Nursing notes from LPNs or RNs  are not acceptable sources for risk-adjustment diagnoses.

The following nursing specialties are recognized as acceptable provider/specialty types:

- Certified Nurse Midwife

- Certified Clinical Nurse Specialist

- Certified Registered Nurse anesthetist

- Nurse Practitioner

2 Comments

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  By Lmarie, May 16, 2011 @ 8:47 AM

  Does a health plan need the facility’s (clinic) permission to add a chronic condition to a claim when the evidence of evaluation and treatment is found in the documentation? Our problem is the very rural areas are coders who do not know anything about risk adjustment and are constantly disagreeing with out findings because they think you ONLY code the reason for the visit no matter what information I give them regarding the importance of coding chronic conditions when addressed/assessed and treated. Any guidance you can offer would be a great help!
• 

  By J. Matt Yuill, M.D., CPC, May 16, 2011 @ 9:01 AM

  A health plan does not need a provider’s permission to submit documented ICD-9-CM codes to the RAPS database. Any documented chronic or acute condition that a certified coder could abstract from the proper face-to-face documentation (i.e. signed, dated, credentialed by acceptable specialty type) may be submitted for risk adjustment purposes. All of the chart auditing vendors and any coders working for a plan may abstract and code diagnoses that are properly documented and submit to the plan or submit to CMS on behalf of the plan.

  Ideally, these additional codes would be submitted on claims in the first place for ease of processing, but you may submit ICD-9-CM codes to RAPS that have been collected in other means, such as a superbill, chart audit, etc.

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