Why Medical Risk Adjustment Matters

Medical Risk Adjustment (MRA) is the process of modifying payments and benchmarks to predict health plan spending based on enrolled beneficiary/patient population health status.¹ MRA allows the Centers for Medicare & Medicaid Services (CMS) to estimate future spending for health plans, while allowing providers to understand the health characteristics and disease burden of their managed population.² MRA is used in several value-based care models to reward physicians for providing high-quality, effective care. Initially employed by CMS to adjust capitation payments to Medicare Advantage (MA) plans, MRA is now used to calculate expenditure benchmarks for Medicare Shared Savings Program (MSSP) Accountable Care Organizations (ACOs) as well.

This toolkit presents two distinct MRA models. Although both are similar in purpose and structure, they each have unique characteristics that address different patient populations. This toolkit references the CMS-HCC model more frequently to feature Medicare patient population best practices and highlight relative chronic conditions that “risk adjust” under the CMS-HCC model.

The two MRA models covered are:

• CMS-HCC (Hierarchical Condition Categories) risk adjustment model. MA plans and MSSP ACOs use this model to set contract rates. Generally, this model estimates higher expenditures for sicker beneficiaries and lower expenditures for healthier ones.³
• HHS (Department of Health and Human Services)-HCC risk adjustment model. Commercial health plans began using this model in 2014, influenced by the Affordable Care Act. CMS payments to contracted health plans are adjusted by patient demographics (such as age, gender, Medicaid eligibility and disabled status), diagnosis claim data, medical chart notes, and financial status. HHS-HCC characteristics also include disease interactions and diagnostic sources, and they are predictive of future medical and
  drug spending.

MRA TERMINOLOGY

Key Definitions

Medical Risk Adjustment

• Medical Risk Adjustment methodology aims to offset the cost of providing health coverage for patients who are chronically ill and represent a relatively high-risk population. Medical Risk Adjustment use patients’ demographic data (age, sex, etc.) along with diagnoses to determine risk scores.

Hierarchical Condition Categories (HCCs)

• HCCs are used to calculate risk scores. ICD-10 diagnoses are ranked and grouped into categories based on similar cost patterns. Higher-weighted HCCs represent higher predicted healthcare costs. For example, diabetes with complications is ranked higher than diabetes without complications. Patients may be included in more than one HCC grouping.

Risk Adjustment Factor

• Risk scores, also known as Risk Adjustment Factor (RAF) scores, are used to calculate a patient’s projected care and associated costs using both retrospective and prospective models in medical risk adjustment that compares chronic conditions that a patient was treated for in the previous calendar year, compared to the current calendar year.
• A patient’s specific demographic values plus HCC values equals their RAF score. The sicker the patient, the higher the score will be above a normalized or healthy RAF score of 1.0 (Example: A patient with a 3.75 score denotes chronically ill status).
• Each patient’s RAF score is erased on January 1 of the current year. This helps to ensure funding is available from the Centers for Medicare and Medicaid (CMS) and improves health plan premiums per member per month (PMPM).⁴

Risk Score

• A risk score is a prospective metric for patients that help indicate whether a particular outcome may occur. Typically, these scores are based on utilization events, which include hospital admissions and emergency department visits, and can sometimes indicate a clinical state for a patient, such as heart disease, diabetes, cancer, etc.
• A risk score is different from a medical risk adjustment factor score, which is based on algorithms used to compare patients exhibiting similar clinical patterns to help predict what outcome may occur. Risk scores are often included in reports generated from health insurance payers, electronic health records (EHRs), and through the manipulation of claims data.

• Risk scores can also allow payers and providers to define challenges and benchmarks for a given population. For example, a risk score for cardiovascular disease may include metric data such as age, diabetes status, smoking history, body mass index (BMI), etc. This data can help to develop preventive strategies and effective clinical treatment.

Prospective Review

• Value-based models, healthcare providers, ACOs and health plans must attempt to use this medical chart review process prior to patient visits to improve accuracy of documenting diagnoses at the point of care throughout the calendar year. This review process should result in significant impact on patients’ RAF scores and improved benchmark targets under risk and value-based arrangements.

