Risk Adjustment Process
Risk adjustment, a component of Medicare Advantage and the Affordable Care Act (ACA), helps align payments to health plans with the risk characteristics of people enrolled in each plan.
Accurate risk adjustment relies on comprehensive, face-to-face health assessments of patients. These assessments result in appropriate medical record documentation and diagnosis coding. The diagnosis codes are then submitted to the health plan on a claim and used to determine the level of risk associated with the patient.
Florida Blue has risk adjustment programs in place that align with our commitment to ensuring that quality of care is maintained through the physician-patient relationship. These programs help identify care and coding opportunities that can help prevent and/or detect conditions and encourage members to schedule health screenings, tests and vaccines.
RPM Revenue Program Management
For More Information
If you have questions or want to learn more about risk adjustment refer to the following:
Read our monthly QRPM newsletters.
| Release Date | Topics |
|---|---|
| December 2021 | ICD-10-CM Diagnosis and Guideline Changes for 2022 |
| October 2021 | Hierarchical Condition Category (HCC) |
| September 2021 | Dementia Documentation and Coding |
| August 2021 | Telehealth Documentation |
| July 2021 | Cancer and Coding of Neoplasms |
| June 2021 | Chronic Obstructive Pulmonary Disease |
| May 2021 | Peripheral Vascular Disease |
| April 2021 | Congestive Heart Failure |
| March 2021 | Chronic Kidney Disease |
| February 2021 | Diabetes Mellitus |
| January 2021 | Annual Wellness Visit |
| December 2020 | Rheumatoid Arthritis |
| November 2020 | Cardiac Arrhythmia |
| October 2020 | Cancers and Neoplasms |
| September 2020 | Chronic Kidney Disease and Chronic Kidney Disease with Other Conditions |
| August 2020 | Major Depression, Major Depressive Disorder |
| July 2020 | Amputations, Artificial Openings and Transplants |
| June 2020 | Diabetes Mellitus |
| May 2020 | Documentation Tips for Prevalent Conditions |
| April 2020 | Annual Wellness Visit |
- Read about coding details and tips in our Florida Blue Medicare and Commercial Risk Adjustment Best Practices and Coding Educational Guide 2020.
- View the schedule for documentation and coding training that earns you continuing education credits.
- Register for training or attend a webinar through the Availity®¹ learning center.
- Read about our risk adjustment process, including documentation and coding, quality data and how accurate coding affects your practice.
- Read FAQs on the Comprehensive Quality & Risk Program.
- Send an email to RiskAdjustmentTraining@bcbsfl.com.
1 Availity, LLC is a multi-payer joint venture company. For more information or to register, visit availity.com.
FB PRV PROG 006 NF 102021