ICD10monitor June 23, 2025
The traditional narrative that risk-adjustment coding is exclusive to Medicare Advantage (MA) is no longer accurate.
In 2025, commercial insurers, particularly those managing Patient Protection and Affordable Care Act (PPACA) marketplace plans and employer-based products, are heavily relying on risk-adjusted payment models. This evolution is pushing health information management (HIM) professionals and coding teams into new territory, where documentation integrity, chronic disease capture, and accurate coding are essential for sustainable reimbursement.
A Broader Landscape for Risk Adjustment
Risk adjustment is a statistical process that modifies payments based on a patient’s disease burden and demographic risk. It was initially rooted in Medicare Advantage through the Centers for Medicare & Medicaid Services Hierarchical Condition Category (CMS-HCC) model, but today, risk adjustment has...
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