icd code for high raf score

Full Answer

What is a good RAF score for a patient?

A RAF score of 1.00 indicates the patient is expected to use an average amount of resources. A score above 1.00 indicates high risk and therefore the patient is expected to use more than the average amount of resources. Conversely, a RAF score below 1.00 indicates low risk and less than average resource consumption is expected.

What is the ICD 10 code for risk adjustment?

Risk adjustment is a payment methodology that uses ICD-10-CM codes, organized into Hierarchical Condition Categories (HCCs), to establish a risk score for each patient. Medical coders have a special role when it comes to coding for risk adjustment, and there are measures they can implement to increase coding accuracy.

How much does Medicare reimburse for high RAFs?

AVERAGE MEDICARE PATIENT’s RAF IS 1.0 National Average 1.0 = $9000 non-MA CMS reimburses 1% HIGHER for every 0.01 RAF increase Approximately $900 for ever 0.1 RAF increase PATIENT RAF Score DIAGNOSIS CODING DRIVES THE RAF SCORE RAF SCORE DRIVES THE REIMBURSEMENT PROPER DOCUMENTATION RETAINS THE REIMBURSEMENT

What does a low RAF score indicate?

Lower RAF score indicates healthierpopulation Lower RAF score may also indicatethe following issues: Patientshave not beenseen Lack of adequatechart documentation Lack of completeand accurate ICD10 coding HealthierPopulation 11 The RAF score identifies the members health status and drives reimbursement. Reimbursement Model RAF-HCC 12

What is a high RAF score?

A RAF score of 1.00 indicates the patient is expected to use an average amount of resources. A score above 1.00 indicates high risk and therefore the patient is expected to use more than the average amount of resources.

What are RAF codes?

A RAF score, or risk adjustment factor score, is a medical risk adjustment model used by the Centers for Medicare & Medicaid Services (CMS) and insurance companies to represent a patient's health status. RAF scores are used to predict the cost for a healthcare organization to care for a patient.

What is RAF and HCC coding?

HCC coding relies on ICD-10-CM coding to assign risk scores to patients. Each HCC is mapped to an ICD-10-CM code. Along with demographic factors such as age and gender, insurance companies use HCC coding to assign patients a risk adjustment factor (RAF) score.

What is the average Medicare patient RAF score?

1.000For most payers, a risk score of 1.000 is an average patient. Medicare calculates a beneficiary's RAF on an annual basis or cost per beneficiary per year. For example, if the RAF for your patient is 1.000, Medicare would expect to spend $10,000 on that patient.

What affects RAF score?

Each patient's RAF score depends on your coding. Medicare Advantage and exchange plans are paid based on patients' RAF scores. A score of 1.00 is average, with the decimal places representing percentages above or below average.

What is the difference between RAF and HCC?

HCC codes are additive, and some have multipliers. Population complexity/severity affects payment in many Medicare contracts. RAF is used for benchmarking for quality and safety. RAF enables identification and stratification for patient management.

What is an HCC RAF score?

RAF Score = Patient Demographics (Age, Gender, etc.) + Sum of HCC Codes (Factor) The risk adjustment factor score identifies a patient's health status. Each patient has a RAF score, which includes demographic elements like age and gender that can impact the final number.

How is RAF score calculated?

The amount the government pays is calculated by a formula—multiplying the government's “county rate” by the patient's risk adjustment factor or RAF score. County rate x RAF score = Monthly capitation rate.

What is RAF in medicine?

The Center for Medicare & Medicaid Services' (CMS) Hierarchical Condition Category (HCC) risk adjustment model assigns a risk score, also called the Risk Adjustment Factor or RAF medical abbreviation “RAF score”, to each eligible Medicare Advantage (MA) beneficiary.

How can I improve my RAF score?

