Disease interactions significantly impact a patient’s overall risk score. When providers document and code these interactions correctly, Medicare and healthcare organizations gain a more complete understanding of the patient’s condition. This helps ensure the patient receives appropriate care, and the provider is credited for the full scope of care they deliver.
What Are Disease Interactions?
Disease interactions occur when two or more related conditions coexist and increase a patient’s expected healthcare costs beyond the sum of the individual conditions. CMS recognizes that certain combinations of conditions introduce additional clinical complexity and risk. When providers document specific condition pairs together, CMS applies a higher combined risk score (RAF).
For example, diabetes and congestive heart failure are serious conditions individually. When a patient has both, CMS considers the combination a risk multiplier. The resulting interaction reflects the greater clinical burden and anticipated resource needs for that patient. When documented properly, this combination increases the patient’s risk score.
Common CMS-Recognized Interactions
Not every condition pairing results in an interaction effect. CMS identifies specific combinations that qualify for interaction adjustments. These interactions reflect greater management complexity. Common examples include:
- Congestive Heart Failure & Diabetes
- Congestive Heart Failure & COPD
- Congestive Heart Failure & Renal Disease
- Cardiorespiratory Failure & COPD
- Congestive Heart Failure & Specified Heart Arrythmias
Why Do Disease Interactions Matter?
In the HCC model, disease interactions make a meaningful difference in how CMS calculates a patient’s risk score. That score drives reimbursement. When providers fail to capture these interactions through accurate coding and documentation, the patient’s score underrepresents their true clinical complexity, leading to inadequate funding for care.
How to Capture Interactions Effectively
To capture disease interactions accurately, providers must document and code all conditions that coexist at the time of the encounter, and affect patient care, treatment, or management. Providers should assess and document these conditions, even if stable, at least once a year.
By documenting and coding disease interactions thoroughly, providers paint a complete picture of each patient’s health. This leads to appropriate reimbursement and supports high-quality, value-based care.
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