Risk Adjustment Documentation & Coding

Risk Adjustment Documentation & Coding
2nd Ed.
2020 © American Medical Association
Sheri Poe Bernard, CCS-P, CPC, CRC, CDEO
ISBN-13: 978-1-64016-039-2
eISBN-13: 978-1-64016-040-8
Coding & Classification


Capturing risk in medical documentation and coding successfully gives a complete and accurate picture of your patients’ health; but it is also critical for ensuring proper reimbursement, managing cost, projecting future resource requirements, and delivering high-quality care.

Chronic diseases are not outliers, especially in older patients. 80% percent of older adults have at least one chronic condition. If you have any Medicare patients with chronic conditions and if you are participating in Merit-based Incentive Payment Systems (MIPS), the AMA’s Risk Adjustment, Documentation and Coding 2e (RA, 2e) will help you capture the care rendered so the severity of your patients’ illnesses is adequately captured to reflect your utilization. If you omit risk-adjusting diagnoses because a specialist is managing the care of your patient’s chronic condition, you are hurting your MIPS efficiency rating. Most chronic conditions will impact the overall health of the patient; therefore, they are appropriate to capture for your documentation.

In a value and outcome-based health care environment, lack of specificity in ICD-10-CM coding and documentation has ripple effects for a practice and its patients, like – loss of important data and financial returns and increased patient risk. Continuity of care and a complete picture of a patient’s overall health are key to quality care. Connecting diagnosis with comorbidities (causes) with ICD-10-CM codes (such as hypertension with heart disease or diabetes and hyperlipidemia with diabetes, etc.) for patients with chronic conditions helps improve care and documentation. RA, 2e, covers this in detail and can help you document your patient’s health and wellbeing, and help you get the right reimbursement, especially for your high-risk patients.

Use Risk Adjustment Documentation & Coding, 2nd Edition, to:

  • • Improve documentation in general and in relation to severity of illness and chronic diseases with risk adjustment parameters.
  • • Code more accurately with expert guidelines and recommendations.
  • • Connect diagnosis with comorbidities (cause) with the checklists in the teaching/training tools for the 10 most common chronic diseases.

The impact of risk-adjustment coding (hierarchical condition category (HCC) coding) on a practice is significant because:

  • • More than 75 million Americans are enrolled in risk-adjusted insurance plans. This population represents more than 20% of those insured in the United States.
  • • Insurance risk pools under the Affordable Care Act include risk adjustment.
  • • CMS, which disbursed more than $900 million in MIPS bonuses for 2020, is tightening requirements for these bonuses, and has also proposed expanding audits on risk-adjustment coding.


  • • Five chapters delivering an overview of risk adjustment, common administrative errors, best practices, and guidance for development of internal risk-adjustment coding policies, which are organized by diagnoses topic (diabetes, dementia, ischemic heart, etc). Each topic has separate guidance for documentation and for coding.
  • • 10 ICD-10-CM teaching/training tools for the top-10 most-common chronic diseases to help with documentation and coding.
  • • 10 ICD-10-CM coding aid for quick reference and code selection for the top-10 most-common chronic diseases.
  • • Two appendices offering mappings and tabular information of ICD-10-CM codes that risk-adjust to CMS-HCCs (used for MIPS) and RxHCCs.

Learning and design features:

  • Vocabulary terms highlighted within the text and defined at the bottom of the page.
  • "Advice/Alert Notes" that highlight important coding and documentation advice from federal regulatory sources.
  • "Sidebars" that provide derivative story and additional information, such as:
          o "Coding Tips" " that guide physicians and coders with practical advice from sources like AHA's Coding Clinic and cautionary notes about conflicts and exceptions.
          o "Clinical Examples" that underscore key documentation issues for risk adjustment.
          o "Clinical Coding Examples" that provide snippets or full encounter notes and codes to illustrate risk-adjustment coding and documentation concepts.
          o "Documentation tips" that highlight recommendations to physicians regarding what should be included in the medical record or how ICD-10-CM may classify specific terms.
          o "Examples" that explain difficult concepts and promote understanding of those concepts as they relate to a section.
          o "FYI" call outs that provide quick facts.
          o "Abstract & Code It!" exercises that test diagnosis abstraction and coding skills (exclusive to Chapter 4).

Assessment tools for instructors and independent learners:

  • Extensive end-of-chapter "Evaluate Your Understanding" sections that include multiple-choice questions, true-or false questions, and audit- and Internet-based exercises.
  • • Two downloadable course tests and slide presentations for each chapter.
  • • Exclusive content for academic educators: A test bank containing 100 questions and a mock risk-adjustment certification exam with 150 questions.

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