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Network Matters
News and Information for the
Harvard Pilgrim Health Care Network

January 2015

Diagnosis Coding for HEDIS and Risk Adjustment 

The diagnosis codes that providers submit to Harvard Pilgrim affect the quality of patient care and influence a number of performance and quality measures, including our HEDIS scores and the Affordable Care Act’s risk adjustment scores. To ensure that these measures are accurate and complete, Harvard Pilgrim offers the following helpful coding reminders.

Definitive Diagnosis vs. Symptoms
It’s important that the diagnosis codes and clinical documentation that you submit are consistent and accurately reflect the patient’s condition. Ensuring that only definitive diagnosis are documented is crucial for accurate NCQA HEDIS measurements.

HEDIS measures are a tool used by health plans to evaluate performance on important aspects of care and service, assess quality, and identify areas for improvement. Specifically, HEDIS uses the number of members who are diagnosed with a specific disease as the denominator for several measures (for example the number of members with rheumatoid arthritis). To avoid inadvertently including patients without a specific condition in a measure, Harvard Pilgrim recommends billing a diagnosis code for a specific disease such as COPD or rheumatoid arthritis only after the diagnosis is confirmed.

In the outpatient setting (including physician offices), diagnoses documented as "probable," "suspected," "questionable," or "rule-out" should not be coded for billing as if they are established. Rather, the conditions should be coded to the highest degree of certainty for that encounter, such as symptoms, signs, abnormal test results, or other reason for the visit.

Submitting a claim using a diagnosis code when the condition is being questioned may inadvertently indicate the necessity for diagnostic testing and/or medications, and a gap in care according to the HEDIS measure. This may result in lower HEDIS scores. If you have any questions, please call Harvard Pilgrim’s Clinical Programs Department at 800-287-9793.

Importance of Coding and Documentation
In addition to making certain that you submit diagnosis codes for definitive conditions only, please check that there are no gaps in coding. Complete coding supports high quality patient care, helping to ensure that appropriate screening tests are received and assessment of a patient’s chronic conditions is ongoing.

As we’ve noted in previous Network Matters articles, the Affordable Care Act’s (ACA) risk adjustment program has created an opportunity for health plans and providers to review coding practices for identification and correction of any common coding gaps. The ACA risk adjustment program measures and compares the relative health status among health plans’ membership by calculating risk scores. The accuracy of these risk scores is dependent on complete and accurate reporting of definitive diagnoses by physicians. Harvard Pilgrim is currently conducting outreach to select providers aimed at closing coding gaps, and encourages you to keep the following tips in mind when reporting diagnosis codes:

  • All relevant, confirmed diagnosis codes should be reported via claims submission at least once per year for each patient (preferably every 6 months).
  • Be aware of how many diagnosis codes per claim are allowed in your system. Harvard Pilgrim’s systems are capable of accepting more than 20 diagnosis codes in a single claim.
  • Confirm that the provider billing office submits all relevant diagnoses from that encounter with the claim regardless of its impact to claims payment. If you use a clearinghouse, confirm that they are not dropping diagnosis codes.

If you have any further questions about the ACA and Harvard Pilgrim’s risk adjustment program, please contact our Revenue Management department at 617-509-2199.

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Eric H. Schultz,
President and Chief Executive Officer

Richard Weisblatt PhD,
Senior Vice President, Provider Network

Annmarie Dadoly,

Joseph O'Riordan,
Contributing Writer

Kristin Edmonston,
Production Coordinator