Concurrent Review

• This medical chart review process has a “clean as you go” approach and allows clinical staff to review medical record documentation on an ongoing basis as patients are seen throughout the year. This process helps to streamline billing, reduce denials and decrease inaccurate claims. A patient’s RAF score is derived solely based on documentation of diagnoses and other social determinants of health elements not always listed in the medical chart.

Retrospective Review

• This medical chart review process identifies relevant encounters and patient assessments after patients have been seen in the previous calendar year. It allows missed diagnosis codes that were not submitted on claims in the previous year to be documented during the current calendar year. This process focuses on patients who have already had an encounter during the previous year and current calendar years but whose conditions have not been documented between the two periods.

Medical Risk Adjustment Models

• Medical Risk Adjustment models are developed by CMS and use HCCs to reimburse healthcare organizations differentially based on disease burden and demographics. CMS uses two models: CMS-HCC, most commonly used by original Medicare and Medicare Advantage organizations, and HHS-HCC, developed through the passage of the Affordable Care Act (ACA) and including additional categories for all patient demographics.

Medical Risk Adjustment Models

Centers for Medicare and Medicaid Hierarchical Condition Category (CMS-HCC) Model

This model was originally based on reimbursement under Medicare Part C (Medicare Advantage) and Part D (drugs). This model is prospective in nature, meaning previous claims and EHR patient data is used to predict and review patient status for diagnoses for the following year. Currently, there are more than 70,000 ICD-10 diagnostic codes, with approximately 10,000 ICD-10 codes that map to an HCC. There are 86 HCC rankings and 15 distinct diagnostic categories under the current 2020-year reporting.⁵ The revised HCC model is evolving into phases over the next few years to include an additional weighted bonus for having a higher number of chronic conditions. HCC values are determined by CMS and vary depending on disease burden (a cancer in remission vs. chronic disease status). Diagnostic data is captured by assessing claims with dates of service during the current calendar year and comparing it to previous years’ data.

Diagnoses Included:

• High-cost medical conditions such as current cancer, heart disease or hip fracture, COPD, status amputation and diabetes
• Highest weighted conditions such as HIV, sepsis, opportunistic infections or cancers.
• Acute vs. chronic status codes, etiology (cause of disease) and manifestation (signs of illness).

Diagnoses Excluded:

• Codes that do not predict future cost (appendicitis, for example).
• When symptoms necessitate a high variability in coding.
• Codes from lab, radiology, home health or other departments that may not be reliable.

Department of Health and Human Services Hierarchical Condition Category (HHS-HCC) Model

Originated in 2014, the HHS-HCC model is a concurrent model, meaning it uses diagnoses from a specific time period to predict cost in the same period. This model was developed after the passage of the Affordable Care Act (ACA) to reimburse marketplace health plans for infants, children and all-age adult patient populations. Diagnostic data is captured by assessing claims with dates of service during the current calendar year.

Side-by-side comparison of the two models

CMS-HCC	HHS-HCC
Used by CMS to pay Medicare Advantage plans for enrollees	Used by CMS to pay health insurers in ACA marketplace
Base year (current year) diagnoses determine next year’s rates	Uses current year diagnosis coding to set risk payments in current year
Developed for >65-year-olds and disabled patients of all ages	Developed for all age patients
Pediatrics and obstetrics diagnosis codes are not assigned risk values	Includes categories for infants, children and adults, and includes obstetrical diagnoses
Does not include drug costs	Includes drug costs
Model used by many software programs; integrated into EMR systems.	Model less well-known by medical practices
Rulemaking: proposal at the end of December; final rates in April	Payment to health insurers for caring for sicker patients in ACA

 

 

Coding & Documentation Best Practices

Medical Risk Adjustment

A common acronym utilized by coders to identify documentation that supports coding accuracy is M-E-A-T. You can utilize this handy tool as you complete your documentation.

Including one or more of the M-E-A-T details at a face-to-face visit for each condition that requires or affects patient care treatment or management will put you on the path to success in capturing risk.

Monitor signs, symptoms, ordering or reviewing and referencing of tests/labs, disease progression or disease regression.

Evaluate test results, medication effectiveness, physical exam findings and response to treatment.

