Risk Adjustment

Member Acuity and Risk Adjustment

Aetna Better Health of New Jersey’s members have a broad distribution of health status, ranging from good health to multiple chronic illnesses.   Collectively, the sickest members of any health plan require the most attention and care; they also drive the highest cost of care.  To address this, New Jersey Medicaid funds Medicaid Managed Care plans based on a complex calculation that includes members’ degree of morbidity (referred to as acuity) through the State’s Risk Adjustment Payment Model.  In this model, the more a plan’s members have certain chronic conditions, the higher the Risk Score the State assigns to the plan.  Accurate Risk Scoring requires that members with these conditions have all of their chronic conditions documented in claims.   Reporting on member acuity starts and ends with the provider. 

Diagnosis Coding in Claims

Encounters are electronic documents created in the claims process and reported to the State of New Jersey, showing each service provided to members.   The diagnosis codes in each encounter drive the calculation of each plan’s Risk Score.  Each time a member with a chronic condition has that condition addressed at a visit, the diagnosis should appear on the claim. It is critical that providers document all chronic illness diagnosis codes on every applicable claim.  Evaluation of the codes and subsequent Risk Adjustment analysis is done by the State on a bi-annual basis.  Thus, providers should include the diagnosis code on every patient claim at every visit when it was addressed to ensure that the diagnosis is captured and utilized in the most current encounter analysis.  

Acute Visits

Members with chronic conditions who may not have seen their provider for periodic checkups may still present for episodic or acute conditions. These visits are opportunities to address their chronic conditions.  If your member visits you for an episodic or acute condition and a chronic condition is currently present and addressed during the visit, the chronic condition diagnosis should be coded and included on the claim.

For example, a member with type 2 diabetes presents to the office with bronchitis. During the visit, along with treatment of bronchitis, you also provide reminders on the management of diabetes and the risk of elevated blood-glucose levels related to the acute bronchitis.  The claim should include both the diagnosis of acute bronchitis and the diagnosis of diabetes. 

Our Partnership

Aetna Better Health of New Jersey is your partner in caring for all of our members, including our highest acuity members. We offer Integrated Care Management and our Quality program mails visit reminders and calls members, all in an effort to get them the care that they need. 

Aetna Better Health of New Jersey thanks you for your continued commitment to assisting our members.

View our Top 10 Tips - Risk Adjustment Coding and Medical Documentation below.

Top 10 Tips - Risk Adjustment Coding and Medical Documentation

Include patient’s name and date of service on each page of the medical record.

Five+ diagnosis codes for every visit represents “best practice” documentation.

Document all diagnosis codes to the highest level of specificity.

Include assessment and treatment plans for each diagnosis (i.e. Assessment: Improved – Treatment Plan – Discontinue Medication).

Reaffirm and document prior chronic conditions reflected in past visit notes during every visit.

For each condition noted, documentation must support that the physician Monitored, Evaluated, Assessed/Addressed, Treated (MEAT).

Include notes on any areas in need of assessment, evaluation or screening.

Ensure physician signature, credentials, and date are included to authenticate medical record.

Utilize and provide Clinical Documentation Improvement (CDI) alerts from your EMR system.

The more information – the better – to ensure proper documentation of the medical record.

Proper coding and documentation: it’s a win-win for physicians and health plans, ensuring:

  • Appropriate reimbursement
  • Accurate claims data
  • Increased specificity to identity patients for disease and care management programs
  • More comprehensive descriptions of patients’ health and conditions