for the coming year. Risk adjustment models improve reimbursement and provide a better picture about patient populations.

Diagnosis codes from patient charts and using these illnesses (along with their comorbidities and complications) determine the ICD codes, which drives risk. Diagnosis codes are a good starting point for analyzing known conditions and speculating on potential risks. The more severe or complex a diagnosis, the higher the risk value that is assigned.

Risk adjustment assists in the financial forecasting of future medical need.

HPP’s Risk Adjustment Impact

• Medicare Retrospective Chart Reviews performed by clinical coding team.
• Electronic Patient Assessment Solution Suite (ePASS) through Inovalon for selected Medicare members.
  • ePASS member eligibility information on Medicare roster panel on portal.
• Inovalon In-Home Assessments (IHAs) for both Medicare and Medicaid members
• Stellar Health’s web-based recapturing incentive program for both Medicare and Medicaid members if provider is eligible.
• Provider Education
  • One-on-one trainings
  • Provider reports
  • Webinars on coding, documentation and risk adjustment

Resources

• HPP’s ICD-10 Coding Guide booklet is intended to reduce the amount of time office personnel spend determining ICD-10 coding information. It can help ensure that your claims are processed in an accurate and timely manner. This booklet was updated in April 2023.
• CMS and Coding guidelines are available at www.cms.gov

Support & Help

If you have questions, please email Christina Rock, HPP’s Supervisor of Clinical Education at crock@jeffersonhealthplans.com.