Assess or address by discussion, acknowledging, reviewing records, documenting status/level conditions and counseling.

Treat with prescribing/continuation of medications, referral to specialist for treatment/consultation, surgical/other therapeutic interventions and plan for management of condition(s).

Comprehensive Documentation Examples

CHF: Stable – No notable edema or dyspnea. Continue lasix, lisinopril and bisoprolol.
GERD: No complaints. Symptoms controlled by meds.
AAA: Abdominal ultrasound ordered.
MAJOR DEPRESSION: Continued feelings of hopelessness. Will refer to psychiatrist.

Tips:

• Document each patient encounter as if it is the only encounter.
• All chronic and complex conditions should be reviewed and documented annually.
• Review and document conditions managed by a specialist.
• Review and update the patient’s active problem list at each visit.
• Avoid using the words “history of” in the progress note for a chronic but currently stable condition such as COPD, DM or atrial fibrillation.

Example: “CHF, stable. Will continue same dose of Lasix and ACE inhibitor.”

Coding Best Practices

Documentation Best Practices

HCC Financial differences in coding specificity

No Conditions coded (Demographics only)	Some conditions coded (claims data only)	ALL conditions coded (chart review by certified coder)
76-year-old female | .468	76-year-old female | .468	76-year-old female | .468
Medicare Eligible | .177	Medicare Eligible | .177	Medicare Eligible | .177
Diabetes Mellitus (DM) not coded	DM (no manifestations) | .118	DM with Vascular Manifestations | .368
Vascular Disease not coded	Vascular Disease without complication | .299	Vascular Disease with complication | .41
Congestive Heart Failure (CHF) not coded	CHF not coded	CHF coded | .368
No interaction	No interaction	+ Disease Interaction bonus RAF (DM + CHF) | .182
Patient Total RAF | .645	Patient Total RAF | 1.062	Patient Total RAF | 1.973
PMPM Payment for Care | $452	PMPM Payment for Care | $743	PMPM Payment for Care | $1,381
Yearly Reserve for Care | $5,418	Yearly Reserve for Care | $8,921	Yearly Reserve for Care | $16,573

Potential Practice Barriers

1. Not coding to the highest level of specificity. Specific coding relies on provider documentation and accuracy within medical chart notes.

2. Missing documentation. Provider documentation needs to be legible, and it should include enough details to allow coders to correctly code for claim submissions.

3. Not building a strong coder/provider relationship. Consulting with and building relationships with providers is key to help coder and billing teams clarify claims appropriately.

How to Improve Coding and Documentation

1. Document and code disease interactions.

2. Document and code coexisting current conditions.

3. List the first ICD-10 diagnostic code for the diagnosis, condition and problem relating to the visit or encounter. Then, list additional codes that describe any coexisting conditions.

4. Do not code treated conditions such as a pregnancy or another condition that has resolved. History codes can be used as secondary when a condition such as diabetes impacts treatment.

5. Providers must categorize treated conditions appropriately within the patient’s medical history section. 

6. Current diagnoses can come from anywhere in the note but must be supported by a provider’s documentation.

7. Ideally, review all the medical decision-making. Ensure a patient’s medical history, the exam portion, and/or the assessment and plan include valid diagnoses.

Cannot use to assign a definitive diagnosis code in outpatient records:	May be used to define a definitive diagnosis code in outpatient records:
Suggestive of/Symptoms of/Likely	Early/Underlying
Consistent With/Compatible With	Evidence of
Suspicious for/Pending	Element of
Probable/Suspect/Tendency/Possible	Component of
Presumed/Sign(s) of/Suspect	Significant
Pre-___/or____vs.____	Compensated
Rule-Out/Perhaps/Questionable	Results Show_________

 

 

Documentation Requirements

The following charts highlight the approved medical chart documentation elements in order for medical risk adjustment to apply.

