Diagnosis Specificity

The realities of ICD-10 mean improved clinical documentation combined with complete and specific diagnosis coding drives your patient’s risk scores. In today’s Pay-for-Value world, getting diagnosis coding correct is essential to a medical group’s success.

The move to ICD-10 has driven many groups to increase electronic charge capture in the EMR. These efforts, combined with clinical documentation improvement (CDI) initiatives are critical to success in today’s pay-for-value world. While extremely important, these efforts alone do not ensure success with value-based reimbursement.

With pay-for-value programs, patients’ risk scores are critical to estimating the cost of caring for patients. Diagnosis codes and patient demographic data drive risk scores. Payers rely on claims data for diagnosis information. Submitting accurate and complete diagnosis information on insurance claims is your only mechanism to ensure the payers fully understand your patients’ health.

Risk Adjustment impacts the projected cost (in terms of dollars, time, and effort) payers allocate for treatment of a patient.   Diagnosis based risk adjustment impacts the following Pay-for-Value programs:

  1. Medicare Advantage Payers and Providers covering Medicare Advantage Patients
  2. Accountable Care Organizations (ACO)
  3. Comprehensive Primary Care Plus Program participants
  4. MACRA/MIPS Programs

With bonus dollars and penalties ranging from 4% to 9% of insurance revenue for MIPS and a significantly higher dollar impact for ACO’s, CPC+, and Medicare Advantage programs, medical groups cannot afford to miss the mark with diagnosis coding and the resulting risk adjustment.

RCxRules facilitates appropriate diagnosis coding by automatically reviewing 100% of the diagnosis codes passing from the EMR to the Revenue Cycle system. By leveraging all the published diagnosis coding guidelines, RCxRules will flag any encounter which lacks the appropriate diagnosis specificity. This allows the coders to review the encounter and make any appropriate corrections.   RCx also reports on situations where the clinical documentation does not support the level of diagnosis coding on the charge. This level of reporting supports provider education efforts on both clinical documentation improvements and diagnosis coding improvements.

Protect your revenue and your future.

Pay-for-value programs are not going away. CMS’s stated goal is for 85% of all Medicare FFS payments are tied to quality or value by the end of 2016, and 90% by the end of 2018.

Your physicians and your staff are working harder than ever, and the regulations continue to evolve. RCx is committed to leveraging our technology to help providers thrive in this difficult environment.      

Our rules engines in constantly evolving to keep pace with the ever-changing requirements that will define healthcare for the next decade to come.

Let’s face this challenge together.