Skip to Main Content

Risk Adjustment

Risk Adjustment is the method developed and used by the Department of Health & Human Services (HHS) to predict health costs of members enrolling in Affordable Care Act (ACA) or Medicare Advantage (MA) plans. Risk Adjustment prevents health plans from only attracting and enrolling healthy members; or adverse selection. Effective Risk Adjustment programs ensures members are receiving quality care and enable health plans to offer more comprehensive and affordable benefits to members.

Arkansas Health & Wellness is required by law to report complete and accurate diagnostic information on enrollees. This information is gathered from claims data and information obtained from medical record reviews and audits.

We encourage all providers to take every face-to-face encounter as an opportunity to provide comprehensive care and document chronic conditions, co-existing conditions, active status conditions, and pertinent past conditions using the applicable ICD-10 code and supporting the condition with proper documentation in the medical record.

Arkansas Health & Wellness is required to validate member diagnosis annually through Risk Adjustment Data Validation (RADV) audit. Health Plans also engage in chart review projects to ensure member diagnosis are being reported accurately.

Arkansas Health & Wellness engages providers through various incentive programs that reward providers for risk adjustment gap closure.

Condition status Z codes are informative and distinct from “history of” codes. “History of” codes indicate a past condition has been resolved and is not present. Condition status codes indicate that a patient is either a carrier of a disease or has the sequela or residual of a past disease or condition. The status can affect the course of treatment and its outcome but they are most commonly overlooked. [1]

Amputation Status – Category Z89

Codes in category Z89 describe traumatic or post-procedural absence of a limb, when there are neither complications of the amputation nor treatment directed toward the site. Documentation should include anatomical location and laterality.

Artificial Opening Status – Category Z93

Codes in category Z93 describe functional artificial opening status. Artificial openings can be permanent or temporary depending on circumstances of creation. These codes are appropriate when no treatment is directed at the site. Documentation should include date of initial procedure and/or reversal, if applicable.

Organ Transplant Status – Category Z94

Category Z94 codes identify post-transplant status when there are no complications of the transplanted organ. A code from this category is appropriate as an additional code when treatment of a condition does not affect the function of the transplanted organ.

Supplemental Oxygen or Respirator Dependence – Category Z99

Category Z99 codes identify supplemental oxygen or ventilator dependence status when there is no complication or malfunction of the equipment on which the patient is dependent.[2] Dependence status can be for a short or long period of time in the hospital, another medical setting, or at home. Dependence on supplemental oxygen status is appropriate for any patient using long-term supplemental oxygen, regardless of the duration of use each day. Use dependence on respirator [ventilator] status codes when respiratory device or equipment is for life sustaining support.

Renal Dialysis Status

ICD-10-CM includes codes for dependence on renal dialysis and noncompliance with renal dialysis. These codes are appropriate when the presence of AV shunt for renal dialysis is indicated.

Lifelong Chronic Conditions[3]

Lifelong chronic conditions often require ongoing medical attention and the associated diagnosis are typically unresolved once diagnosed. It is appropriate to report these conditions, even when stable, if documented in any part of the medical record at the time of the encounter.

 
Condition Description ICD-10 Diagnosis[4]
HIV/AIDS B20 , Z21
Hemolytic Anemias D56.0, D56.1, D56.5, D57.0-D57.1
Disorders of Immunity D81.0 - D81.7, D81.89, D81.9, D82.0 - D82.1, D83.1, D84.1

Coagulation Defects and Hemorrhagic Conditions

D66, D67
Metabolic Disorders E70.0 - E72.9, E74.0 - E74.2, E74.4 - E74.9, E75.00 - E75.4, E76.01- E77.9, E78.71 - E78.72, E79.1 - E79.9, E80.0 - E80.3, E84 - E85, E88.01, E88.4-, E88.89
Pervasive Developmental Disorders F84.-
Systemic atrophies primarily affecting thecentral nervous system  G10 - G12.9
Extrapyramidal and movement disorders G20 - G23.9
Degenerative diseases of nervous system G31.81 - G31.83
Demyelinating diseases of the central nervoussystem  G36.0, G37.0
Diseases of myoneural junction and muscle G71.0 - G71.11, G71.2
Cerebral Palsy and Paralytic Syndromes G80.-, G82.-
Other Disorders of the nervous system G90.1, G90.3, G93.7
Auto-inflammatory syndromes M04.-
Congenital Malformations Q00.0 - Q02, Q04.0 - Q07.9, Q65.-, Q77.0 - Q78.9, Q79.6-, Q86.-, Q87.1 - Q87.89, Q84.4, Q89.8
Chromosomal Abnormalities Q90.0 - Q93.9, Q95.2 - Q95.3, Q96.0 - Q99.9

It is important to include all condition details in documentation. Report all applicable Z status codes and chronic condition diagnosis codes

  • When presence affects medical decision making or a pertinent factor of overall health; and/or
  • During a wellness or physical exam, at least once per calendar year for as long as they exist

Reference:
1 ICD-10-CM Chapter 21: Factors influencing health status and contact with health services

Occasionally, a reported diagnosis may be omitted from a claim due to errors or limitations of electronic claims submission. Improve the capture of risk adjustment conditions by entering the diagnosis codes on the claim correctly.

