What is risk adjustment?
Risk adjustment is a payment methodology used by the Centers for Medicare & Medicaid Services (CMS) to ensure health plans are reimbursed appropriately for covering the cost of care for Medicare Advantage and Affordable Care Act (ACA) members. To ensure that CMS has an accurate picture of the members' health status, health plans rely on providers to conduct face-to-face visits, document conditions appropriately in the medical record, and ensure conditions are submitted on a claim.
Having accurate claims and documentation data allows us to:
- Identify members who may benefit from disease and medical management programs
- Plan and evaluate our current programs
- Design new programs for managing chronic conditions
- Minimize practice disruptions for medical record requests and claim resubmissions by reducing the need for chart reviews
Blue Cross Blue Shield of Massachusetts partners with provider organizations to receive direct electronic medical records (EMR) access, allowing us to extract only the information we need. This method eliminates the need for your office staff to pull medical records and send them to us, saving resources for your individual practices. For more information on setting up remote EMR access, please contact Risk Adjustment at 1-617-246-3059.
Important risk adjustment telehealth information
In an April 10, 2020 memo, CMS instructs Medicare Advantage organizations to allow telehealth service diagnoses for risk adjustment if they meet certain criteria.
Medicare members can use telecommunication technology for services that typically would occur in person. Examples: evaluation and management, medical office visits, mental health counseling sessions.
Telehealth visits must meet the criteria for risk adjustment eligibility; they must be:
- Via interactive audio and video technology
- From an inpatient, outpatient, or professional service
- From a face-to-face encounter
- From an acceptable provider type
An electronic signature must occur within 180 days of each encounter. A valid electronic signature must contain:
- Provider name
- Credential
- Date stamp
- Time stamp
- Signature statement such as: completed by, signed by, finalized by, verified by
Resources
Fact sheet
Risk Adjustment In-home care program with Signify Health™
Coding tip flashcards
Active voice
Chronic kidney disease
Diabetes
DVT
Fracture
Major depressive disorder
Status codes
TAMPER
Unconfirmed diagnosis
Contact us
For questions about documentation and coding, send an email to the Risk Adjustment Coding Quality Education Team.
