Risk Adjustment 101Chronic Respiratory Failure J96.1-• Hypoxemia due to a pulmonary condition is...
Transcript of Risk Adjustment 101Chronic Respiratory Failure J96.1-• Hypoxemia due to a pulmonary condition is...
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