Diagnosis “pointers” connect the diagnosis made by the provider to each CPT® code billed on the claim. Only four (4) diagnosis pointers can be listed per CPT® code.

  • Identify the 4 most important or serious diagnoses that the procedure is intended to treat
  • Enter the diagnosis pointers in order of severity.

Maximize reporting opportunities:

Avoid missing eligible risk adjustment conditions by thorough documentation and accurate diagnosis coding.

  • Address all conditions present at the time of the encounter that require treatment or management.
  • Report all chronic conditions that impact treatment or care, even if stable. This includes pertinent status codes.
  • Explicitly state each diagnosis and provide documented evidence of support in the medical record.
  • Capture all valid ICD-10 diagnosis codes in the appropriate order on the claim form. 

Always follow the current ICD-10-CM Official Guidelines for Coding & Reporting[1] Refer to the Medicare Claims Processing Manual2 for additional information.

1500 Claim Form Instructions (PDF) - Coming soon

Health Insurance Claim Form (PDF) - Coming soon

Documentation Requirements[1]

Documentation must:

  • Result from a face-to-face encounter with acceptable provider in an acceptable setting type
  • List the complete date of service (month/day/year)
  • Contain at least two patient identifiers on EACH page of every document (Name, DOB, MRN)
  • Include legible handwritten signature with credentials or proper EMR electronic authentication
  • Explicitly state the diagnosis and clearly document supporting evidence of an active/current condition

Condition Assessment

Assess the status of conditions for which interventions are recommended or underway. Code all documented conditions that coexist at the time of the encounter/visit, and require or affect patient care treatment or management.  This includes ongoing chronic conditions, even if stable.

Documentation from past dates of service may not be used to report codes for the current date of service.

Current/Active Diagnosis

MEAT & TAMPER are used as tools to help coders determine if a condition can be coded as current or active. At least one of the following elements must be present in at least one section of the medical record (Subjective, Objective, Assessment, Plan) to substantiate the presence of a condition:

  • Monitor, Evaluate, Assess/Address, Treat
  • Treat, Assess, Monitor/Medicate, Plan, Evaluate, Refer

History Of

Do not code conditions that have been treated or no longer exists. Documentation where the provider has used the term(s) “history of” will be coded using the appropriate diagnosis code for the historical condition. The condition should not be referenced as a “history of” if it is a chronic condition currently undergoing treatment.

Condition Lists

Conditions mentioned in Past Medical History or Active Problem List must be supported in another section of the medical record in order to verify the condition is active. The best practice is to include evidence of current review in the form of medication, referrals, order of lab tests, etc. in the assessment and plan.

Specificity

Document to the highest degree and code to the highest specificity. The ICD-10 diagnosis code must match the wording used in documentation. Explicitly state the diagnosis and follow the official conventions and guidelines for coding and reporting.

Consistency

Be clear and consistent throughout the medical record when documenting details of a condition. A diagnosis cannot be validated when the record contains conflicting information.

Reporting

When a condition is assessed and documented in a face-to-face encounter, include the corresponding ICD-10 diagnosis code on the claim form submitted to the health plan.

Telehealth[2],[3]

Telemedicine Visits provided via synchronous audio and video technology meet the face-to-face requirement for risk adjustment. Documentation must include that the visit was performed using interactive audio/video with real-time, two-way communications. Virtual Check-Ins, E-Visits, and Telephone Visits are not acceptable.

[2] Medicare has expanded telehealth coverage and eased current restrictions for the duration of the COVID-19 crisis. During this time, telehealth services that meet the face-to-face documentation requirements can be used for risk adjustment.

Resources

The Official ICD-10-CM Guidelines[4] are the authoritative source for diagnosis coding and documentation. Please refer to the current year’s guidelines for detailed instructions.  These guidelines and other information about risk adjustment can be found on CMS’s website

Preventive visits are an important part of the process of keeping patients healthy. These visits improve quality of care and patient health outcomes by identifying patients who need disease management and intervention.

