Risk Adjustment Coders: Partners for Financial Success in Value-Based Care

As more providers pivot to and embrace value-based care, their foremost concern is delivering the highest quality service to patients while using available resources appropriately. But they also have another priority that stays top of mind: ensuring their financial solvency under a new care model. 

Financial success requires a multi-faceted strategy, and accurate coding of services is a vital component. However, providers can’t protect their bottom line alone. They need help.  

Risk adjustment coders partner with practices to help them understand the importance of correctly using condition codes to estimate patients’ future healthcare costs.  

Hierarchical condition category (HCC) coding is a risk-adjustment model that uses diagnosis and symptom information to give patients a risk score. Patients with higher scores have more complex or chronic conditions and usually require more services.  

Because these risk scores are based on condition codes, inaccurate recording can lead to over- or underpayments. Inaccurate coding also directly affects the level of resources providers receive.  

“Risk-adjusted coding is very important to value-based care,” explains Diedra Mallory, CPC, CRC, manager of risk adjustment coding for Innovista Health. “Our providers must have the resources necessary to treat the conditions they see on a regular basis,” Mallory says. “Patients with chronic illnesses take up a lot of resources. A risk adjustment coder ensures practices are educated and can provide the necessary information to payers about their services.” 

The Role and Impact of Risk Adjustment Coders 

Ultimately, risk adjustment coders serve as a provider’s eyes and ears for coding. They make certain the office staff understands how to capture the details about every patient encounter correctly. 

“Our number-one priority is staying abreast of different coding changes and updates to guidelines that come across periodically,” Mallory says. “We’re responsible for staying informed about how our providers can correctly document how sick or how well their patients are.” 

With that knowledge, risk adjustment coders conduct chart audits to detect coding errors or fraudulent activity. These audits can also confirm a practice’s compliance with the latest regulations and guidelines. There are several types of risk adjustment audits: 

• Retrospective: Looking back through three years of data to identify opportunities for improvement 
• Quality assurance: Analyzing documentation to ensure it meets compliance standards 
• Prospective: Providing clinicians with patient medical chart updates 
• Post-visit: Ensuring providers bring patients in for follow-up visits 

A big part of the risk adjustment audit process is identifying the high-risk patients or patients who drive up costs by using the emergency room rather than scheduling an appointment with a primary care provider or using an urgent care clinic or mobile medical provider like Dispatch Health. 

In addition to chart audits, risk adjustment coders have several other responsibilities, including: 

• Completing post-visit health risk assessments for insurance companies to collect additional revenue for clinics 
• Maintaining quality and productivity standards for code selection, coding review, and daily chart quantity 
• Assessing upcoming appointments to identify patient files that need coding reviews 

In some cases, risk adjustment coders use chart audits to significantly alter and augment a patient’s healthcare experience. For example, in a recent review, Mallory pinpointed a patient who frequently missed appointments due to lack of transportation and unfamiliarity with telehealth services. Consequently, his diabetes and congestive heart failure weren’t managed well. Mallory seized the opportunity to improve his situation. 

“I reached out and explained to his provider that they didn’t see this patient often because he lacked transportation and wasn’t technologically savvy,” she says. “They connected with him, explained the telehealth instructions, and walked him through how to schedule transportation before his appointments. Now, he’s much more regular with his visits and his symptoms are under better control.” 

A Day in the Life of an Innovista Risk Adjustment Coder 

During a typical day, a risk adjustment coder conducts audits either on-location or remotely. Mallory most often uses retrospective reviews. Many practices have electronic medical records, but they don’t always allow remote access to files. Others still maintain paper records that coders must sift through manually.  

“I go through the files page by page, looking for inconsistencies and seeing if providers document their chronic condition services appropriately,” she says. “We review the entire file—treatment plans, labs, specialist consultations, diagnostic testing, home health visits, and physical and occupational therapy.” 

Any problems or gaps in care are opportunities to educate providers and their staff about proper coding, links between certain conditions, and the importance of thorough documentation. During these reviews, office managers and staff can ask any questions. 

“Often, I show them which patients to focus on and ask if they need any help with or have experienced any barriers with annual wellness visits,” Mallory says. “Suggesting workflow revisions can also help some offices.” 

After an audit, if possible, she likes to spend a few minutes with each provider to share her findings and make recommendations directly. 

The Impact of Education 

Sometimes, providers are hesitant to change the way their staff codes services, citing lack of time to fill out all the necessary documentation. 

To help make it easier, Mallory says, “We try to streamline workflows and infuse some of the requirements into what they’re already doing day-to-day. It may be one extra document to fill out or scan—something that doesn’t feel like we’re adding to everything already on their plate.” 

To help providers succeed, the Innovista risk adjustment team offers several resources: 

• Condition-specific newsletters that include information about complications and associated conditions that may also develop  
• A coding resource guide that includes frequently used and commonly captured codes divided by condition 
• Training sessions to help provider offices with multiple locations adhere to the same workflows 

In addition, they offer guidance about the best way to assign coding responsibilities, such as spreading any new responsibilities across the whole team so that everyone becomes familiar with the processes, and no one gets burned out. 

Achieving Financial Success 

For every practice, Innovista risk adjustment coders typically have an annual goal in mind. For those with low risk-adjustment factor scores—scores that help estimate the cost of Medicare beneficiaries—they may only need to encourage greater coding specificity, more intentional documentation, or more staff involvement. 

By actively engaging with offices through regular meetings and education, Innovista risk adjustment coders can help providers earn a 5–10% improvement in their bottom line. And that is a big step toward achieving financial success in value-based care.