Learn How Top-Performing Organizations Improve RAF Score Accuracy—Free eBookTo increase RAF score accuracy, start with HCC coding: ... Leverage your current EMR/RCM workflows: ... Educate providers on HCC coding's impact on reimbursement: ... Prepare for each patient visit: ... Employ—and value—HCC coding experts:More items...•

What are HCC risk scores?

The CMS-HCC risk score for a beneficiary is the sum of the score or weight attributed to each of the demographic factors and HCCs within the model. The CMS-HCC model is normalized to 1.0. Beneficiaries would be considered relatively healthy, and therefore less costly, with a risk score less than 1.0.

How is Medicare risk score calculated?

The purpose of the Medicare risk scores is to estimate a relative cost factor. (i.e., it is a payment risk score). CMS calculates individual beneficiary-level risk scores by adding the relative factors associated with each beneficiary's demographic and disease factors.

What do the letters on Spitfires mean?

Spitfires had a few different markings, but primarily there were two. One, written in smaller, often black, text was the aircraft serial number and stayed with it for its entire life. The other, usually either side of the roundel was the squadron and airrcraft id: Image source. XT was 603 Squadron.

How are RAF squadrons numbered?

The basic RAF squadron badge is the same for all squadrons, a circlet in Air Force Blue surmounted by a crown. The squadron number is on both sides of the circlet at 900 & 2700 positions, the words Royal Air Force appear in the lower half and Squadron in the top half. A motto appears below this in a scroll.

What do the letters on the side of a Lancaster bomber mean?

During World War Two Lancasters were identified within a squadron with letters which for ease of hearing were extended with a word identifier such as M-Mother, Q-Queenie, R-Roger and L-London.

What are the RAF ranks?

RAF RanksPilot Officer.Flying Officer.Flight Lieutenant.Squadron Leader.Wing Commander.Group Captain.Air Commodore.Air Vice-Marshal.More items...

How to calculate RAF score?

How are RAF Scores Calculated? 1 The more accurately and completely you represent the disease burden of your patient in your documentation, the greater your monthly capitation and the lower the chance of clawbacks. 2 The relative RAF adjustments for different disease burdens are not necessarily intuitive. An amputated pinky toe carries triple the capitation adjustment of controlled diabetes. 3 Make sure you see your patients at least once every 12 months to keep them healthy and address all their chronic illnesses. Otherwise, CMS won’t know their disease burden while calculating their capitation—they wipe the disease burden slate clean each year, so you’ll be covering their healthcare costs with less money. 4 Because of advantageous differential capitation rates, assuming the care of patients in the nursing home is sustainable and well worthwhile.

How often is the capitation rate adjusted for a diagnostic code?

It takes a while for CMS to do it’s calculations. Broadly speaking, diagnostic codes are collected and capitation rates adjusted for each patient every 6 months, so it can be some time before a submitted diagnostic code can actually affect the capitation rate.

What is the conversion factor for Medicare?

The “conversion factor” for demographics usually range from 0.6-1.2—based on age, sex, whether the patient is in a nursing home and why they’re eligible for Medicare in the first place. In general, the more vulnerable to illness you would expect a person to be, the higher the demographic conversion factor.

What is overcoding in risk adjustment?

Overcoding in risk adjustment refers to using an incorrect code with a higher score value rather than the correct code based on documentation.

Why is it important to not submit diagnosis codes?

As much as it is important to accurately capture all conditions that currently exist and require treatment, it is equally important to not submit diagnosis codes for conditions the documentation does not support.

Can a coder make an educated determination of the correct code?

There may be instances in which the coder cannot make an educated determination of the correct code and clarification from the provider is necessary prior to claim submission. If warranted, the provider may attach an addendum to the office note clarifying the documentation.

Should risk adjustment coders document only for risk adjustment?

Risk adjustment coders should never suggest what to document solely for risk adjustment purposes; it is a good idea to avoid focusing on risk value examples when reviewing a medical record with the provider, even if risk value was part of the decision to initiate education to the provider.