Clinical Documentation and Quality Improvement-Accuracy, Quality, and Risk
It is well known that patients with multiple serious medical conditions have higher costs of care and require more resources. In a typical fee-for-service model there are limited mechanisms to recognize and address these discrepancies. Risk Adjustment is a model that adjusts reimbursement based on the presence or absence of serious medical conditions such as diabetes or heart failure. Over time, more accurate coding results in more accurate reimbursement. As we continue to evolve the health care system to a more closely aligned fee-for-value model, risk adjustment plays a key role and has the potential to truly align resources and care.
This activity will review the basics of the risk adjustment system in Medicare and how accurate and appropriate diagnosis, documentation, coding, and care lead to improved patient benefits, such as transportation, and lower copays—as well as improved reimbursement for health plans and providers. The activity will move from an overview to a condition-focused review.
At the end of this educational activity, participants should be able to
- Identify how risk adjustment provides an opportunity to align care across the health care delivery spectrum
- Understand how accurate and appropriate risk adjustment leads to sufficient resources to increase patient benefits
- Explain why medical practices should improve their documentation in response to the transition from fee for service to fee for value
- Describe how to follow disease improvement or progression using ICD-10 codes reflecting the patient’s condition
- Discuss how ICD-10 codes may be used in the pay-for-performance program
- Discuss the level of detail required by the new system and how to improve accuracy and specificity in documentation
Nikki Macalalad, MSN, APRN, FNP-C
Associate Director of Clinical Coding Education, CDQI
Southwest Medical Associates--part of OptumCare
Las Vegas, Nevada
Disclosures of Relevant Financial Relationships
In accordance with the ACCME Standards for Commercial SupportSM, OptumHealth Education requires all those involved in the development of activity content to disclose their relevant financial relationships. An individual has a relevant financial relationship if such person (or their spouse/partner) has a financial relationship in any amount occurring in the last 12 months with a commercial interest whose products or services are discussed in the activity content over which the individual has control.
OptumHealth Education ensures that the content is independent of commercial bias.
The faculty reported the following:
Nikki Macalalad, MSN, APRN, FNP-C
Ms. Macalalad reported that she is an employee of and own stock in UnitedHealth Group.
Daniel S. Frank, MD
Senior Medical Director
Vice President, Clinical Documentation and Quality Improvement
Sarah Chart-Hart, RN
Rebecca Gleason, RN, CCM
V. Silverstein, MD
Eagle Creek Medical Communications
Durham, North Carolina
Activity Planner Disclosures
Ms. Chart, Ms. Gleason, and Dr. Frank reported that they are employees of and own stock in UnitedHealth Group.
Dr. Silverstein reported that she has no relevant financial relationships.
Method of Participation
There are no fees for participating in or receiving credit for this activity.
For information on applicability and acceptance of continuing education credit for this activity, please consult your professional licensing board.
Participants will receive a certificate upon successful completion of the activity, which includes the following:
- Complete the Pre-Activity Assessment online
- Attend the live in-person training
- Complete the Post-Activity Assessments, Activity Evaluation, and Application for Certificate of Credit forms online
In order to complete the on-line forms, you must be logged into your account. Once logged in, get started by clicking “Begin” and viewing the “CE Info”; then follow the prompts at the bottom of the screen. At the end of the activity, you will be able to view, save, or print your certificate of participation. The Area of Practice you indicated in your profile corresponds with your certificate type. A complete listing of all of your activities can be found under “My Account”, “My Activities.”
In support of improving patient care, OptumHealth Education is jointly accredited by the Accreditation Council for Continuing Medical Education (ACCME), the Accreditation Council for Pharmacy Education (ACPE), and the American Nurses Credentialing Center (ANCC) to provide continuing education for the health care team.
Credit Designation Statements
OptumHealth Education designates this live activity for a maximum of 12.00 AMA PRA Category 1 Credit(s)™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.
American Academy of Family Physicians
This live activity, Clinical Documentation and Quality Improvement - Accuracy, Quality, and Risk, from 10/02/2016 - 10/01/2017, has been reviewed and is acceptable for up to 12.00 Prescribed credit(s) by the American Academy of Family Physicians. Physicians should claim only the credit commensurate with the extent of their participation in the activity.
The American Academy of Physician Assistants (AAPA) accepts credit from organizations accredited by the ACCME.
The American Academy of Nurse Practitioners Certification Program (AANPCP) accepts credit from organizations accredited by the ACCME and ANCC.
A certificate of attendance will be provided to learners upon completion of activity requirements, enabling participants to register with licensing boards or associations that have not been pre-approved for credits. To apply for credit types not listed above, participants should use the procedure established by the specific organization to which you wish you apply credit.
This activity is provided by OptumHealth Education.
This activity is supported by Optum—Collaborative Care.
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These materials are intended only for those that attended the live activity on Monday, March 6, 2017.
This activity is designed to meet the educational needs of physicians—including family physicians—and other health care professionals who have an interest in in health care economics and risk adjustment.
- 12.00 AMA - Physicians
- 12.00 Attendance - General Attendance