Transcription of Risk Adjustment Coding and HCC Guide
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Risk Adjustment Coding and HCC Guide
Power up your Adjustment Coding and HCC Guide2018 Optum360, LLCiContentsIntroduction .. 1 History and purpose of RAF ..1 Key Terms Definitions ..3 Acceptable provider types/SOS ..5 The provider s role ..6 Payment Methodology ..8 RAF Payment Timeline ..12 Coding and Documentation ..15 Explanation of impact of good documentation (table example).. 15 CMS 20 Coding Guidelines .. 44 Tools (MEAT/TAMPER) .. 48 Coding Scenarios/Examples/Teaching .. 59 Audits .. 79 Medicare Advantage Risk Adjustment Data Validation (RADV) .. 79 Health Effectiveness Data & Information Set (HEDIS) .. 87 Internal Care and Quality Improvement Audits ..91 Care and Quality Improvement Audits .. 91 Appendixes - Includes HCC with description, hierarchies, and ICD-10 Mappings .. 103 CMS HCCs .. 105Rx HCCs .. 395 PACE .. 445 HHS-HCC .. 495 RAF weights tables .. 5352018 Optum360, LLC1 IntroductionThe traditional fee-for-service payment model has been widely used since the 1930s when health insurance plans initially gained popularity within the United States.
hyperlipidemia, and obstructive sleep apnea (OSA). This note validates that the breast cancer is an active problem which is being treated. The provider documented that the patient is undergoing treatment with tamoxifen and is seeing an oncology provider. The history portion of this note also shows that it was updated on the date of service (DOS).
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