Initial Preventive Physical Exam

Medicare Advantage members are eligible for an Initial Preventive Physical Exam (IPPE) within the first 12 months of enrollment.  The IPPE is also known as the “Welcome to Medicare” visit. The purpose of this visit is to review medical and social history and provide preventive services education.

Annual Wellness Visits

Beneficiaries are also eligible for an initial Annual Wellness Visit (AWV) after the first 12 months of enrollment and a subsequent AWV once per calendar year after the initial AWV. The AWV includes Personalized Prevention Plan Services (PPPS) and Health Risk Assessment (HRA). It does not include a physical exam or other diagnostic procedures.

Annual Physical Exams

Routine Comprehensive Physical Exams (CPE) are performed without relationship to treatment or diagnosis for a specific illness, symptom, complaint, or injury.  An annual CPE includes an appropriate history/exam with risk counseling and/or intervention. The extent and focus of exam depends on the age and gender of the patient.

Annual Wellness Visits[1]

Visit Description HCPCS Eligibility

Welcome to Medicare Exam

G0402

Once in a lifetime benefit performed within first 12 months of enrollment

Initial AWV

G0438

Once in a lifetime benefit performed 12 months after IPPE or enrollment date

Subsequent AWV

G0439

Once per calendar year after the initial AWV

Routine Comprehensive Physical Exams[2]

Exam Description CPT© Code

Patient Age

Initial Exam

Subsequent Exam

Age 18-39

99385

99395

Age 40-64

99386

99396

Age 60+

99387

99397

What diagnosis codes should be reported?[3]

Category Z00 includes codes for Routine Health Exams “with” or “without” abnormal findings and should be the primary diagnosis. Report additional codes, if applicable, for pre-existing and chronic conditions as well as newly discovered conditions and/or abnormalities documented during the routine exam.
Follow the current year’s Official ICD-10-CM Guidelines for Coding and Reporting

Who can perform the AWV?

  • PHYSICIAN - doctor of medicine or osteopathy
  • QUALIFIED NON-PHYSICIAN - physician assistant, nurse practitioner or clinical nurse specialist
  • MEDICAL PROFESSIONAL – health educator, registered dietitian, nutrition professional, or other licensed practitioner
  • CLINICAL STAFF - registered nurse, licensed practical nurse, medical assistant

Non-qualified medical professionals and clinical staff  must be under the direct supervision of a physician or qualified non-physician are not permitted to perform any part of the AWV that requires the exercise of independent clinical judgment or the making of clinical assessments, evaluations, or interpretations

What can be reported with the AWV?

Preventive Services Screenings Vaccines & Administration
  • Diabetes self-management training
  • Bone mass measurement
  • Nutrition therapy for diabetes or renal disease
  • Ultrasound for abdominal aortic aneurysms
  • Breast cancer
  • Prostate cancer
  • Colorectal cancer
  • Diabetes
  • Cardiovascular disease
  • Depression
  • Pneumococcal
  • Influenza
  • Hepatitis B

Refer to Medicare Benefits Policy Manual for other preventive services covered with an IPPE/AWV.

What can be reported with the CPE?

Ancillary Studies Screenings Vaccines
  • Laboratory
  • Radiology
  • Other procedures
  • Vision
  • Hearing
  • Developmental
  • Toxoid
  • Administration
  • Risk/Benefit Counseling

Tobacco smoking cessation counseling and substance abuse screening/intervention are included with CPE. Refer to CPT© Code book for guidance on other services covered at the time of a preventive medicine exam.

Can preventive visits be performed on the same day as another visit?

A separately identifiable E/M service may be performed if prompted by symptoms or chronic conditions assessed during the AWV/CPE. Select the appropriate level of E/M services based on the following:

  • The level of the medical decision making as defined for each service; or
  • The total time for E/M services performed on the date of the encounter.

Append modifier -25 to the E/M service (99202 – 99215) when performed on the same day as an AWV (G0402, G0438 - G0439) or CPE (99385 - 99387, 99395 – 99397)

Reference:
[2] AAPC. 2021 Procedural Coding Expert. American Academy Holdings, 2020. [VitalSource Bookshelf].

All services provided require medical record authentication. Signatures may be handwritten or electronic. Rubber signature stamps are not acceptable unless an exception has been granted due to a physical disability.

Manual Signatures

  • Legible hand written signature with credential – No date of signature required
  • Hand written signature or initials if provider name/credential on pre-printed progress note
  • If the names of two or more physicians are listed on the note, then the provider must have his/her name identified, such as pre-printed name/credential
  • Initials over a typed or pre-printed name with credential
  • “Scribble”-as long as acceptable provider name with credentials is indicated.
  • Digitalized signature: handwritten and scanned into computer must be legible or provider name with credentials must be on record.

