What is a Medicare Risk Adjustment Factor (RAF)? | HIAcode.com

In 2003, the Centers for Medicare and Medicaid Services (CMS) implemented Risk Adjustment Factors (RAF) and Hierarchical Condition Category (HCC) coding to identify individuals with serious and/or chronic illnesses and assign them a risk factor score that is based on a combination of demographic information and reported diagnoses.

How it works: Diagnoses are reported using ICD-10-CM diagnosis codes and submitted by providers. The higher the number of chronic conditions listed, the more care is assumed—thus a greater cost for delivering that care.

What it means: For coders, the push toward value-based care and the HCC payment model have increased the significance of coding accurately and thoroughly. The coding of chronic conditions is not only used in determining healthcare outcomes, they are driving costs and, ultimately, reimbursement.

Let’s look at RAF in action and determine which example has the most thorough documentation:

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Example 1:

Chief Complaint: Chest pain.

HPI: Jane Doe is a 74 y.o. female who presents with chest pain. Pt is status post cardiac cath with coronary intervention in 2010 and 2014 who presents as transfer from the dialysis center for chest pain and possible NSTEMI. Patient states that around 1:30 pm she started having chest pain that radiates to her back. She describes the pain as a “heavy feeling” that “goes up into her neck” associated with numbness and tingling down her arm. She took Aspirin and Nitro which helped with the pain. She endorses a recent cold with cough but denies fevers or chills. Currently on Plavix, Toprol XL, Synthroid, Zocor and Lisinopril. Current 0.5 PPD cigarette smoker.

Past Medical History: Thyroid disease, Wears glasses.
Past Surgical History: Cardiac cath with coronary intervention. History hernia repair.

Exam: Temperature: 98.8°F, Heart Rate: 78, BP: 161/55, Respiratory Rate: 18.
Pain Score: 3
Constitutional: Appears in good health, appears stated age, no distress andvital signs reviewed.
Eyes: Conjunctiva clear. Pupils equal and round.
ENT: ENMT without erythema or injection, mucous membranes moist.
Neck: Supple, symmetrical, trachea midline.
Respiratory: Clear to auscultation bilaterally. No wheezes, rhonchi, or rales.
Cardiovascular: Regular rate and rhythm, S1, S2 normal, no murmur, click, rub or gallop.
Gastrointestinal: Soft, non-tender, Bowel sounds normal, non-distended.
Genitourinary: Deferred.
Musculoskeletal: Head atraumatic and normocephalic.
Integumentary: Skin warm and dry. No rashes and no lesions.
Neurologic: Grossly normal, CN II – XII grossly intact, Alert and oriented x3.
Lymphatic/Immunologic/Hematologic: No lymphadenopathy.
Psychiatric: Normal affect, behavior, memory, thought content, judgement, and speech.

Assessment/Plan:

Diagnosis
Chest pain possible NSTEMI (non-ST elevated myocardial infarction)
-Trop 52 before transfer; 54 currently; will continue to trend
-Previous Echo 2013: EF: 60-65%. Grade 1 diastolic dysfunction
-Heparin gtt continued
-NPO for cath tomorrow
-Continue Plavix, Toprol XL
-Started Lipitor and Aspirin

Hypothyroidism
-TSH 10.3; T4 pending
-Continue home synthroid for now
DVT/PE Prophylaxis: Heparin

Example 1 Codes

R07.9 Chest pain, unspecified
E03.9 Hypothyroidism (RxHCC)
F17.210 Nicotine dependence, cigarettes
Z79.02 Long term current use Plavix
Z79.899 Other long term drug therapy

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Example 2:

Chief Complaint: Chest pain.

