Providers should code all members based on risk

It’s important for providers to base coding on each member’s level of risk, or severity of illness and intensity of care, whether the member is covered through one of our commercial, Medicare Advantage or Medicaid plans. Health care providers should also maintain clinical documentation to support the risk-based coding.

Here’s why we’re encouraging providers to adopt this unified approach to risk-based coding and documentation for all members:

• The core principles related to risk-based coding methodologies and goals are shared across all lines of business:
• Blue Cross commercial and BCN commercial
• Medicaid, for Blue Cross Complete
• Medicare Advantage, for Medicare Plus Blue℠ and BCN Advantage℠
• Providers can develop more streamlined strategies and workflows when they code for all members based on risk levels. They can also tailor the details to the specific requirements for each line of business, as needed.

This more unified approach to risk-based coding and documentation will be used in the ongoing education, support, reporting and communication about proper coding that Blue Cross, BCN and Blue Cross Complete offer through:

• Coding webinars
• Documents that detail frequently asked questions along with answers
• In-office or virtual education about coding and documentation questions
• Regular updates to providers about regulatory or program changes

Other benefits of risk-based coding and documentation

When providers’ coding and records reflect the precise nature and severity of the member’s conditions:

• Care teams can make more informed decisions and provide more seamless care coordination, which in turn lead to improved patient outcomes.
• Blue Cross, BCN and Blue Cross Complete can reduce the administrative burden on providers, resulting in less frequent denials and inquiries from coders. This will allow providers to spend more time on patient care than on resolving coding and documentation issues. 
• Providers can reduce the chance that they’ll be subject to audits and penalties.

How the processes are similar

There are important ways in which the risk-based coding and documentation processes are similar for all lines of business. Specifically, these processes:

• Rely on complete and accurate clinical documentation to calculate risk scores effectively, with an emphasis on capturing chronic conditions and claims submissions. Similar chronic conditions frequently drive risk adjustment — for example, diabetes, chronic kidney disease, chronic obstructive pulmonary disease and congestive heart failure.
• Require providers to document with specificity and include details that support the diagnosis codes. Using ICD-10 codes and submitting the documentation that aligns with those codes are fundamental to all lines of business. This means that providers must:
• Identify the key codes tied to risk adjustment and submit them to the health plan through claims.
• Avoid common errors such as upcoding or under-coding.
• Follow the coding guidelines issued by the Centers for Medicare & Medicaid Services and other regulatory bodies.

Application to other areas

This new approach to risk-based coding education across lines of business will eventually be applied in other areas, such as the Healthcare Effectiveness Data and Information Set, or HEDIS^®, measures, the CMS Star Rating system, and pharmacy claims and documentation.

HEDIS^® is a registered trademark of the National Committee for Quality Assurance.