Problem Lists vs. Reality: Improving Risk Adjustment Coding Accuracy for Medicare Advantage Plans

by  Jessica Hocker, CPC, CPB, CRC
Apr 20th, 2023

As Medicare Advantage (MA) plans continue to grow, the importance of accurately coding medical conditions cannot be overstated. Risk adjustment coding is vital for determining the expected cost of providing healthcare to an individual based on their health status. The more severe a patient's health condition, the more funding the MA plan receives from the Centers for Medicare & Medicaid Services (CMS) to provide care for that patient. Ensuring that medical conditions are coded accurately is crucial for MA plans to receive the appropriate funding to provide quality care to their members.

Problem lists are a tool that clinicians use to document medical conditions, which is intended to provide a snapshot of a patient's health status and guide clinicians in developing a treatment plan. However, incomplete or inaccurate problem lists can pose significant challenges to risk adjustment coding.

Incomplete problem lists can arise due to time constraints in documenting all of a patient's medical conditions during a brief encounter, or patients not disclosing all of their medical conditions during a visit. This can lead to under-reporting of medical conditions, resulting in under-coding and lower funding for MA plans.

Inaccurate problem lists can also arise due to errors in diagnosis or coding. Clinicians may misdiagnose a condition or use a code that does not accurately reflect the severity of the condition. This can lead to over-reporting or under-reporting of medical conditions, which can affect risk adjustment coding accuracy.

Furthermore, problem lists do not capture all the necessary information required for accurate risk adjustment coding. Details such as the duration or severity of a condition, or whether the condition is stable or worsening, are not included in problem lists. Such information is important in determining the expected cost of care for a patient.

To address these challenges, MA plans should use other sources of information, such as claims data and clinical documentation improvement (CDI). Claims data provides a more complete view of a patient's health status by including information on the services patients have received and the medical conditions that have been coded by providers. CDI is a process that involves reviewing clinical documentation and making recommendations for improvement to ensure that the documentation accurately reflects the patient's health status. By using CDI, missing or inaccurate diagnoses can be identified, and targeted provider education can be carried out to ensure that conditions are documented in a way that accurately reflects their severity and impact on the patient's health.

In addition to these strategies, providers can take steps to ensure that problem lists are up-to-date and accurate. Annual Wellness Visits (AWVs) offer an opportunity to review and update a patient's problem list. During an AWV, providers can review the patient's medical history and ensure that all current medical conditions are documented in the problem list. Providers can also discuss any symptoms or conditions that the patient may have experienced since the last visit and update the problem list accordingly.

Furthermore, providers can use AWVs to address the challenge of incomplete problem lists. By asking open-ended questions and providing a safe and supportive environment, providers can encourage patients to disclose any medical conditions that they may have been hesitant to discuss during a regular visit. This can help to ensure that problem lists are as complete as possible, which can improve risk adjustment coding accuracy.

In summary, while problem lists are a valuable tool for clinicians in documenting a patient's health status, they are not always accurate or complete. This can pose significant challenges to risk adjustment coding, which affects the funding that MA plans receive to provide care to their members. MA plans may use resources such as claims data and CDI, to ensure that they have a complete and accurate picture of a patient's health status and are able to provide the best education to providers so they can take steps to validate that problem lists are up-to-date and accurate. By doing so, MA plans and providers can ensure that they receive the appropriate funding to provide high-quality care to their members.