2021 Risk Adjustment Strategy and Program Readiness

As plans begin to wind down the year, one thing is clear. The COVID-19 pandemic put a strain on the entire healthcare industry and, for risk adjustment in particular, the disruption caused by the pandemic resulted in both adverse consequences (i.e., decreases in preventative encounters such as annual wellness visits) as well as some positive effects like the acceleration of telehealth adoption across providers.

The one certainty is that plans must start vetting out their 2021 risk adjustment strategy.

Here are several strategic planning items to help your organization prepare as we ring in the new year:

1. 2020 MA Final Run Extension

CMS is accepting 01/01/2019 – 12/31/2019 dates of service (DOS) for the 2020 final run until 08/02/21, adding 6 months for risk adjustment data submission. The 2020 interim final run deadline is still 02/01/21.

Keeping the end of January as your goal to submit most, if not all, 2019 DOS supplemental data supports two tracks. First, the strategy allows Medicare Advantage Organizations (MAOs) to accrue and recognize the 2020 final PY revenue as they normally would. Second, MAOs can use the time to capture remaining residual opportunity through interventions they did not deploy earlier.

Plans can take advantage of additional time in these ways:

  • Create a chase project for members who were new to plan in 2020 (not new to Medicare)
  • Launch a second pass (2LR) coding review for targeted populations
  • Perform a data submission reconciliation project to identify any missed or dropped records across the data submission supply chain (e.g., claim, supplemental, RAPS, and EDS)

2. Transition to 100% EDS for Risk Score Calculation

CMS announced the shift to 100% EDS for 2022PY in their Advance Notice Part 1 for CY2022. This makes 2021 DOS claim capture incredibly important as supplemental RAPS diagnoses are removed from risk score calculations. GHG projects a 1-3% impact to risk scores as plans adjust to the new methodology.

  • Create reporting models that rely solely on encounter data responses
  • Invest heavily in deploying prospective risk adjustment programs and capturing diagnoses close to the point of care ensuring they are reported in claim transactions
  • Implement a comprehensive EDS error correction and remediation process
  • Perform a final RAPS to EDS reconciliation to determine the true risk adjustment impact
  • Assess your prevalence of submitting linked versus unlinked chart reviews
  • Confirm your submission partner has a sunset plan in place for RAPS

GHG recently hosted a webinar with Pareto Intelligence and Episource surrounding the best deployment strategies to ensure your upstream encounter data is accurate, complete, compliant, and ready for submission. Click here to watch the webinar recording on demand.

3. Compliance

Lawsuits continue against MAOs referencing the False Claims Act which holds plans accountable for the “accuracy, completeness and truthfulness of the submitted data”. MAOs should continue to assess their risk adjustment programs for accurate and complete submissions of diagnoses data.

  • Perform targeted Hierarchical Condition Category (HCC) reviews for conditions at high risk of documentation errors
  • Assess whether your organization ‘looks both ways’ to identify codes that are not substantiated by proper documentation
  • Consider deploying and investing in prospective and concurrent coding programs that incorporate provider education

4. Evaluate Vendor Performance and Contracts

MAOs rely heavily on vendors to manage successful risk adjustment programs. These organizations specialize in an array of service delivery areas such as suspecting analytics, prospective technology enabled solutions, medical record retrieval, diagnosis coding, in-home assessments, telehealth, RADV/IVA, HEDIS, EDS and RAPS submissions, and data integrity. The contributions from your partners can make or break your final outcomes.

How many vendors are you currently working with? Are they meeting your expectations?

  • Review end-of-project performance and confirm SLAs were met
  • Ensure MSAs and SOWs are current and executed
  • Determine if current fee schedules are market competitive
  • Explore new services and technologies
  • Consolidate where it makes sense

5. Coding and Documentation Updates

Changes in the evaluation and management (E/M) level calculation methodology for 2021 DOS move away from a counting and measuring of the complexity of tasks (e.g., History, Exam, or ROS), into a simpler definitive measurement of E/M.

Physicians can now base the code assignment on either total time related to the visit or medical decision making related to the visit.

A reduction in the amount of historical data required may have a negative impact on the ability for plans to capture chronic conditions documented in the note, but not coded in the encounter. Extensive problems lists, past medical, and past surgical histories are often heavily utilized during retrospective chart reviews. With less focus on these elements in calculation of E/M, this criteria may fall from encounter documentation.

How Health Plans can prepare:

  • Monitor electronic medical record (EMR) encounter templates to ensure changes do not impact the amount of data captured from encounter review.
  • Ensure members are still receiving comprehensive type visits to capture all chronic conditions (i.e., annual wellness visits or initial preventive physical examination).

2021 ICD10 Guidelines Updates

Notable changes in the Official ICD10 Guidelines revolve around new diagnoses of COVID-19 and vape use disorder. Neither of the new codes (U0.70 Vaping-related disorder; U0.71 COVID-19) are included in the CMS or Health and Human Services risk adjustment models, although interactions with other HCCs would follow usual ICD10 protocols of first-listed or additional diagnosis. No combination codes or Hierarchy for COVID-19 have been added.

Below are 2021 updates relevant to risk adjustment (Medicare, Medicaid, and/or HHS models):

Documentation by Clinicians Other than the Patient’s Provider

  • “Patient self-reported documentation may also be used to assign codes for social determinants of health, as long as the patient self-reported information is signed-off by and incorporated into the health record by either a clinician or provider.”

Endocrine, Nutritional, and Metabolic Diseases (E00-E89)

  • “If the patient is treated with both insulin and an injectable non-insulin antidiabetic drug, assign codes Z79.4, Long-term (current) use of insulin, and Z79.899, Other long term (current) drug therapy. If the patient is treated with both oral hypoglycemic drugs and an injectable non-insulin anti-diabetic drug, assign codes Z79.84, Long-term (current) use of oral hypoglycemic drugs, and Z79.899, Other long-term (current) drug therapy.”

Diseases of the Circulatory System (I00-I99)

  • Hypertensive Heart and Chronic Kidney Disease
    • “For patients with both acute renal failure and chronic kidney disease, the acute renal failure should also be coded. Sequence according to the circumstances of the admission/encounter.”

Pregnancy, Childbirth, and the Puerperium (O00-O9A)

  • Puerperal Sepsis
    • “Code O85 should not be assigned for sepsis following an obstetrical procedure (See Section I.C.1.d.5.b., Sepsis due to a post-procedural infection).”
  • COVID-19 Infection in Pregnancy, Childbirth, and the Puerperium
    • “During pregnancy, childbirth or the puerperium, when COVID-19 is the reason for admission/encounter , code O98.5-, Other viral diseases complicating pregnancy, childbirth and the puerperium, should be sequenced as the principal/first-listed diagnosis, and code U07.1, COVID-19, and the appropriate codes for associated manifestation(s) should be assigned as additional diagnoses. Codes from Chapter 15 always take sequencing priority.”

The most notable change for Health Plans applies to Social Determinants of Health (SDOH). These have been classically hard to capture, underutilized but growing in importance. Key factors are provider network education around these conditions, and ‘patient’s words’ are sufficient documentation to support capture.


GHG’s subject matter experts can help with the development or remediation of your risk adjustment strategy for 2021. Reach out to GHG’s Senior Director of Risk Adjustment Solutions, Eric Shapiro, to start the conversation.