RiskAdjustment101

Agenda

• RiskAdjustmentModel• HierarchicalConditionCategories(HCC)• PatientExample

• Documentation• MEAT• DocumentationGuidance

• ChronicConditions• RiskScoreCalculations• StepsforPhysicianPractices• GoldenRuleofDocumentation

RiskAdjustmentModel

RiskAdjustmentandHierarchicalConditionCategoryCoding

v RiskAdjustment andHierarchical Condition Category(HCC)coding isapaymentmodelmandated bytheCenters forMedicare andMedicaid Services (CMS) in1997. Implemented in2003,thismodel identifies individuals withserious orchronic illness andassigns ariskfactorscoretothepersonbaseduponacombination ofthe individual’s health conditions anddemographic details. Theindividual’s health conditions areidentified viaInternational Classification ofDiseases – 10 (ICD–10)diagnoses thataresubmitted byprovidersonincomingclaims. Therearemorethan9000ICD-10codesthatmapto79HCCcodes intheRiskAdjustment model.

v MAplans useHierarchical Condition Categories (HCCs) inordertodeterminepaymentratesfordiagnoses. TheHCCmodel usedforMApatients categorizesICD-10-CMdiagnosis codes intodisease groupsthataresimilar bothclinicallyandfinancially. CMScreates ahierarchysothatpatients' conditions arecodedforthemostseveremanifestation among relateddiseases.

HierarchicalConditionCategories(HCC)

Diagnoses thatareincluded intheRiskAdjustmentmodel aregroupedinto79differentcategories knownasHierarchical Condition Categories orHCC’s.EachHCCisassigned arisk-adjusted factor(RAF),whichisarelativeweight, similar tothe inpatient DRGsystem.

CMScreated ahierarchysothatpatients' conditions arecodedforthemostseveremanifestation amongrelated diseases.

HCC Description…thendropthe

HCC(s)listedinthiscolumn

HCCValueCommunity,NonDual,Aged

8 MetastaticCancerandAcuteLeukemia 9,10,11,12 2.6259 LungandOtherSevereCancers 10,11,12 0.97010 LymphomaandOtherCancers 11,12 0.67711 Colorectal, Bladder,andOtherCancers 12 0.30112 Breast,Prostate,andOtherCancersandTumors 0.14617 Diabetes withAcuteComplications 18,19 0.31818 Diabetes withChronicComplications 19 0.31819 Diabetes withoutComplications 0.10421 Protein-CalorieMalnutrition 0.54522 MorbidObesity 0.27323 OtherSignificant EndocrineandMetabolicDisorders 0.228

PatientExample

Condition ICD-10 HCC RAF

65yearoldfemale (demographics) 0.312

Malignantneoplasm ofBladder C67.9 011 0.301

Angina I20.9 088 0.140

DMIIwithnephropathy E11.21 018 0.318

Emphysema J43.9 111 0.328

CHF I50.9 085 0.323

Thrombocytopenia D69.6 048 0.221

Total 1.943

These areknownconditions thepatient has

Condition ICD-10 HCC RAF

65yearoldfemale (demographic) 0.312

DMIIwithnephropathy E11.21 018 0.318

Emphysema J43.9 111 0.328

Total 0.958

This iswhathasbeen capturedsofarthisyear

Disease InteractionCHF*DM+0.154CHF*COPD+0.190

Documentation

Ø RiskAdjustment diagnosis mustbebased onclinicalmedical recorddocumentation fromaface-to-faceencounter

Ø Coded accordingtothe ICD-10-CMGuidelines forCodingandReporting

Ø Assigned based ondatesofservicewithinthedatacollection period

Ø Submitted fromanappropriate riskadjustment providertypeandanappropriateriskadjustment physician datasource

Documentation inthemedical recordiscrucialandnecessary toensureexcellence inhealthcare.Documentation isalegalrecordthatmust holdindefense and justification ofcare.Itisrequired.