Covered Facilities for Medical Risk Adjustment	Non-Covered Facilities for Medical Risk Adjustment
Short-term (general and specialty) Hospitals	Free-standing Ambulatory Surgical Centers (ASCs)
Medical Assistance Facilities and Critical Access Hospitals	Home Healthcare
Community Mental Health Centers	Free-standing Renal Dialysis Facilities
Federally Qualified Health Centers and Rural Health Clinics
Religious Non-Medical Healthcare Institutions
Children’s Hospitals
Long-term Hospitals
Rehabilitation Hospitals
Psychiatric Hospitals

 

Acceptable Document Sources	Unacceptable Document Sources
History and Physical	Super Bill
Progess Note	DME and Home Health
Discharge Summary	Telephone Notes
Consultation	Physician Orders
Operative Reports and Procedures Notes with Post-Operative Diagnoses	List of Patient-Reported Outcomes
Full Inpatient Medical Records	Prescriptions

Acceptable Physician Types for MRA

General Practice	Interventional Pain Management	Nephrology
General Surgery	Gastroenterology	Hand Surgery
Allergy/Immunology	Internal Medicine	Optometry
Otolaryngology	Osteopathic Medicine	Certified Nurse Midwife*
Anesthesiology	Neurology	Certified Registered Nurse Anesthetist*
Cardiology	Neurosurgery	Infectious Disease
Dermatology	Speech Language Pathologist	Endocrinology
Family Practice	Oral Surgery	Podiatry
Hospice and Palliative Care	Ophthalmology	Nurse Practitioner*
Pathology	Cardiac Electrophysiology	Psychologist
Plastic and Reconstructive Surgery	Physical Medicine and Rehabilitation	Audiologist
Psychiatry	Geriatric Psychiatry	Physical Therapist*
Colorectal Surgery	Pulmonary Disease	Rheumatologist
Thoracic Surgery	Urology	Occupational Therapist*
Chiropractic	Nuclear Medicine	Clinical Psychologist
Pediatric Medicine	Geriatric Medicine	Pain Management
Peripheral Vascular Disease	Emergency Medicine	Interventional Radiology
Sleep Medicine	Gynecologist/Oncologist	Physician Assistant*
Dentist	Hospitalist	Advanced Heart Failure and Transplant Cardiology
Medical Toxicology	Hematopoietic Cell Transplantation and Cellular Therapy	Licensed Clinical Social Worker*

 

Unacceptable provider types for MRA
Medical Assistant	Registered Medical Assistant
Licensed Practicing Nurse	Physician Assistant Student
Licensed Professional Counselor	Nurse Practitioner in Training w/o Credentials

 

*Mid-level providers can document and code medical risk adjustment during annual patient encounters. However, some performance related programs may only be tied to the primary physician the patient is attributed.

Reference Guide to Select Medical Risk Adjustment Conditions

The following five MRA conditions are complex and often misdiagnosed, proving challenging for the diagnostic coding and documentation process.

• Diabetes
• Congestive Heart Failure
• Chronic Kidney Disease
• Depression
• Hypertension

Diabetes Coding & Documentation Guide

The Center for Medicare and Medicaid Services (CMS) has associated diabetes and several of its disease manifestations with HCC codes. If complications are present, the causal relationship between conditions should be documented, and the conditions diagnosed and coded to the highest degree of specificity possible. ICD-10 identifies approximately 200 codes that indicate diabetes mellitus type I, type II or secondary diabetes mellitus and its manifestations. These 200 codes map to one of the following three HCCs:

• HCC17 – Diabetes with Acute Complications
• HCC18 – Diabetes with Chronic Complications
• HCC19 – Diabetes without Complication
• Accurate ICD-10 coding along with complete and accurate patient documentation is required to support submission of any HCC to CMS.

Provider Considerations

Diabetes is associated with a risk of complications that may affect one or more of an individual’s organ systems. Documentation and the ICD-10 code submitted by a provider for patient services should reflect the relationship between the condition and severity of disease.

Ask the following questions to determine correct coding. Is the diabetes:

• Type I or Type II
• Secondary to another condition
• With or without complications
• With ketoacidosis
• With hyperosmolarity
• With coma
• With renal manifestations
• With ophthalmic manifestations
• With neurological manifestations
• With peripheral circulatory disorders
• With other specified manifestations (acute vs. chronic ulcer and location)
• With unspecified complication

Documentation Tips:
• Documentation should clearly state the patient has diabetes and describe any complications associated with it. Clearly establishing the causal relationship between the conditions is important when it is the provider’s impression that diabetes has caused one or more complications. Words that are helpful to create this relationship include “due to,” “because of,” “secondary to” or “related to.” Providers may also use the word “diabetic” to show that diabetes is the root cause of the manifestation.