Electronic Signature Elements

  • Authentication    
  • Practitioner’s name
  • Credentials noted
  • Date signed *must be within 180 days of date of service
  • “Last Updated” is an approved electronic signature date as long as the Electronic signature wording is an approved authentication.    
    • If elements of the electronic signature are not met in its entirety, an attestation is needed.
    • Practitioner credentials can be pre-printed anywhere within the DOS.

Transcribed Records

  • Provider Signature authentication statement
  • Provider name
  • Provider credentials
  • Date note signed
    • Note: To identify a transcribed note, look for indicators such as “Transcribed by”, “Date dictated (DD)”, and/or “Date Transcribed (DT)”.

Authentication Examples
(Not all inclusive)

Accepted by

Completed by

Electronically signed by

Released by

Acknowledged by

Confirmed by

Electronically verified by

Reviewed by

Approved by

Digitally signed by

Encounter sign off by

Signature on file

Authenticated by

E-Authenticated by

Finalized by

Signed

Authorized by

Edited by

Generated by

Signed by

Closed by

Electronically generated

Performed by

Validated by

Reference: Medicare Program Integrity Manual (PDF)

Cerebrovascular accident (CVA), also known as a stroke, occurs when there is an interruption to blood flow that supplies oxygen to the brain.[1] There are two different types of strokes:

  • Ischemic Stroke  - blockage of blood vessel in the brain due to a blood clot or stenosis
  • Hemorrhagic Stroke - bleed into the brain caused by a broken blood vessel
A stroke is an emergent event that requires treatment in an acute care setting.[2]

Residual or late effects (sequelae) caused by a stroke may be present from the onset of a stroke or arise at ANY time after the onset of the stroke. Some conditions develop slowly and exist over extended periods. Others develop suddenly and last only a few days or weeks.

A transischemic attack (TIA) is a temporary episode of neurologic dysfunction caused by ischemia without acute infarction. It is sometimes referred to as a mini stroke because the symptoms are similar to that of a stroke. The symptoms can resolve within minutes, or can last up to 24 hours. 

Documentation

Detailed documentation is necessary for proper code selection.

  • Specify the location or source of hemorrhage and its laterality
  • Specify the source of occlusion and the vessel affected
  • If applicable, identify the specific neurologic or cognitive deficit, identify the affected extremity and laterality and whether dominant or non-dominate side, and specify the type of event as the causing the sequelae

Key Terms:[3]

  • Stenosis – narrowing
  • Occlusion – complete or partial obstruction
  • Thrombosis – stationary blood clot lodged in vessel
  • Embolism – blood or other clot carried through vessel
  • Meninges – protective membranes surrounding the cerebral cortex (brain)
    • Dura matter (outer), Arachnoid (middle), Pia matter (inner)
  • Epidural - between dura matter and skull
  • Subdural - between dura matter and arachnoid
  • Subarachnoid - between arachnoid and pia matter
  • Precerebral arteries – vertebral, basilar, carotid
  • Cerebral arteries – anterior, middle, and posterior

Coding

Assign the most specific code as appropriate according to documentation. More than one code may be assigned if specific code is available for separate locations. Watch for parenthetical notes found in the tabular list (e.g. excluded conditions, coding sequence).

Acute conditions must only be reported when present and actively being treated. Chronic conditions should be reported when treatment is required and/or affects care.  Once a condition has resolved, it should no longer be reported as active.

ICD-10-CM Codes[4]

  • Category I60 – I62: Non-traumatic cerebral hemorrhage
  • Category I63: Cerebral Infarction
  • Category I65 – I68: Other cerebrovascular disorders and diseases
  • Category I69: Sequelae of cerebrovascular disease

Acute conditions found in Category I60 – I67 are applicable to the initial event.

After discharge from acute care, the condition is classified by:

-   Sequela (late effects) found in Category I69; or

-   Personal history of CVA or TIA without residual deficits, Z86.73

  • Transient cerebral ischemic attack, G45.9 should be reported at the time of initial diagnosis. Refer to personal history of TIA and CVA without residual deficits,  Z86.73 for subsequent encounters
  • See Category S06 for Intracranial hemorrhage due to accident or injury (traumatic)
  • See Category I97 & G97 for guidance on intraoperative and postoperative events. Causal relationships must be clearly documented.
  • Use Additional code to identify presence of:
    • alcohol abuse and dependence (F10.-)
    • exposure to environmental tobacco smoke (Z77.22)
    • history of tobacco dependence (Z87.891)
    • hypertension (I10-I16 )
    • occupational exposure to environmental tobacco smoke (Z57.31)
    • tobacco dependence (F17.-)
    • tobacco use (Z72.0)

NOTE: The information listed here is not all inclusive and is to be used as a reference only. Please refer to applicable coding and documentation resources for the current year. [5],[6]

Peripheral Vascular Disease (PVD) describes any disorder of the blood vessels outside the heart and chest or disorders that affect blood flow through the arteries and/or veins.

