Risk Adjustment/Coding Toolkit

Risk Adjustment Coding Compliance Guidance Procedure (D-EDR-RAPS08B)
To improve the quality, accuracy and integrity of member data as it relates to reporting the health status of members and to ensure minimal variation in coding practices.

Risk Adjustment Coder
Under minimal supervision using established procedures, abstracts medical information from various sources in the patient medical record for Medicare Advantage Risk Adjustment (MARA) and Healthcare Reform (HCR) Risk Adjustment projects. Designs and works with forms for collection of data and performs surveillance checks to monitor the accuracy of data. Ensure appropriate documentation and data collection according to specific project or audit requirements. Provides for quality assurance activities and coordinates auditing processes with leadership. Work collaboratively with various HAP departments and HAP’s provider community to obtain accurate submission of risk adjustment data through coordinated medical chart review activity. Promote education on the importance of comprehensive medical record documentation and correct coding. Position is responsible for maintaining a culture of integrity through coding compliance and adherence to CMS program guidelines.

Risk Adjustment Financial Analyst III
Under minimal supervision provide assistance to the Manager of the Medicare Advantage Risk Adjustment. Works closely with the Lead Medicare Advantage Financial Analyst in ensuring the finance responsibilities for the Medicare Advantage program are performed. Assists Lead tasks in the development and coordination of MA risk adjustment projects. Coordinate project start-up for chart review and Audits. Assist with HHS HCR RADV Audits as necessary. Assist with department control procedures, financial and reporting systems to provide specialized information to various users. Under minimal supervision perform analysis, reconciliation and problem solving, and understanding of the complexities of the Medicare Advantage program. Assist Lead in working with Henry Ford Medical Group, information systems, Membership & Billing departments and Altegra Health (Risk System). Coordinate system testing, enhancing data integrity, and work with internal as well as external customers to create and

Risk Adjustment Health Information Analyst
Retrieves all medical records for CMS Risk Adjustment Data Validation (RADV) audits, Health care Reform (HCR) RADV audits and internal Medicare Advantage Risk adjustment projects as needed. Using excel and /or Access logs, monitors and tracks incoming medical records. Monitor and track what records have been received and which remain outstanding. Works directly with multiple HAP departments to write and approve provider mailings. Works closely with Provider Relations Department to reconcile the correct payment amount for medical record as indicated in provider contracts. Actively communicates with the provider community in order to obtain medical records before deadlines. Processes incoming medical records and performs quality checks to ensure that the correct records are retrieved. Works closely with Medical Record Retrieval vendors to resolve any issues related why records cannot be obtained. Audits medical record vendor invoices to ensure proper payment for services. Perfor

Risk Adjustment Lead Financial Analyst
Under minimal supervision provide assistance to the Director and Manager of the MA Risk Adjustment Department in ensuring the finance responsibilities for the Medicare Advantage program are performed. Lead all projects and tasks in the development and coordination of MA risk adjustment projects. Leads and coordinates all start up for Medicare Risk Adjustment CMS Audits. Assist with HHS HCR RADV Audits as necessary. Coordination and production of department control procedures, financial and reporting systems to provide specialized information to various users. Under minimal supervision perform analysis, reconciliation and problem solving, and understanding of the complexities of the Medicare Advantage program. Act as a liaison between Henry Ford Medical Group, information systems, Membership & Billing departments and Altegra Health (Risk System). Coordinate system testing, enhancing data integrity, and work with internal as well as external customers to create and maintain the Me

Risk Adjustment Financial Analyst II
Under limited supervision assists the FA III Analyst and/ or Lead Analyst with all Medicare Advantage Risk Adjustment project work including project start up, tracking and summarization. Project work consists of creation of project descriptions and detailed instruction on startup sample selection. In addition support maintenance of the Altegra Health Risk view system by assisting with testing of new release and monthly load as well as monitor new requests for enhancements to the system and/or submission of trouble tickets to Altegra Health Support team.

