{"id":31572,"date":"2024-03-06T14:19:16","date_gmt":"2024-03-06T19:19:16","guid":{"rendered":"https:\/\/avalere.com\/?p=31572"},"modified":"2024-09-23T12:20:08","modified_gmt":"2024-09-23T16:20:08","slug":"trends-in-risk-adjustment-coding-operations","status":"publish","type":"post","link":"https:\/\/advisory.avalerehealth.com\/insights\/trends-in-risk-adjustment-coding-operations","title":{"rendered":"Trends in Risk Adjustment Coding Operations"},"content":{"rendered":"<p><span data-contrast=\"auto\">Health plans use member charts collected from providers to evaluate clinical evidence of submitted diagnosis codes for risk adjustment. Proper and effective coding operations are critical for both (1) ensuring that plans have sufficient documentation to substantiate diagnoses submitted for risk adjustment and (2) obtaining the most accurate and holistic view of their members to improve care and services. Avalere conducted in-depth interviews with seven experts responsible for overseeing coding operations, ranging from small to large plans. Through our discussions, combined with our industry experience, we have identified the following themes in coding for risk adjustment:<\/span><span data-ccp-props=\"{&quot;201341983&quot;:0,&quot;335559739&quot;:0,&quot;335559740&quot;:240}\">\u00a0<\/span><\/p>\n<h2><b><span data-contrast=\"auto\">Theme 1: Plans are increasingly raising the bar for coder accuracy requirements as part of regular performance monitoring.<\/span><\/b><span data-ccp-props=\"{&quot;201341983&quot;:0,&quot;335559739&quot;:0,&quot;335559740&quot;:240}\">\u00a0<\/span><\/h2>\n<p><span data-contrast=\"auto\">Requiring coders to maintain an accuracy rate of 95% or higher has been typical in the industry. However, a 96\u201397% accuracy rate is becoming more common, particularly as the stakes become higher in risk score accuracy. Plans typically audit and test coder performance anywhere from annually to as frequently as monthly depending on the health plan\u2019s size and available resources.<\/span><span data-ccp-props=\"{&quot;201341983&quot;:0,&quot;335559739&quot;:0,&quot;335559740&quot;:240}\">\u00a0<\/span><\/p>\n<h2><b><span data-contrast=\"auto\">Theme 2: Provider engagement is an important aspect of coding operations.<\/span><\/b><span data-ccp-props=\"{&quot;201341983&quot;:0,&quot;335559739&quot;:0,&quot;335559740&quot;:240}\">\u00a0<\/span><\/h2>\n<p><span data-contrast=\"auto\">Health plans regularly offer education and support to providers and their coding staff to improve their coding and documentation practices. Plans rely heavily on provider engagement, education, and adequate documentation to meet regulatory and policy standards to strengthen their risk adjustment operations. In practice, coders will adhere to official guidelines utilizing industry standard approaches such as Monitoring, Evaluation, Assessment, Treatment (MEAT) or Treatment, Assessment, Monitor\/Medicate, Plan, Evaluate, Referral (TAMPER) to determine which conditions should be reported during patient encounters. Health plans with robust analytics can tailor provider outreach and education by identifying providers prone to risks (e.g., evidence of highest error rates, documentation errors, coding errors)\u00a0<\/span><span data-ccp-props=\"{&quot;201341983&quot;:0,&quot;335559739&quot;:0,&quot;335559740&quot;:240}\">\u00a0<\/span><\/p>\n<h2><b><span data-contrast=\"auto\">Theme 3: Plans are looking to integrate analytics into their compliance programs.<\/span><\/b><span data-ccp-props=\"{&quot;201341983&quot;:0,&quot;335559739&quot;:0,&quot;335559740&quot;:240}\">\u00a0<\/span><\/h2>\n<p><span data-contrast=\"auto\">Plans are increasingly interested in improving their analytic capabilities to use their data to identify possible areas that will reduce financial and legal risks. Sophisticated software and enhanced analytic capabilities offer preventive pathways that can identify inaccurate coding or unsupported documentation, thereby reducing risks and adequately preparing a plan for potential HHS-OIG audits. These types of analytics capabilities should consider the member\u2019s total clinical profile and longitudinal record. They can be a valuable tool as part of overall compliance programs to proactively monitor for risk areas and inform solutions.<\/span><span data-ccp-props=\"{&quot;201341983&quot;:0,&quot;335559739&quot;:0,&quot;335559740&quot;:240}\">\u00a0<\/span><\/p>\n<p><span data-contrast=\"auto\">Health plans should consider evaluating their coding operations regularly to assess and improve operational efficiencies, maintain compliance with current guidelines and state and federal laws, and to effectively set and achieve plan goals.<\/span><span data-ccp-props=\"{&quot;201341983&quot;:0,&quot;335559739&quot;:0,&quot;335559740&quot;:240}\">\u00a0<\/span><\/p>\n<p><span data-contrast=\"auto\">To learn more about how to implement industry best practices in risk adjustment coding and how Avalere can help, <\/span><a href=\"https:\/\/pages.avalere.com\/Keep-In-Touch.html\"><span data-contrast=\"none\">connect with us<\/span><\/a><span data-contrast=\"auto\">.