Physician Responsibilities for
CMS Medicare Risk Adjustment

Funding and other program decisions made by the Centers for Medicare and Medicaid Services (CMS) is dependent upon the accuracy of the information that Medicare Advantage (formerly Medicare+Choice) organizations supply to CMS. Risk adjustment helps to improve the accuracy of this information.

While procedural codes remain important for providers’ reimbursement of fee-for-service Medicare beneficiaries, the risk-adjustment model relies on ICD-9-CM diagnosis code specificity. As published by CMS in its training documentation, the responsibilities of physicians and other health care providers who treat Medicare patients include:

• Accurately reporting ICD-9-CM diagnosis codes, including
  secondary diagnoses, to the highest level of specificity
• Maintaining accurate and complete medical record documentation (ICD-9-CM codes submitted must be justified with proper documentation.)
• Alerting the Medicare Advantage organization to any erroneous data that has been submitted and following the procedures for correcting erroneous data
• Reporting claims and encounter data in a timely manner,
  generally within 30 days of the date of service or discharge from a hospital’s inpatient facilities

Talk with your administrative staff and clinicians about the continued importance of ICD-9-CM diagnosis coding. In addition to proper reimbursement, accurate recording of health-related data helps to create future possibilities for education and clinical care research.