Documentation and Coding Essentials for Physicians: Risk Adjustment

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Documentation and Coding Essentials for Physicians: Risk Adjustment

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Documentation and Coding Essentials for Physicians: Risk Adjustment


The purpose of this course is to learn the importance of quality documentation when reporting for provider services. We will explore some common clinical situations and identify how documentation can affect the ICD-10-CM diagnosis codes assigned for the encounter. Documentation supporting the patient’s diagnostic conditions has become increasingly important with the current environment focusing on quality of care by enacting more value-based programs as well as pay for performance. This is a trend moving away from the quantity of services rendered so that the focus can be on the quality of care provided to the individual patient and the resulting outcomes.

This course will also explore the basic mechanics of risk adjusted methodologies that utilize diagnostic and demographic data to determine the true complexity of an individual patient’s health status. We will identify how quality documentation supports the codes assigned and the provider’s vital role in this process. For documentation that is not clear or insufficient, this can result in a physician query. We will discuss what situations may prompt a query to occur and the expectations of the provider. Lastly, we will wrap up with how provider documentation may also be used by risk adjusted methodologies to support the validity of the diagnoses reported for an encounter.

Documentation and Coding Essentials for Physicians: Risk Adjustment

Course Modules

18 eLearning modules + final exam

  • Introduction to Provider Documentation
  • The Coding Guidelines
  • Introduction to Risk Adjusted Methodologies
  • RA Methodologies: Neoplasms
  • RA Methodologies: Diabetes
  • RA Methodologies: Metabolic Disorders
  • RA Methodologies: Substance Use Disorders
  • RA Methodologies: Psychiatric Disorders
  • RA Methodologies: Hypertension, Heart Failure, and CKD
  • RA Methodologies: Acute Mis, CAD, and Angina Pectoris and Arrhythmias
  • RA Methodologies: Cerebral Infarction
  • RA Methodologies: COPD and other Lung Disorders
  • RA Methodologies: Pneumonia
  • RA Methodologies: Vertebral Fractures Without Spinal Cord Injury
  • RA Methodologies: Hip Fractures and Dislocations
  • RA Methodologies: Artificial Openings & Amputations
  • Physician Query Process
  • Risk Adjustment Validation Audits
  • Final Exam

Documentation and Coding Essentials for Physicians: Risk Adjustment

About the Authors

Laurie L. Prescott, MSN, RN, CCDS, CDIP, CRC, is the CDI education director with HCPro. Prescott serves as a full-time instructor for the CDI Boot Camp as well as a subject matter expert for the Association of Clinical Documentation Improvement Specialists (ACDIS).

Prescott is a frequent speaker on HCPro/ACDIS webinars and author of The Clinical Documentation Improvement Specialist’s Complete Training Guide. She started her nursing career in 1985 as a graduate of the University of Vermont School of Nursing. Since that time she has worked at a variety of organizations, including academic, large, and small community hospitals. She has worked in a number of nursing roles, including as manager in the areas of medical/surgical, ICU, PACU, and endoscopy. Her experience also includes specialization as a compliance officer.

HCPro has confirmed that none of the faculty/presenters, planners, or contributors have any relevant financial relationships to disclose related to the content of this educational activity.

Shannon E. McCall, RHIA, CCS, CCS-P, CPC, CPC-I, CEMC, CRC, CCDS, and Director of HIM and Coding. Shannon McCall directs all of HCPro’s Certified Coder Boot Camp® programs. She is the developer of the Certified Coder Boot Camp®—Inpatient Version and the Evaluation and Management Boot Camp®. Most recently she collaborated with the CDI team to develop the Risk Adjustment Documentation and Coding Boot Camp®. As a consultant for HCPro, she works with hospitals, medical practices, and other healthcare providers on a wide range of coding-related issues with a particular focus on education, coding reviews, and audits.

McCall has extensive experience with coding for both physician and hospital services. Prior to joining HCPro, she worked for a national medical practice management company, where her duties included serving as a client manager and an in-house coding trainer. She also previously worked for a national consulting firm focusing on hospital inpatient, outpatient, and ER services.

McCall is accredited as a Registered Health Information Administrator, a Certified Coding Specialist, and a Certified Coding Specialist–Physician by the American Health Information Management Association (AHIMA), and is an AHIMA-approved ICD-10-CM/PCS instructor. She is also accredited as a Certified Evaluation and Management Coder, a Certified Professional Coder, and a Certified Risk Adjustment Coder, and is an AAPC-approved instructor of the Professional Medical Coding Curriculum. Additionally, she is a Certified Clinical Documentation Specialist and has served on the Advisory Board of the Association of Clinical Documentation Improvement Specialists (ACDIS). McCall holds a Bachelor of Science in Health Information Administration from the Medical University of South Carolina.

Continuing Education

This program has the prior approval of AAPC for 3 continuing education hours. Granting of prior approval in no way constitutes endorsement by AAPC of the program content or the program sponsor.

HCPro is accredited by the Accreditation Council for Continuing Medical Education (ACCME) to provide continuing medical education for physicians.

HCPro designates this educational activity for a maximum of 3 AMA PRA Category 1 CreditsTM. Physicians should only claim credit commensurate with the extent of their participation in the activity

This program has been approved for 3 continuing education units for use in fulfilling the continuing education requirements of the American Health Information Management Association (AHIMA).

Documentation and Coding Essentials for Physicians: Risk Adjustment


You will have access to your courses for 1 year from the purchase/order date.