The Coding Corner

April 2022
Risk Adjustment Coding Update and Coding Examples

The following examples are from visits that had missed coding opportunities. These missed coding opportunities will affect the patients’ Risk Adjustment Factor (RAF) scores that support allocated dollars for healthcare costs in 2023. It is necessary to update patient’s conditions each year to help support a patient’s health status.

Coding Example 1

  • Patient has his annual exam visit. He has Type 2 diabetes, controlled through diet and salt intake. His A1c is at goal. He is taking Lisinopril for his hypertension and he has hyperlipidemia. He has stopped smoking and is eating a low-fat diet, which has helped reduce his lipid levels. He is currently seeing oncology for his thyroid cancer that was identified this past year. Overall, he is following his treatment plan. I have encouraged weight loss due to his obesity and BMI is >40. I will plan to see him in 3 months for his follow-up and hope to see weight reduction.
  • Coding by provider:
    • Diabetes Type 2: E11.9
    • Hypertension: I10
    • Thyroid Cancer: C73
  • Accurate Coding Capture:
    • Thyroid Cancer: C73
    • Diabetes Type 2 with complications: E11.69
    • Hypertension: I10
    • Hyperlipidemia: E78.5
    • Morbid Obesity E66.01
    • BMI>40: Z68.41

Coding Example 2

  • Coding Annual Visits as Z00.00 only, not addressing Chronic Conditions
  • Chronic Conditions:
    • Diabetes Type 2: current A1c: 8.9
    • Takes an oral diabetes Rx
    • Overdue diabetes eye exam and patient has cataracts
    • CKD 2
    • COPD
  • Coding by provider: Z00.00 only and did not address chronic conditions
    • Accurate Coding Capture:
      • Diabetes with CKD 2: E11.22, N18.2
      • Diabetes long term oral Rx: Z79.84
      • Diabetes with cataract: E11.36, H26.9
      • CKD 2: N18.2
      • COPD: J44.9

Coding Example 3

  • Many providers are still missing Morbid Obesity Coding Capture Accurately. BMI>35 will risk adjust. The E code and Z code must be captured together in order for the coding to risk adjust. An estimated $2,800 will go into a patient budget to support obesity annual care: Nutrition, Weight Counseling, and Medication.
  • Provider Example: Patient weight is 307lbs their BMI>45
    • Coding by provider: Morbid Obesity Z66.01
    • Accurate Coding Capture should be: Morbid Obesity Z66.01, BMI>45 Z68.4
  • Provider Example: Patient weight is 187lbs their BMI>36
    • Coding by provider: Obesity E66.9
    • Accurate Coding Capture should be: E66.9, BMI>36 Z68.36

Please reach out to Shawn Bromley with additional questions or interest regarding Risk Adjustment Coding capture. or 978-238-6902.

2021 OIG Workplan

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Please click here for the most recently added Work Plan items