Why is my Risk Score so low when my patients are so sick?

A risk score is a numeric representation of the health status of your patients based on factors developed by the Centers for Medicare and Medicaid Services (CMS). Each patient has a risk score and your practice has one too. The practice’s risk score is an average of the risk scores for all your patients.

Remember that your practice’s risk score is a numeric representation of the health status of your patients based on the ICD-9-CM codes submitted by most of the providers who have treated that patient. In many cases, clinicians are too general in their documented diagnoses (which may not yield accurate reimbursement under Risk Adjustment) when the patient actually has more specific diagnoses which are reimbursable under the Risk Adjustment paradigm. Sometimes, providers are pressed for time and fail to assess, document and report a risk adjusted condition during a specific period and the condition “falls off” the patient’s health profile.

Still other times, a patient may, in fact, be receiving treatment for certain conditions that are risk adjusted, but especially if the conditions are stable, the physician may not have documented them properly or at all.

Our analysis has revealed that Coleman Consulting Group identifies, on average, at least 85% more diagnoses than the physician has documented by the time of the chart review. A great deal of the time, the company’s work involves constant re-education to providers about the nuances of select diagnoses which are not being properly captured by the physician, thereby negatively impacting the group’s revenue.

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