Documentation:MEAT

Alldatesofservicemustbesigned (withcredentials) anddated bythephysician(provider)oranappropriate extender (forexample, anon-physician practitioner suchasaPA,NP,CNS,etc.)

Documentation:DocumentationGuidance

Patientname,dateofservice(DOS) andanadditionalpatientidentifier(e.g., dateofbirth[DOB]) isrequiredoneverypage.

Chiefcomplaint (CC):“Follow-up”aloneisnotavalidCC.Thedocumentationmustdescribewhythepatientispresentingforfollow-up.

Exam:Examdrivenbythepatienthistory,describingindetailanypertinentpositivefindingsandanychronicfindingsthataffectthecareandtreatmentofthepatient.

Medicaldecision-making:Assessmentthatdocumentsthediagnosis,itsstatusandanycausalrelationships(e.g., diabetic,duetodiabetes).Assessmentthatdocumentsnotonlyconditionsbeingtreated,butanychronicconditionsthataffectthecareandtreatmentofthepatient.

Planthatspecifiestreatmentforeachconditionlistedintheassessment,including,butnotlimitedto,diet,medications,referrals,laboratoryorders,patienteducationandreturnvisits.

Authentication:Paperrecord:Authenticationbytheproviderauthoroftheprogressnotewhichincludesalegiblenameandcredential, ahand-writtensignatureandthedatesigned.EMR:Authenticationbytheproviderauthoroftheprogressnote,password-protectedtothatprovideronly,attheendofthenote(forexample, authenticatedby,approvedby),includingtypednameandcredentialandthedateauthenticated.

ChronicConditions

• Recapture chronicconditions everyyear• Conditions weknowthepatient has– Problem list,conditions treated lastyear

andstillmonitored and/ortreated• Conditions others havedocumented – Hospital, Consults, andRadiology

• Capture the lowhangingfruit• Highprevalence conditions• Conditions inremission• Frequently over-looked conditions

• Identifynewdiagnosis• Newconditions thatdevelop• Existing conditions noone identified inthepast

ChronicConditions

Stablevs.Resolved• Classicchronicconditionsthatmayimprove

• Diabetes(“Improvedormanagedwithlifestylechanges”)

• CHF(“Manageriskfactors”“StableorImproved- continuemonitoring”)

• Angina(“stable,refillNitroglycerin”)

• Resolved• Anythingconsiderscuredbytreatment• SickSinusSyndromewithpacemaker• AAAs/prepair

• Inpatientonly• CVA• MI(cancodeupto4weekspostdischarge)

ChronicConditions

HighPrevalenceConditions

• DiabetesMellitus(type2)withComplicationsE11.-• ChronicKidneyDiseaseE11.2-• PeripheralAngiopathy E11.5• NeuropathyE11.4-

• COPDJ44.9• SenilePurpura D69.2• MorbidObesityE66.01• MajorDepressionF32.-,F33.-• CongestiveHeartFailureI50.-• AtrialFibrillation,ChronicI48.2• RheumatoidArthritisM06.9

ChronicConditions

ConditionsinRemission

• MajorDepression,Single,FullRemissionF32.5• Patient hashadtwoormoredepressive episodes inthepastbuthasbeenfree

fromdepressive symptoms forseveralmonths. Thiscategorycanstill beused ifthepatient isreceiving treatment toreduce theriskoffurtherepisodes.

• AlcoholDependence,inRemissionF10.21• Afteranalcoholic hassuccessfully stopped drinkingforaperiodoftime orhas

changed thepattern ofusetoonethatdoesnotmeet thecriteria ofdependence, adiagnosis ofalcoholdependence maystill applybuttheconditionwillbeclassified asinremission.

