8. What Is a Claim?
A claim is a formal request for payment submitted by a healthcare provider to a health plan or government payer (e.g., Medicare) for services rendered to a patient. It includes diagnosis codes, procedure codes, dates of service, and billing information.
9. What Is an Encounter?
An encounter refers to any interaction between a patient and a healthcare provider (in-person, telehealth, etc.). In risk adjustment, only face-to-face encounters are generally acceptable for submitting diagnoses.
10. What Is a Provider?
A provider is any qualified healthcare professional or facility that delivers care (physicians, nurse practitioners, hospitals, clinics, etc.). In risk adjustment, only certain provider types are acceptable sources for diagnosis codes.
11. What Is a Member?
A member (or beneficiary/enrollee) is an individual who is covered by a health insurance plan. In Medicare Advantage, members are the patients whose risk scores determine plan reimbursement.
12. ICD-10-CM Basics
The International Classification of Diseases, 10th Revision, Clinical Modification (ICD-10-CM) is the standard system used in the U.S. to report medical diagnoses. Accurate and specific ICD-10 coding is the foundation of risk adjustment.
13. CPT and HCPCS Basics
- CPT (Current Procedural Terminology): Codes used to report medical, surgical, and diagnostic procedures.
- HCPCS (Healthcare Common Procedure Coding System): Includes CPT codes plus additional codes for supplies, equipment, and services not covered by CPT.
These code sets are critical for determining whether an encounter qualifies for risk adjustment.