Risk Adjustment True or False
Risk adjustment is important for medical loss ratio
What is true?
Common diagnoses that can be identified by just looking at a patient's BMI
What are morbid obesity and malnutrition? [Morbid obesity is BMI >/=40 or BMI 35-39.9 with complications; malnutrition is suggested by BMI <18.5. Remember that these diagnoses have important clinical implications.]
This member conducts clinical counseling visits with patients and families, including leading caregiver support needs, related to serious illness.
Who is the social worker?
This must be completed after administering a medication during a visit.
What is document in Salesforce?
List 3 benefits of P+.
What are improved patient experience, higher quality of care, reduced cost of care delivery, 24/7 access to a clinician, comprehensive interdisciplinary care (SW, behavioral health, HMBC MD, NP, RN care manager, pharmacist), collaborative relationships with patients' providers, home-based primary care,
As a clinician, learning the components of risk adjustment is purely a coding exercise and is a waste of my time.
What is false? [A risk score that reflects the actual medical complexity of a patient allows us to financially cover the cost of successful aging in place for our pts!]
These are 2 common "tubes/openings" that are commonly found on reviewing prior notes
What are tracheostomy, feeding tube/gastrostomy tube, indwelling urinary catheter dependence, colostomy or ileostomy [Remember, these must be open and functioning to contribute to risk score]
This member provides chronic condition management, provides guidance for PCM meetings and is on-call after hours.
Who is the Associate Medical Director (AMD)?
This person answers all after-hours calls and triages them to the after-hours NP/MD if further care is needed.
Who is the triage RN?
This calculation is the medical expenses (i.e. claims paid) divided by the insurance premiums received.
A problem listed in the problem list counts as clinical documentation for risk score capture purposes
What is false? Listing a problem in the problem list alone is insufficient documentation - remember that each problem needs sufficient supporting documentation like the MEAT acronym (monitor, evaluate, assess, treat)]
These are 2 important types of cardiology studies to review for risk score capture
What are EKG and echo? [EKG can show atrial fibrillation or other arrhythmias, echos can show systolic or diastolic CHF as well as pulmonary hypertension, remember to read the whole echo report and not just the impression]
This member provides medication consults for providers, virtual patient consults and comprehensive medication reconciliation.
Who is the pharmacist?
This should be filled out with the patient name, drug name, dosage, and instructions (includes a max of 72 hours worth of medications).
What is the white pill envelope?
If the NP is out doing visits and is worried about a hospitalized patient's medical treatment and transition of care, they can contact this team member to help coordinate care.
Who is the RN Care Manager?
I should start documenting in a way that supports risk score capture immediately.
What is true? [Scoring for the prior calendar year impacts the following year's score. The codes we document this year will be our only way to impact next year's scores.]
A common place to find incidentally noted aortic atherosclerosis or ectasia
What are radiology studies such as CT scans and chest xrays? [These diagnoses are often incidentally noted when patients have scans for other reasons - document the diagnosis in addition to your management]
This member has a panel of high complex patients, provides guidance during PCM meetings, and is available after-hours.
Who is the home-based medical care (HBMC) physician?
True or False: if a patient is symptomatic during an urgent visit, the clinician must contact the PCP before administering the medication.
What is false?
This is defined as "highly coordinated, person-centered approach that enables people living with significant medical, behavioral health, and social challenges to achieve their goals for better health and well-being."
What is complex care?
Coders can look at a problem (medical history) list and assume history of a chronic disease, like history of COPD, is referencing an active diagnosis
What is false! [Remember: Actively managed problems need to be documented in the Assessment/plan section.]
On lab review, a blood disorder in which both a low and high result can support an HCC code
What are throbocytopenia and thrombocytosis (low and high platelets) [Remember that pancytopenia and neutropenia also carry risk score weight]
This member provides complex medical care [e.g. condition management, (de)prescribing] for a panel of patients from various risk levels and presents at PCM
Who is the nurse practitioner?
This role, on a volunteer/paid basis, is responsible for completing urgent weekend visits.
A patient diagnosed with dementia with behavioral disturbances is making it difficult for caregiver to sleep. A consult to this care team member can explore psychiatric medication to address the concerns.
Who is the behavioral health provider?