Coding Tips:
• When a patient has diabetes and a manifestation of other related conditions, those should be coded for the patient (i.e. neuropathy due to diabetes, or chronic kidney disease secondary to diabetes).

Congestive Heart Failure Coding & Documentation Guide

Congestive Heart Failure (CHF) is the condition in which heart disease causes breathlessness and abnormal sodium and water retention, often resulting in edema. The congestion occurs either in the lungs or peripheral circulation or both, depending on whether the heart failure is right sided or general. CHF is progressive and often requires chronic disease management. The most frequently observed clinical manifestations include shortness of breath, edema and weight gain. The HCC associated with CHF includes the following.

• HCC 130 – Congestive Heart Failure

Provider Considerations:
Ask the following questions to determine
correct coding:

1.  Was heart failure present on admission (POA)?
2.  What type of heart failure is it?

• Systolic
• Diastolic
• Systolic and diastolic

3.  What is the acuity of the heart failure?

• Acute
• Acute on chronic
• Chronic

4.  Is the heart failure known to be due to an underlying condition?

• Any causative cardiomyopathy
• Hypertension
• Hypertension with chronic kidney disease
• Acute myocardial infarction this admission or within the last four weeks
• Relationship with chronic renal failure, volume overload, or non-cardiac pulmonary edema
• Due to malfunction of cardiac prosthesis
• Following cardiac surgery
• Secondary to hypertensive heart disease link supported by physician

Documentation Tips:
• When documenting heart failure, include the following:

• Type – systolic, diastolic, etc.

• Acuity – acute, chronic, etc.

• Disease status – stable, improved, etc.

• Treatment plan – medicines, lifestyle changes, etc.

Documentation for CHF should include left-sided heart failure, right-sided heart failure or both, and include either acute heart failure, chronic heart failure or acute on chronic heart failure. If known, link CHF to other associated conditions, i.e. hypertension (HTN) & chronic kidney disease (CKD).

Coding Tips:
• In ICD-10, the term “congestive” is considered a non-essential term for heart failure. ICD-10 has no code for “congestive” heart failure; the term is included in code I50.9 – heart failure unspecified.

• When documentation of systolic and/or diastolic heart failure is present, “congestive” is included in the code(s) I50.2 Systolic (congestive) heart failure, I50.3 Diastolic (congestive) heart failure or I50.4 Combined systolic (congestive) and Diastolic (congestive) heart failure.

Chronic Kidney Disease Coding & Documentation Guide

Chronic Kidney Disease (CKD) is a slowly developing condition. A review of a patient’s diagnostic studies, relevant clinical findings and the stage of CKD must be documented for a CKD diagnosis to be coded for HCC classification. The Center for Medicare and Medicaid Services (CMS) has associated approximately 60 ICD-10 codes related to a patient’s renal status to identify five HCC codes.

• The HCC codes associated with renal status are:
• HCC 134 – Dependence on Renal Dialysis
• HCC 135 – Acute Renal Failure
• HCC 136 – Chronic Kidney Disease (Stage 5)
• HCC 137 – Chronic Kidney Disease, Severe (Stage 4)
• HCC 138 – Chronic Kidney Disease, Moderate (Stage 3)

Provider Considerations:

Ask the following questions to determine correct coding:

1. Is the condition chronic?
Risk factor scores assigned to conditions are different, based upon the need for ongoing care and complications associated with the condition.

2. What is the cause of the kidney disease?
There are multiple causes of kidney disease.  When known, the causative factor should be identified, documented and coded.

3. What is the stage of kidney disease?
The higher the stage of kidney disease the more care the patient is likely to need. When the stage of CKD is not documented, it is coded as unspecified, which is not associated with a risk factor score.

4. Does the patient require dialysis or transplant?

Coding Tips:
• Code for severity of CKD by designated stages 1-5 using N17-N19 series.