Risk Adjustment Medical Coder Lead
Oversight of daily output of chart reviews for Medicare Advantage Risk Adjustment (MARA) and Healthcare Reform (HCR) Risk Adjustment projects. Assist coders with routine coding questions and monitors the quality and quantity of daily coded output. Research coding questions using Coding Clinic and other resources as necessary. Assists with documentation of processes, thorough written policies and procedures including writing, reviewing, updating and storage. Perform coding and abstracting on routine and special projects. Build a strong knowledge of the systems and assist Financial Analyst with testing of new releases.

Risk Adjustment Manager
Responsible for development and execution of projects concentrated on complete and accurate reporting of the health status of HAP’s Medicare Advantage (MA) and Commercial Qualified Health Plan (QHP) membership to CMS. Coordinate various HAP/HFHS departments and HAP’s provider community to obtain accurate submission of risk adjustment data through coordinated medical chart review activity. Promote education on the importance of comprehensive medical record documentation and correct coding. Position is responsible for achieving results which contribute to HAP’s financial goals by optimizing MA and QHP premium revenue while simultaneously maintaining a culture of integrity through coding compliance and adherence to CMS program guidelines.

Coding Workshop: Case Study Examples and Best Practices Review
This session is designed for individuals within Health Plan Alliance member health plans who are certified coders a/or supervising certified coders, and who have responsibility for coding, documentation and other activities related to RADV audits for MA and/or the ACA products.

Risk Adjustment Department Best Practices
Risk Adjustment Best Practices Summary document for Health New England. Contains information around Policies, Procedures, Tools and Roles in the Health New England Risk Adjustment department.

Risk Adjustment Organizational Chart
Organizational Chart showing the location of the Risk Adjustment department at Health New England.

CMS CY 2018 Advance Notice
Advance Notice of Methodological Changes for Calendar Year (CY) 2018 for Medicare Advantage (MA) Capitation Rates, Part C and Part D Payment Policies and 2018 Call Letter

Aspire coding workgroup case studies Feb 2017
This call is one in a series designed for the Alliance coding work group. These calls showcase one health plan at a time, whose team is responsible for sharing multiple coding case studies with the other group members for discussion.

Risk Adjustment Best Practices Worksheet
This template and worksheet is designed to assist Health Plan Alliance member organizations in sharing risk adjustment department best practices. Information gained through this exercise will be presented at the 2017 Feb Risk Adjustment Value Visit and shared in the member library.

Recording: Alliance coding work group - SelectHealth case studies
This call is one in a series designed for the Alliance coding work group. These calls showcase one health plan at a time, whose team is responsible for sharing multiple coding case studies with the other group members for discussion.

SelectHealth Coding Workgroup case studies Jan 18, 2017
This collection of case studies from SelectHealth are for the Jan 18 2017 Alliance coding workgroup session.

Recording: Alliance coding work group: Gundersen case studies

Gundersen coding work group case studies Nov2016
This collection of case studies from Gundersen Health plan is for the Nov 2016 coding work group webinar and discussion

ICD-10-CM Official Guidelines for Coding and Reporting - FY 2017
The Centers for Medicare and Medicaid Services (CMS) and the National Center for Health Statistics (NCHS), two departments within the U.S. Federal Government?s Department of Health and Human Services (DHHS) provide the following guidelines for coding and reporting using the International Classification of Diseases, 10th Revision, Clinical Modification (ICD-10-CM). These guidelines should be used as a companion document to the official version of the ICD-10-CM as published on the NCHS website. The ICD-10-CM is a morbidity classification published by the United States for classifying diagnoses and reason for visits in all health care settings. The ICD-10-CM is based on the ICD-10, the statistical classification of disease published by the World Health Organization (WHO)

Recording: Alliance coding work group: Paramount case studies
This collection of case studies is used as a training tool and resource for the Alliance coding work group and is referenced by coders attending our webcast workshop in Sept 2016. Participants in the live call earn CEUs from AAPC and AHIMA.