ChronicConditions

FrequentlyOverlookedConditions

• AtherosclerosisofAortaI70.0• Reviewradiologyreports(bodyofthenote)• Addtochronicproblems(suggestinclude“chestx-ray2003”)

• ProteinCalorieMalnutritionE44.-• PatientswithaBMIof≤18.9• Albumin<3.5

• ObesityHypoventilationSyndromeE66.2• PatientswithaBMIof≤35• ComorbidOSA

• AmputationStatusZ89.-• PhysicalExamfindings

• Ostomy StatusZ93.-• PhysicalExamfindings

ChronicConditions

IdentifyNewDiagnosis

ChronicRespiratoryFailureJ96.1-• Hypoxemiaduetoapulmonaryconditionischronicrespiratoryfailureby

definition.**NOTEthatthisdoesnotapplytonocturnalhypoxemiainthesettingofOSAortonon-respiratorycauseslikeCHF.

• Patientswhoaresupposedtoweartheiroxygen24/7butdon't,maystillbeclassifiedas"chronicrespiratoryfailure"patients.

ThrombocytopeniaD69.6• Acompletebloodcountoffewerthan150,000platelets

PulmonaryHypertensionI27.2• CanbelocatedonanECHOorRadiologyreport

TortuousArteryI77.1• CanbelocatedonRadiologyReport

RiskScoreCalculations

Correctcoding iskeytosubmitting validclaims. Toensure claims areasaccurate aspossible, usecurrentvaliddiagnosis andprocedurecodes andcodethemtothehighestlevel ofspecificity.

Encounter Data isthemostvaluable• Claims data• Providesauthentication fordiagnoses submitted• Potential formaximizing codecapture

CMSStricture Rules forRebilling Claims• Claims should berebilled inthere entirety

• Including alldiagnoses submitted onoriginal claim• CMS-1500standard claimformandaccepts

12diagnoses• CMSvoidsthefirstclaim billed

• Replaced withsecond claimbilled

RiskScoreCalculations

CMSandUHChavebeguntrackingtheactualDOS apatientwasseencomparedtothetimelyfilingofclaims.

• ThetimelyfilingperiodforbothpaperandelectronicMedicare claimsis12months,oronecalendar year,afterthedateofservice.• UHCisreviewingclaimsbilled≥90daysaftertheDOS

• IfclaimsarenottimelyfiledthisopensadoorforaRADVaudit• TheCentersforMedicareandMedicaidServices(CMS)perform riskadjustmentdata

validationauditsonpatients'medicalrecords. Riskadjustmentdatavalidation(RADV) istheprocessofverifyingdiagnosiscodessubmittedforpaymentaresupportedbymedicalrecorddocumentation.

• ALLdocumentationofaface-to-face encountermustbesignedandauthenticated• Auditsandlackofsignaturerequirements allowsforCMSfinancialtakebacks

StepsforPhysicianPractices

q Ensure thatyouarecapturing allappropriateHCC’sontheclaimwithsupportingdocumentation inthemedical record

q Review andupdateNPIandTaxonomy information andkeepuptodate

q Ensure thatyouareusingvalidCPTandICD-10-CMcodes inyourencounter datanowandinthefuture

q Submit claims onALLface-to-face encounters withaqualifying provider

q Ensure thatyouaresubmitting encounters onthecorrectforms

q Timely filingofclaims

Goal - Eliminate errorsthatwillprevent aclaimfrombeingprocessed thereby increasingtheopportunity fortheHCC’storeachCMSforprocessing.

StepsforPhysicianPractices

q Document andcapture allchronicconditions annually.

q Manage yourpatient population

q Clean upyourproblem list toaccurately reflect allchronicconditions

q Submit allassessed andtreated conditions throughclaims, including BMIstatus

GoldenRuleofDocumentation

The Golden Rule …

“If it’s not documented by the physician/provider, it didn’t

happen.”

In healthcare compliance and in coding, there isnodeviation from thisprinciple.We can’t code it if itisn’tdocumented, and thuswe can’t bill for it.

Questions

PleasesubmitcodinganddocumentationquestionstoRAFeducation@cnchealthplan.com