For Organizations and Clinicians.
New to risk coding? Check out my succinct, value-packed, yet incredibly easy-to-understand risk adjustment factor (RAF) post for absolutely everything you need to know to be successful in one easy bite. It’s the only primer on the web written by a PCP who’s been there/done that—and been wildly successful at doing it. That’s probably why it’s so great!
More in-depth, yet still easy-to-understand primers on how to succeed working within Medicare Advantage here and here. Or simply click here and scroll down for the mother load.
And now, on to Success Codes:
If you’re working a Medicare Advantage contract, chances are you’ve been inundated with reference sheets and training programs with endless lists of ICD-10 codes you need to keep a watch out for. Maybe they even tell you what specific documentation is needed so you don’t end up here.
These efforts enable your medical directors or insurance reps to check their boxes and prove to their supervisors that they’ve “educated” you. Have you actually been educated?—well, you are reading this.
As a back-up (and possibly as a preliminary to supplanting you altogether) your organization probably has passive coding tools running in the background of your EHR as well, popping up code submission prompts until you’re ready to do real violence to your screen.
Information overload, ineffectively presented.
Yet you want to do well for yourself and by your patients.
What to do?
Don’t worry.
It’s actually pretty simple.
For true mastery you don’t need to know all those risk codes.
The acute stroke and heart attack codes, the metastatic cancers—those are all going get submitted in the normal course of treatment. Don’t worry about those.
You just need to master the small number of codes that won’t get submitted at all unless you do it yourself—they’re the ones you simply MUST capture if you want to succeed.
I call them “Success Codes”.
Periodically, you’ll be seeing specific “Success Codes” discussed in this space.
I’ll identify the name of the condition, its ICD-10 “neighborhood” and throw in a few pearls along the way. Pay special attention to any lines in red text—they’re especially key.
Given the specificity of the ICD-10 system, most of the codes won’t be present to the final character, but you can figure out the last digit or two based on your patient’s own specific presentation.
I’ll even throw in the relative RAF score—the conversion factor that affects the amount of your monthly payments—so you can see that catching these codes is well worth the effort.
For your reference, when I state that a RAF adjustment is in the neighborhood of 0.1-0.3, that means once the data works its way through the system, your patient’s monthly capitation will increase by up to 10%-30%—not huge but It’ll definitely help you pay your way.
Codes with a greater than 0.5 (up to a 50%) increase is a “must catch” if you want to do well.
If a condition with a RAF of 0.8 (80%) or more is available, then catching it is absolutely mandatory if you want to succeed—miss it an you’re condemning yourself to a year’s worth of indifferent financial performance at best. And a big, long term financial loss at worse.
You are risk-sharing. You’re responsible for paying for part of the costs of your patient’s care. Make sure you capture the resources to do so.
(If you aren’t risk-sharing within your organization, stop reading now. Get a new job—your current employer sees you as a tool.)
Remember, we’re talking about medical conditions that are both truly present and that you have clinically addressed.
Documenting illness that either aren’t actually there or that you didn’t take care of is simply fraud—and definitely NOT worth the cost. Ask him.
Learning the “Success Codes” is a big reason why I did so well in my Medicare Advantage experience.
I concentrated on the codes I knew no one but me was going to catch. That way I avoided being overwhelmed with minutia and I could concentrate on taking good care of my patients.
You concentrate on the “Success Codes” as well.
Your outperformance will astonish—everyone.
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