• If a patient is receiving dialysis treatment, use code E18.6

• For patients who have received a kidney transplant, code potential complications from the transplant and any evidence of impaired kidney function.

• Complications should be coded using T86.1 plus any subcategory conditions that may influence the functionality of the transplanted kidney.

• Code other potential chronic conditions, such as hypertension, hypertensive heart disease and diabetes mellitus.

Documentation Tips:
• To support a diagnosis of CKD, documentation must indicate that the patient has chronic kidney disease and include at least one of the following:

• Review of diagnostic reports
  (blood, urine, imaging)

• Pertinent clinical findings.

• Stage of CKD

• Management of CKD.

Documentation related to kidney disease should include any additional or secondary conditions that may be present.  Clearly state any causative relationship that exists between the conditions.

Major depressive disorder Coding & Documentation Guide

Major depressive disorder or clinical depression is a common but serious mood disorder. Major depressive disorder can be seen in patients who have suffered a depressive episode lasting at least two weeks, as manifested by at least five of the following symptoms: depressed mood, loss of interest or pleasure in most or all activities, insomnia or hypersomnia, change in appetite or weight, psychomotor retardation or agitation, low energy, poor concentration, thoughts of worthlessness or guilt, and recurrent thoughts about death or suicidal ideation. ICD-10 diagnostic codes in this category are based on patients having various levels of depression severity and episodic frequency. Major depressive disorder falls into one HCC mapping:

• HCC 55 – Major Depressive, Bipolar, and Paranoid Disorders
  

Provider Considerations:

Several evidence-based media tools are effective in screening for depression. The Patient Health Questionnaire (PHQ-9) is a nine-question instrument for patients to complete in a primary care setting to screen for the presence and severity of depression. The results are used to assist providers in making a depression diagnosis and ranking the severity.

Documentation Tips:
• Be specific in terms of severity:
Mild, Moderate, Severe.

• Specify episodes: Single, Recurrent, Remission.

Coding Tips:
• Avoid broad terms and unspecified codes such as “Depression”, F32.9 (ICD 10 CM code).

• Be thorough in picking up the details in documentation. This can lead to a better understanding of depression and assist with accurate coding.

• Remember to code out other mood affective disorders, such as, Manic (F30.-) and Bipolar
(F31.-).

HYPERTENSION Coding & Documentation Guide

Hypertension (HTN), also known as high blood pressure (HBP), is a common condition in which the blood pressure in the arteries is constantly elevated. The medical guidelines issued by American Heart Association (AHA) define a blood pressure reading above 130 over 90 millimeters of mercury (mmHg) as hypertensive. When left untreated, high blood pressure can lead to co-morbid complications, such as heart failure and chronic kidney disease. Hypertension presumes a relationship between hypertension and either heart involvement and kidney involvement conditions and are often coded as related using the word “with.” These conditions should be coded as related in the absence of provider documentation, unless documentation clearly states conditions are not related.

The HCC associated with hypertension include the following:

HCC 85 – Congestive Heart Failure

HCC 136 – Chronic Kidney Disease (Stage 5)

Provider Considerations:

1. An additional code is required to identify the type of Congestive Heart Failure Coding from the I50 (HCC-85) series chart.

2. An additional code is required to identify the stage of CKD from the N18 (HCC-136) series chart.

Documentation Tips:
• When documenting hypertension, include both the type (essential or secondary), and the causal relationship (renal or pulmonary).

• Document occurrence of patient tobacco use and elevated blood pressure reading.

Coding Tips:
• Code Essential Hypertension as ICD-10 code: I10.

• Assign a secondary code from heart disease or kidney disease when there is a causal relationship implied in a paper record (“due to hypertension” or “with hypertension”).

• If the provider specifies a different cause for hypertension other than heart or kidney involvement, the secondary condition would be coded separately and not linked.

• If the secondary condition is hypertensive chronic kidney disease, there is a presumed relationship between hypertension and chronic kidney disease. Therefore, the only secondary code used indicates CKD stage (stage 1 -5, end stage renal disease).

• Use additional diagnostic code(s) to identify tobacco use: history of tobacco dependence, tobacco use, exposure to tobacco and tobacco dependence.