<\/span><span data-ccp-props=\"{&quot;201341983&quot;:0,&quot;335559739&quot;:0,&quot;335559740&quot;:240}\">\u00a0<\/span><\/p>\n","protected":false},"excerpt":{"rendered":"<p>Health plans use member charts collected from providers to evaluate clinical evidence of submitted diagnosis codes for risk adjustment. Proper and effective coding operations are critical for both (1) ensuring that plans have sufficient documentation to substantiate diagnoses submitted for risk adjustment and (2) obtaining the most accurate and holistic view of their members to&hellip;<\/p>\n","protected":false},"author":17,"featured_media":12512,"comment_status":"open","ping_status":"open","sticky":false,"template":"","format":"standard","meta":{"_acf_changed":false,"footnotes":""},"categories":[3],"tags":[1032],"content-categories":[1023],"class_list":["post-31572","post","type-post","status-publish","format-standard","has-post-thumbnail","hentry","category-insights","tag-future-health-plans","content-categories-coverage-and-payment","entry","has-media"],"acf":[],"yoast_head":"<!-- This site is optimized with the Yoast SEO plugin v24.0 - https:\/\/yoast.com\/wordpress\/plugins\/seo\/ -->\n<title>Trends in Risk Adjustment Coding Operations | Avalere Health Advisory<\/title>\n<meta name=\"robots\" content=\"index, follow, max-snippet:-1, max-image-preview:large, max-video-preview:-1\" \/>\n<link rel=\"canonical\" href=\"https:\/\/advisory.avalerehealth.com\/insights\/trends-in-risk-adjustment-coding-operations\" \/>\n<meta property=\"og:locale\" content=\"en_US\" \/>\n<meta property=\"og:type\" content=\"article\" \/>\n<meta property=\"og:title\" content=\"Trends in Risk Adjustment Coding Operations | Avalere Health Advisory\" \/>\n<meta property=\"og:description\" content=\"Health plans use member charts collected from providers to evaluate clinical evidence of submitted diagnosis codes for risk adjustment. Proper and effective coding operations are critical for both (1) ensuring that plans have sufficient documentation to substantiate diagnoses submitted for risk adjustment and (2) obtaining the most accurate and holistic view of their members to&hellip;\" \/>\n<meta property=\"og:url\" content=\"https:\/\/advisory.avalerehealth.com\/insights\/trends-in-risk-adjustment-coding-operations\" \/>\n<meta property=\"og:site_name\" content=\"Avalere Health Advisory\" \/>\n<meta property=\"article:published_time\" content=\"2024-03-06T19:19:16+00:00\" \/>\n<meta property=\"article:modified_time\" content=\"2024-09-23T16:20:08+00:00\" \/>\n<meta property=\"og:image\" content=\"https:\/\/advisory.avalerehealth.com\/wp-content\/uploads\/2018\/09\/3135-1-Eric_Levine_600x400.jpg\" \/>\n\t<meta property=\"og:image:width\" content=\"600\" \/>\n\t<meta property=\"og:image:height\" content=\"400\" \/>\n\t<meta property=\"og:image:type\" content=\"image\/jpeg\" \/>\n<meta name=\"author\" content=\"cturner\" \/>\n<meta name=\"twitter:card\" content=\"summary_large_image\" \/>\n<meta name=\"twitter:creator\" content=\"@avalerehealth\" \/>\n<meta name=\"twitter:site\" content=\"@avalerehealth\" \/>\n<meta name=\"twitter:label1\" content=\"Written by\" \/>\n\t<meta name=\"twitter:data1\" content=\"cturner\" \/>\n\t<meta name=\"twitter:label2\" content=\"Est. reading time\" \/>\n\t<meta name=\"twitter:data2\" content=\"3 minutes\" \/>\n<!-- \/ Yoast SEO plugin. -->","yoast_head_json":{"title":"Trends in Risk Adjustment Coding Operations | Avalere Health Advisory","robots":{"index":"index","follow":"follow","max-snippet":"max-snippet:-1","max-image-preview":"max-image-preview:large","max-video-preview":"max-video-preview:-1"},"canonical":"https:\/\/advisory.avalerehealth.com\/insights\/trends-in-risk-adjustment-coding-operations","og_locale":"en_US","og_type":"article","og_title":"Trends in Risk Adjustment Coding Operations | Avalere Health Advisory","og_description":"Health plans use member charts collected from providers to evaluate clinical evidence of submitted diagnosis codes for risk adjustment. Proper and effective coding operations are critical for both (1) ensuring that plans have sufficient documentation to substantiate diagnoses submitted for risk adjustment and (2) obtaining the most accurate and holistic view of their members to&hellip;","og_url":"https:\/\/advisory.avalerehealth.com\/insights\/trends-in-risk-adjustment-coding-operations","og_site_name":"Avalere Health Advisory","article_published_time":"2024-03-06T19:19:16+00:00","article_modified_time":"2024-09-23T16:20:08+00:00","og_image":[{"width":600,"height":400,"url":"https:\/\/advisory.avalerehealth.com\/wp-content\/uploads\/2018\/09\/3135-1-Eric_Levine_600x400.jpg","type":"image\/jpeg"}],"author":"cturner","twitter_card":"summary_large_image","twitter_creator":"@avalerehealth","twitter_site":"@avalerehealth","twitter_misc":{"Written by":"cturner","Est. reading time":"3 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