Risk adjustment payments are based on the accuracy of diagnoses submitted as part of which coding system?

Risk adjustment payments are based on the accuracy of diagnoses submitted as part of which coding system?

• A. ICD-10-CM codes.
• B. CPT codes.
• C. HCPCS codes.
• D. DSM codes.

Answer: (A)

The concept being tested is how risk adjustment payments rely on accurate diagnosis data, captured with the ICD-10-CM diagnosis coding system. ICD-10-CM provides standardized codes for a patient’s medical conditions, and those codes feed the risk adjustment models to estimate expected costs and determine payments. Procedure and service codes (CPT/HCPCS) describe what was done, not the patient’s conditions, so they aren’t the basis for risk-adjusted payments. DSM codes are used mainly for psychiatric diagnoses in clinical or research settings and aren’t the standard for calculating risk scores in payment models. So, ICD-10-CM codes are the appropriate system for risk adjustment because they reflect the patient’s actual diagnoses used to determine risk and payment.

The concept being tested is how risk adjustment payments rely on accurate diagnosis data, captured with the ICD-10-CM diagnosis coding system. ICD-10-CM provides standardized codes for a patient’s medical conditions, and those codes feed the risk adjustment models to estimate expected costs and determine payments. Procedure and service codes (CPT/HCPCS) describe what was done, not the patient’s conditions, so they aren’t the basis for risk-adjusted payments. DSM codes are used mainly for psychiatric diagnoses in clinical or research settings and aren’t the standard for calculating risk scores in payment models. So, ICD-10-CM codes are the appropriate system for risk adjustment because they reflect the patient’s actual diagnoses used to determine risk and payment.