Why Risk Adjustment Coding Is Important

ICD-10-CM coding has historically taken a back seat to CPT coding when it comes to professional billing. ICD-10-CM is used for a variety of reasons such as tracking disease process and spread of diseases but most importantly it’s been used to drive medical necessity together CPT paid. With productivity standards in coding and CPTs being the “money” codes, ICD-10-CM has really taken a back seat.  Coders will sometimes neglect guidelines or select codes that are less specific just to cut down on time and meet their productivity standards.

Much of the health care industry is still in the fee-for-service mindset. An example of fee-for-service is a patient that goes in to see their Primary Care Physician for management of chronic conditions and the Physician gets a fixed fee regardless of how well or how poorly that condition is managed. If the patient is compliant and keeps their conditions under control, the provider gets a set fee. If the patient doesn’t understand their management plan and has severe exacerbations that land them in the hospital, that provider still gets their fixed fee for the visit. But now that landscape is starting to change. The CMS quality payment program is starting to adjust fees of providers so that providers with good outcomes get a slightly increased fee while providers with poor outcomes get a slightly decreased fee.



It all comes down to good documentation. Providers need to document appropriately to support the codes they are submitting. Billing a specified, higher severity code but not documenting to that severity (or not documenting at all) can have a huge financial impact. CMS estimates that every year there are hundreds of millions of dollars of over payments to Medicare Advantage plans based on diagnoses that were inappropriately submitted. Through programs like the RADV (Risk Adjustment Data Validation) audits, CMS is looking at potentially huge recoupments from the Advantage plans.

The less money the insurance plans have, the less money they’ll have to reimburse providers. While there may not be an immediate punitive impact on the provider there will be a definite trickledown effect. The Advantage Plans are also beginning to conduct their own “validation” audits on providers and group practices in effort to prevent any recoupments from the RADV audits.

This means that risk adjustment coders are not only needed on the insurance level and the federal level but also on the provider level as well. Medical coders will need to know if the documentation is going to support the requirements and guidelines of external audits. Risk adjustment coders are also needed to validate diagnoses as they pertain to the quality payment programs for CMS.

Audits and adjustments are continuing to rise. Risk adjustment coders who can navigate these complicated policies and master the ICD-10-CM guidelines are in high demand. If you’re interested in obtaining your CRC credential and working in risk adjustment check out the Risk Adjustment Online Course we have available. It utilizes the AAPC curriculum for training medical coders but with the addition of some vital supplemental information, great animations, fun extras, and fantastic resources.

Can Medical Coding Be Self-Taught?

I’m a firm believer that you can learn just about anything watching YouTube tutorials. There are lots of amazing, inspirational stories of people building houses, businesses, machinery, and more that were self-taught by watching YouTube tutorials. With the rising cost of education, countless people are looking into such alternatives to learn skills that don’t require formal education. Many people interested in medical coding are curious if they can self-teach these concepts.

Is it possible? Yes. Is it easy? Absolutely not.

Self-taught medical coding is easier for those already working in the health care field that has a good basis of medical terminology and other insurance concepts. It would be extremely difficult for someone who has absolutely no background in healthcare or any exposure to medical coding. While all the three coding books utilized (ICD-10, HCPCS, and CPT) come with instructions, it’s harder to understand how to utilize them from scratch.

Learning medical coding completely for free simply cannot happen because the books need to be purchased, studied, and are mandatory for testing purposes. But, if you’re determined to do self-study, here are the most budget-friendly suggestions I can offer.

These are the books needed for professional medical coding, which is coding for physician and other medical provider services.

CPT is Current Procedural Terminology. This book is for coding for procedures and is required for the CPC (Certified Professional Coder) exam. The CPC exam dictates that you must have the AMA version of CPT books only. I would recommend getting the edition for the year that you will be taking your examination in.

ICD-10-CM is for diagnosis-based coding for professional services.  For the CPC exam, you can use any version of ICD-10-CM that you want. Make sure you have the CM edition, and not PCS. PCS is only utilized for hospital/facility coding, and not required for the CPC exam. Here is a suggestion of one you can purchase easily online through Amazon. You can check out some of the reviews for more information as well.

HCPCs are codes for durable medical equipment, medications, insurance-specific codes for procedures, and other services. You can have any edition of HCPCS book that you want for you or exam.  You can buy the one above off Amazon easily. If you’re an Amazon Prime member they will even ship it to you for free.

Step-By-Step Medical Coding is an instructional guide that is utilized very commonly in medical coding classes in colleges and technical schools. While you won’t be able to access the teacher’s information (such as test answers) there are select case answers and rationale in the back of the student guide. I would suggest purchasing this book as well as the coding books indicated above. Current year coding books are required when you are testing for any certification exams through AHIMA or AAPC.  You can write, draw, highlight or tab the books in just about any fashion you want. You cannot staple, paste, tape, or add additional pages into the book or white-out entire pages of the book for notes.

Check us out on YouTube for some great tutorials and information on medical coding. There is also chapter-specific information that you can find through your YouTube searches. This will help you in understanding the concepts that will guide you to becoming a medical coder. When you’re ready, purchase some of the practice exams through the AAPC to get some simulation of what the certification exam will be like.

While you can’t become a certified coder for free, there are ways to cut down the cost if you are interested in self-study. Power the tools above and try to stay as focused as possible. Make an agenda for yourself and stick to it. Good luck!

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