Social Determinants of Health (SDOH) Coding Reference Guide

SDOH is a tool to better understand population needs and provides an indirect way of looking at how costs impact care. Although these codes do not affect risk adjustment per se, they do help provide a comprehensive picture for providers and payors.

FAQs: Social Determinants of Health Questionnaire

1. Why must I address social determinants of health status codes during patient encounters?
   In an attempt to gauge social and economic patient barriers to receiving care, this information will help ensure each patient’s risk adjustment factor (RAF) aligns and provides necessary health plan resources, improving value-based care.
2. How often do we update coding in the patient’s medical chart?
   Annually or if the patient’s situation has changed.
3. Do I have to address all questions during every patient encounter?
   To get a complete picture of each patient’s social and economic determinants of health, it is recommended to address each section of this form.
4. Do I have to provide enabling services for each of the areas list here?
   Capturing the determinants of health are vital to understand what services each patient needs. Do the best you can to assist each patient comprehensively.

 

Annual Wellness Visits, Routine Physical Exams & Office Visits Coding & Documentation Reference Guide

As organizations transition towards value-based payment models, clinics can transform best practices on preventive care and screening services that treat complex, high-risk patients. Medicare Annual Wellness Visits (AWVs), routine physical exams and general office visits provide opportunities to ensure patients remain as healthy as possible. Not only do these types of encounters encourage multiple gaps in care closure, but they also ensure the needs of chronically ill patients are met. The following coding and documentation tips and charts provide procedural/service-based coding information and feature patient encounter types.

The Medicare AWV is an individualized plan to help improve patient engagement and promote preventive care. A typical AWV includes review of a patient’s medical history, family medical history, potential risk factors for preventable diseases, review of Health Risk Assessment questionnaire, review of providers and prescriptions, and signs of cognitive impairment. Additional services, such as lab work performed during the AWV, are not included and must be billed separately. Additional preventive services, such as colorectal cancer screenings, are reviewed and potentially scheduled during the AWV. The AWV is a covered benefit for Medicare patients over the age of 65 and can be performed every 12 months.

An annual physical examination is an extensive exam similar to Medicare’s AWV service. However, annual physical exams include additional services, such as vital signs check, lung exam, head and neck exam, abdominal exam, neurological exam, and reflex check. Blood work and lab tests are included in annual physical exams, but not within an AWV. Although Medicare does not cover routine physical examinations, some Medicare Advantage plans do offer additional services to cover physical exams. The majority of private insurance plans offer various patient coverage for annual physicals.

Documentation Tips:
•  Include Health Risk Assessment patient responses when performing AWV.

• Create patient’s medical and family history by documenting events, including medications and supplement use, when performing AWV.

• Document height, weight, BMI and blood pressure during both AWV and annual physical exam.

• Review and document potential risk factors and assess functional status when performing AWV.

• Document chronic conditions using the Monitor, Assess, Evaluate and Treat (M-E-A-T) tool when performing both AWV and annual physical exam.

• Document past illnesses, surgeries, medications, allergies, family and social histories, status of chronic conditions, blood pressure, height, weight, BMI, outstanding screenings needed, counseling guidance, physical activity, healthy weight, tobacco use, mental health, immunizations, alcohol and drug use, and sexual behavior during both services to provide a comprehensive visit.

Provider Considerations:

1. Address social determinants of health (SDOH) during both services to provide a comprehensive assessment of the patient.

2.  Provider documentation during both services should include guidance on screenings ordered or offered, even if the patient chooses to decline.

3.  Both services should address recommended preventive services and identify chronic conditions the patient likely has on an annual basis. Both services apply to medical risk adjustment methodology and can help provide a more accurate picture of a patient’s current health status through diagnostic coding and documentation.

Coding Tips:
• Include Evaluation and Management (E/M) services provided along with the AWV. These can be reported with the specified CPT code and modifier -25.

•  If performed, Advance Care Planning (ACP) can be billed in addition to AWV service with the use of modifier -33 to prevent cost-sharing to the patient.

• Ensure modifier -25 is used if separate E/M service is performed by the same physician on the same day as the preventive service is provided.