Peripheral Vascular Disease (PVD) is also known as:

  • Peripheral artery disease (PAD)
  • Peripheral arterial insufficiency
  • (Intermittent) claudication
  • Peripheral angiopathy
  • Spasm of artery
ICD-10-CM code I73.9 - Peripheral vascular disease, unspecified is assigned for all conditions listed above when documented in the medical record.[1]

Arteriosclerosis is the hardening of the arteries. Atherosclerosis is a pattern of arteriosclerosis in which the artery narrows due to the buildup of plaque (fatty deposits) inside the artery the wall.[2]

These conditions are applicable to ICD-10-CM Category I70:

  • Arteriolosclerosis
  • Arterial degeneration
  • Arteriosclerosis
  • Arteriosclerotic vascular disease
  • Arteriovascular degeneration
  • Atheroma
  • Endarteritis deformans or obliterans
  • Senile arteritis
  • Senile endarteritis
  • Vascular degeneration
PVD due to atherosclerosis should be documented, if applicable, to correctly assign codes with higher specificity. Note: Atherosclerosis of extremities; unspecified refers to type, not location.

Signs & Symptoms[3]

Examples include:

  • Claudication - foot, calf, buttock, hip or thigh pain or discomfort when walking that is relieved by rest.
  • Cyanosis - bluish discoloration of the skin resulting from poor circulation.
  • Femoral or Carotid bruit - vascular murmur sound heard over a partially occluded blood vessel on auscultation.
  • Slow healing wound or skin infection
  • Slow capillary refill
  • Numb/painful sensations in extremities
  • Atrophic skin changes
  • Decreased nail growth
  • Abnormal or diminished pedal pulses
  • Non-pressure ulcer
  • Toes or feet appear pale or discolored
  • Ischemic rest pain

Abnormal physical exam findings must be confirmed with diagnostic testing.[4]

  • Ankle brachial index (ABI)
  • CT angiogram (CTA)
  • Doppler ultrasound
  • MRI

Other vascular diseases:

  • Aneurysm
  • Deep vein thrombosis
  • Varicose veins
  • Chronic venous insufficiency
  • Critical limb-threatening ischemia

Complications & Interventions

Early interventions can the lower the risk of complications.[5]

Complications Interventions[6]
  • Limited mobility
  • Infection
  • Amputation
  • Heart attack
Lifestyle Changes Medications Procedures
  • Healthy diet
  • Regular exercise
  • Lose weight
  • Quit smoking
  • Statns
  • Vasodilators
  • Anticoagulants
  • Angioplasty
  • Stents
  • Endarterectomy
  • Thrombolysis (CDT)

Coding & Documentation

Include the following details in the medical record:

  • Cause (e.g., atherosclerosis, stenosis)
  • Location of vein/artery affected (leg, foot, heal, ankle, calf, thigh)
  • Laterality – specify left, right or bilateral
  • Status of the artery (e.g., native, bypass graft, autologous, non-autologous biological)
  • Complications such rest pain, intermittent claudication, ulceration (document ulcer site) or gangrene.

Document diagnostic test results and any clinical findings that support PVD along with disease status and treatment plan.

Also include the following details, when applicable:

  • Risk factors (e.g., tobacco use, high cholesterol, morbid obesity)
  • Counseling provided to patient (e.g., smoking cessation)
  • Co-morbidities such as HTN, DM, and CAD with disease status and treatment plan.

References:

[4] Everett Stephens, MD. Peripheral Vascular Disease Guidelines. [Updated 2017 Dec. 31]. In: Medscape [Internet]. 1994–2020 by WebMD LLC. https://emedicine.medscape.com/article/761556-guidelines

[5] Smith DA, Lillie CJ. Arterial Occlusion, Acute. [Updated 2020 Apr. 23]. In: StatPearls [Internet]. Treasure Island (FL): Stat Pearls Publishing; 2020 Jan. https://www.ncbi.nlm.nih.gov/books/NBK441851/ (http://creativecommons.org/licenses/by/4.0/))

Allwell Coding Tip Sheets And Forms