Why does it matter if the clinician notes the patient’s issue as diabetes or diabetes with complications if the amount billed will be the same either way? When healthcare providersmove to value-based contracts, it is important that they are paid enough in the budget for the population to cover the sum of the estimated costs of care for each patient. Risk adjustment or scaling an average budget up or down based on the documented health of the patients, is how budgets are changed to represent the overall health of that population.Risk adjustment models consider chronic conditions and demographic information that might be valuable for determining patients’ approximate health expenditures. When a clinician assesses a patient’s chronic condition, this information must be submitted on aclaimso that provider organizations can be fairly reimbursed by insurers.
One method that supports risk adjustment, known as “chart scrubbing,”is the review of a patient’s electronic medical record (EMR or the patient’s “chart”) to proactively address discrepancies between what appears on the patient’s clinical problem list (e.g., diabetes, or diabetes with complications) and what has been billed in patient claims data.By ensuring that the problem list is accurate,chart scrubbing canalso provide more complete information to cliniciansso that they can provide the right preventive care to patients before they get sick or end up in the hospital.
While some organizations employ certified professional coders for this chart scrubbing process, Atrius Health, the largest independent medical group in the Northeast, recognized that registered nurses have greater clinical training, experience and judgment. Therefore, three years ago we put together a team of registered nurses to perform this crucial responsibility.