Are Problem Lists Problematic for Risk Adjustment?
If you are even tangentially involved in the risk adjustment efforts in healthcare organizations, you’ve probably fielded a question that goes something like this:
I’m auditing charts for HCC coding. Our Problem Lists are confusing. There’s a variety of acute problems that have been resolved, acute problems still being monitored or treated, chronic conditions that are not actively being treated, chronic conditions that are being treated (and are usually the primary diagnosis for most care interactions), and duplicate diagnoses that are clinically the same problem. What am I supposed to do with all of this?
How would you answer?
The Problem List is a place where risk adjustment, clinical conditions and treatment, and EHRs intersect, and ultimately, converge. One of the problems with these types of intersections is that very few people in a healthcare organization understand all the roads that lead to this intersection, all the folks traveling on that road, or what’s needed to make the path forward smooth, compliant, useful, and patient-centered. This results in well-meaning staff sometimes doing disadvantageous things because they are acting from a narrow viewpoint without a clear understanding of what lies ahead. Unless the organization has a clear strategy, buy-in from all relevant stakeholder groups, impactful training, and a standardized process, this can be a difficult problem to solve.
Here are four things you should consider as you build your Problem List strategy.
The Purpose of the Problem List
The problem list is a reference tool for clinicians to aid in providing good clinical care. It provides a bullet point view of the patient’s medical history by highlighting the conditions that impact the trajectory of the patient’s health over their lifetime. Any condition that is being actively managed, passively managed (watchful waiting), contributes to medical decision making, or relevant to future clinical care should be on the problem list in a way that describes the condition’s relevance to current clinical care.
The Users of the Problem List
While it’s easy to think of doctors, nurses, and other clinicians as the users of the Problem List, it’s easy to forget that patients are also users. With increasing transparency of medical records, it’s important for the Problem List to reflect what the patient knows about their own health. They may expect acute injuries, such as a fall that resulted in stitches or a cast seven years ago, to appear on the Problem List, because it was an important and painful event, while their 20-year history of tobacco use that they quit 10 years ago may not seem important to them. The balance between the purpose and the users of the Problem List is one that requires active and ongoing conversation between patients and clinicians.
People Who Don’t Use the Problem List
Clinicians are the primary people performing data entry and “clean up” of the Problem List. Unless they have been educated accordingly, they likely do not know that ICD-10 codes are not assigned to claims from the Problem List. Many providers have thought they were helping with risk adjustment by keeping the Problem List comprehensive and up to date, but that’s not always the best use of their time since HIM professionals cannot use the Problem List to assign codes to claims. It doesn’t mean Problem List maintenance isn’t valuable- it definitely is! But for capturing HCCs, that’s not the best place for the billing provider to focus their time.
The Nature of the ICD-10 Code Set
To date, there are almost 73,000 ICD-10 codes. That’s a massive leap from where the US was in 2014, with only about 14,000 ICD-9 codes available. The dramatic increase in available codes comes largely from ICD-10 becoming a more granular and flexible taxonomy. Codes can describe active conditions, their sequela, the resultant chronic conditions, or a personal history of the acute condition. All of these are relevant to your Problem List strategy and contribute to success in risk adjustment.
As risk adjustment methodology continues to evolve, understanding how the Problem List contributes to the accurate reflection of the complexity of your patient population, excellence in clinical care and outcomes, and addressing health equity is vitally important to creating a strategy for near- and long-term success. Your strategy doesn’t have to be complicated, but it does need to be thoughtful and comprehensive. To get started building a better strategy with actionable tactics that deliver results, check out our Risk Adjustment and Health Equity workshop or schedule a consultation with us.