HPI: Jane Doe is a 74 y.o. female who presents with chest pain. Pt is status post cardiac cath with PCI and stent placement in 2010 and CABG 2014 who presents as transfer from the dialysis center for chest pain and possible NSTEMI. Patient states that around 1:30 pm she started having chest pain that radiates to her back while on dialysis. She describes the pain as a “heavy feeling” that “goes up into her neck” associated with numbness and tingling down her arm. She took Aspirin and Nitro which helped with the pain. She endorses a recent cold with cough but denies fevers or chills. Currently on Plavix, Toprol XL, Synthroid, Zocor and Lisinopril. Current 0.5 PPD cigarette smoker.

Past Medical History: History of MI in 2010. Dialysis Monday, Wednesday, and Friday for ESRD. The patient also has hyperlipidemia, hypertension and thyroid disease. Wears glasses.
Past Surgical History: Cardiac cath with PCI and stent placement 2010 and CABG in 2014. History hernia repair.
Exam: Temperature: 98.8°F, Heart Rate: 78, BP: 161/55, Respiratory Rate: 18.
Pain Score: 3
Constitutional: Appears in good health, appears stated age, no distress and vital signs reviewed.
Eyes: Conjunctiva clear. Pupils equal and round.
ENT: ENMT without erythema or injection, mucous membranes moist.
Neck: Supple, symmetrical, trachea midline.
Respiratory: Clear to auscultation bilaterally. No wheezes, rhonchi, or rales.
Cardiovascular: Complains of chest pain, heart regular rate and rhythm, S1, S2 normal, no murmur, click, rub or gallop.
Gastrointestinal: Soft, non-tender, Bowel sounds normal, non-distended.
Genitourinary: Deferred.
Musculoskeletal: Head atraumatic and normocephalic.
Integumentary: Skin warm and dry. No rashes and no lesions.
Neurologic: Grossly normal, CN II – XII grossly intact, Alert and oriented x3.
Lymphatic/Immunologic/Hematologic: No lymphadenopathy.
Psychiatric: Normal affect, behavior, memory, thought content, judgement, and speech.

Assessment/Plan:

Diagnosis
Chest pain possible NSTEMI (non-ST elevated myocardial infarction)
-Trop 52 before transfer; 54 currently; will continue to trend
-Previous Echo 2013: EF: 60-65%. Grade 1 diastolic dysfunction
-Heparin gtt continued
-NPO for cath tomorrow
-Continue Plavix, Toprol XL
-Started Lipitor and Aspirin
ESRD
-Dialysis M,W,F
-Check BUN and Creatinine
Hypertension
-Continue Lisinopril
Hyperlipidemia
-Continue Zocor
Hypothyroidism
-TSH 10.3; T4 pending
-Continue home synthroid for now
DVT/PE Prophylaxis: Heparin

Example 2 Codes

R07.9 Chest pain, unspecified
I12.0 Hypertensive chronic kidney disease, ESRD (HCC 136)
N18.6 ESRD (HCC 136)
Z99.2 Dependence on renal dialysis (HCC 134)
I25.2 Old myocardial infarction (RxHCC)
E03.9 Hypothyroidism (RxHCC)
E78.5 Hyperlipidemia (RxHCC)
Z95.1 Presence of aortocoronary bypass graft
Z95.5 Presence of coronary angioplasty implant and graft
F172.10 Nicotine dependence, cigarettes
Z79.02 Long term current use Plavix
Z79.899 Other long term drug therapy

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The documentation thoroughness reflected in the specific details of Example 2 is clearly superior.

The Code Hard Truth: Every Code Counts

While HIM professionals have always known the importance of thorough and complete coding, the theory that EVERY CODE COUNTS now means more than ever.

Coders should familiarize themselves with the HCC payment plan as well as other risk adjusted models. Following Medicare guidelines for documenting and coding chronic conditions can not only enhance quality of care, but also improve financial performance.

Partnering with an experienced coding consulting company can produce measurable improvements. You can expect better documentation and increased coding compliance, thus improving financial and quality indicators. This is the foundation for ensuring overall readiness for new value-based reimbursement models.