Risk Adjustment/Coding Toolkit

Coding work group case study chronic condition in routine exam
It is argued that, according to ICD guidelines, providers should not bill for chronic conditions at routine examinations, even if addressed.

Coding work group case study prostate cancer current vs history
These two "problem charts" have been submitted by Health New England for consideration by the Alliance coding work group, and address the issue of coding cancer current vs. history.

Alliance coding work group: proposed approach
Alliance members met in March 2016 to discuss a potential approach to forming a coding work group, which would support certified coders within member health plans. This document outlines that proposed approach.

Initial idea: Coding work group for the Health Plan Alliance
Jessica Dupont made the initial pitch for our coding work group. Listen to her description of what the group could do for our Alliance members.

Coding Specialist
Perform onsite or electronic audits of medical records/claims to ensure proper medical diagnoses are being submitted for reimbursement. Responsible for the validation of diagnosis codes as well as the identification of missing diagnoses codes submitted on the claim and more.

Risk Adjustment Quality Assurance and Compliance Procedure Manual
To ensure quality submission of HCC codes to the Center for Medicare & Medicaid Services (CMS) by auditing prospective and retrospective chart reviews.

CMS Contract-Level Risk Adjustment Data Validation Medical Record Reviewer Guidance - September 2017
The Contract-Level Risk Adjustment Data Validation (RADV) Medical Record Reviewer Guidance has been created to provide information on the RADV medical record process. These guidelines are used by coders to evaluate the medical records submitted by plans to validate audited diagnoses.