Six strategies to help physicians optimize risk adjustment coding and documentation
Capturing accurate risk scores is vital for maximizing payment under valuebased payment models, yet incorrect or missing clinical documentation can result in millions in lost revenue and significant compliance risk. In fact, the OIG recently found that medical record documentation fails to support approximately 70% of audited risk adjustment codes. It’s something CMS plans to investigate more closely with Medicare Advantage plans, and there could be a trickledown effect on providers. In its FY 2026 budget request to Congress, the agency said it plans to increase its team of medical coders from 40 to approximately 2,000 by September 1, 2025 to address an ongoing backlog of Medicare Advantage Risk Adjustment Data Validation (RADV) audits. The goal? Confirm whether medical records support risk adjustment diagnoses that Medicare Advantage plans submit to CMS. With that said, is there anything providers can do to optimize risk adjustment coding and documentation without putting their own revenue at risk? Fortunately, the answer is yes. Here are six strategies for physician risk adjustment in healthcare.
1. Apply the ‘MEAT’ criteria when documenting. The acronym ‘MEAT’ stands for monitor, evaluate, assess/address, and treat. These criteria help optimize risk adjustment coding and documentation because they ensure that diagnoses used for risk adjustment are not only present but also relevant and active. All of this is essential for accurate physician risk adjustment in healthcare and to ensure high-quality care.
2. Use the most specific diagnosis codes available. To optimize risk adjustment coding and documentation, physicians must report the most specific ICD-10-CM diagnosis code and ensure their documentation reflects the same. Doing this ensures that patient complexity maps to risk adjustment values correctly and promotes accurate physician risk adjustment in healthcare.
3. Perform annual wellness visits and health risk assessments. During these visits, document and code all active chronic conditions—including stable ones—annually to promote accurate physician risk adjustment in healthcare. These visits are opportunities to check in with patients, get an accurate and complete picture of each person’s health status, and optimize risk adjustment coding and documentation.
4. Leverage technology. With proper oversight, the following tools can help optimize risk adjustment coding and documentation while also saving time:
Artificial intelligence (AI) scribes. Recent studies have found that AI scribes save physicians one hour at the keyboard every day, and 84% of physicians say AI scribes have a positive impact on their visit interactions. This technology gives physicians more face-to-face time with patients which can help aid accurate physician risk adjustment in healthcare.
Copy and paste documentation tools. These tools also promote more face-to-face time with patients to aid accurate physician risk adjustment in healthcare. However, physicians must ensure they update documentation during the current patient encounter. Cloned documentation without updates and verification can artificially inflate physician risk adjustment in healthcare and signal a red flag to payers.
Natural language processing or computer-assisted coding. These technologies can better capture diagnoses from clinical notes and optimize risk adjustment coding and documentation.
Pre-visit planning tools. These tools concentrate on physician risk adjustment in healthcare by identifying documentation or coding gaps prior to patient appointments, allowing providers to address them in real time.
Real-time EMR alerts. By focusing on physician risk adjustment in healthcare, these alerts remind physicians to address chronic conditions.
Structured templates in the EMR. Templates prompt physician documentation to optimize risk adjustment coding and documentation.
5. Include all members of the care team. Remember that physicians, nurses, medical assistants, care coordinators, and others can identify and capture chronic conditions and other diagnoses necessary for proper risk adjustment. However, all these individuals must understand the role of coded data in overall risk adjustment. This requires ongoing training and education as risk models evolve over time. Annual training to optimize risk adjustment coding and documentation is key.
6. Audit, audit, audit. Conduct internal audits to ensure coding aligns with documentation and to monitor trends and areas for improvement. Do providers tend to overlook certain chronic conditions? Report unspecified codes? Fail to provide supporting documentation? As CMS ramps up its Medicare Advantage audits, provider coding and documentation will be scrutinized as well. As providers think about how to optimize risk adjustment coding and documentation, they must also be able to defend the codes they report. Audits promote accurate physician risk adjustment in healthcare.
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Medical practices that leverage PMS-agnostic medical billing services are well-positioned to optimize risk adjustment coding and documentation and ensure revenue integrity. Learn how Medusind’s CPC-certified medical coders maintain the highest standards, quality, and accuracy for physician risk adjustment in healthcare. Let us help you maximize revenue and mitigate compliance exposure with specialized medical coding services.
