U.S. Department of Health and Human Services (HHS) requires risk adjustment for commercial small group and individual benefit plans. Similar to the CMS risk adjustment program for MA benefit plans, HHS uses Hierarchical Condition Categories (HCCs) to calculate an annual patient risk score that represents the specific patient’s disease burden. Every year, CMS and HHS require information about the demographic and health of our members. Diagnoses do not carry forward to the following year and must be assessed and reported every year.
The risk adjustment data you give us, including clinical documentation and diagnosis codes, must be accurate and complete. It is critical for you to refer to the ICD-10-CM coding guide to code claims accurately. To comply with risk adjustment guidelines, specific ICD-10-CM codes are required.
- Medical records must support all conditions coded on the claims or encounters you submit using clear, complete and specific language.
- Code all conditions that co-exist at the time of the member visit and require or affect member care, treatment or management.
- Never use a diagnosis code for a “probable” or “questionable” diagnosis. Code only to the highest degree of certainty for the encounter/visit. Include information such as symptoms, signs, abnormal test results and/or other reasons for the visit.
- Specify whether conditions are chronic or acute in the medical record and in coding. Only choose diagnosis code(s) that fully describe the member’s condition and pertinent history at the time of the visit. Do not code conditions that no longer exist.
- Carry the diagnosis code all the way through to the correct digit for specificity. For example, do not use a 3-digit code if a five- digit code more accurately describes the member’s condition.
- Check the diagnosis code against the member’s gender.
- Sign chart entries with credentials.
- All claims and/or encounters submitted to us for risk adjustment consideration are subject to federal and/or UnitedHealthcare audit. Audits may come from CMS, HHS, or us, where we may select certain medical records to review to determine if the documentation and coding are complete and accurate. Give us any requested medical records quickly. Provide all available medical documentation for the services rendered to the member.
- Notify us immediately about any diagnostic data you have submitted to us that you later determine may be erroneous.
CMS HCC risk adjustment
We offer an alternate method of reporting CMS risk adjustment data in addition to the normal claim/encounter submission process. All encounter submissions are required to process 837 Claim Encounter in a HIPAA 5010 compliant format. To supplement a previously submitted 837 Claim/Encounter, you may submit an 837 replacement claim/encounter or send additional diagnosis data related to the previously submitted 837 through the Optum ASM Operations FTP process. If you choose to submit by ASM, you will first need to contact the Optum ASM Operations team at email@example.com to start the onboarding process.