When CMS launched the risk adjustment model for Medicare Advantage payments beginning in 2003, the reason for the change – in many minds – was shortened to, essentially, being paid more for sicker members. While this is one part of the rationale, it can lead to a fundamental disconnect on the justification for the added payments.
Some are under the impression that the key is identifying the member’s chronic conditions that map to the CMS-HCC model. While this may be true, it’s only part of the story. The basis for the payment is for the management of the member’s chronic conditions with HCCs. So, in a nutshell, plans and providers are not paid because the member is “sick” but because they are managing the care of a sick member by assessing and treating those conditions as evidenced by the medical documentation – a seemingly subtle but big difference.
The mental shift then requires that providers not only justify the existence of HCC conditions but when they list those diagnoses in the assessment of a progress note, demonstrate the T-E-A-M of each one. T-E-A-M is an acronym used by medical coders to reinforce the proper documentation required for a medical condition. The note must show how the condition is being Treated, Evaluated, Assessed or Addressed and Managed. This is where many progress notes fall short.
While the member may, in fact, have a specific medical condition, the diagnosis is “laundry listed” on the note’s assessment with little to no support or T-E-A-M. CMS has been clear that there must be evidence of an actual assessment and even the American Medical Association defines in the 2021 E/M coding changes, “A problem is addressed or managed when it is evaluated or treated at the encounter by the physician or other qualified health care professional reporting the service.”
Remember: simply refilling medications, ordering tests, adding templated blurbs with counseling information that is not customized to the patient’s reality, and commenting that a specialist is managing the condition do not constitute T-E-A-M and put in jeopardy your risk adjusted payments.