Surviving the Healthcare World of Risk Adjustment

Friday, December 16, 201610:00am EST

GEORGIA CHAPTER – HEALTHCARE FINANCIAL MANAGEMENT ASSOCIATION

Surviving the Healthcare World of Risk Adjustment

Prepared for Georgia Chapter – Healthcare Financial Management Association

About the Speakers

Robert Paskowski, CPA – Principal, Healthcare ConsultingWith more than three decades of experience, Bob has extensive healthcare expertise in leadership, business strategy, finance, reimbursement, and data analysis. He has senior-level experience in managed care organizations (MCOs) and integrated health systems. Bob has a proven record of accomplishments in team building, business growth, and operational performance. Additionally, he has extensive administrative, financial, and operational experience for both national MCOs (such as UnitedHealthcare, Coventry, and Cigna) and regional provider-sponsored MCOs in the Midwest. Bob specializes in executive leadership in health plans aligned with an integrated delivery system.

Carine Leslie, RHIA®, CCS®, AHIMA-Approved ICD-10-CM/PCS Trainer – Senior Staff, Healthcare ConsultingCarine serves as a Senior Staff Consultant on the firm’s Compliance Advisory team. She has expertise in ICD-10-CM/PCS, ICD-9-CM, CPT-4, inpatient, hospital outpatient, and physician Evaluation and Management (E/M) coding. Carine is a Registered Health Information Administrator (RHIA), a Certified Coding Specialist (CCS), an AHIMA-Approved ICD-10-CM/PCS Trainer, and a member of the American Health Information Management Association (AHIMA) and the Georgia Health Information Management Association (GHIMA).


Agenda

Overview of Hierarchical Condition Categories (HCC)

Overview of Risk Adjustment Factor (RAF)

Documentation and Coding

Impact on Payer Revenue

Hierarchical Condition Categories (HCC) andRisk Adjustment Factor (RAF)


HCC Classification System

70,000+ ICD-10-CM codes 805 diagnostic groups 189 condition categories 189 HCCs 79 categories in CMS-HCC payment model

Note: Only approximately 10,000 ICD-10-CM codes for CMS-HCC

79 Categories in Payment Model

189 Condition

Categories & HCCs

805 Diagnosis Groups

70k+ ICD-10-CM Codes


Examples of Disease Hierarchies for CMS-HCC

Hierarchical Condition Category If the Disease Group Is Listed in this Column…

… then Drop the Disease Group(s) Listed in this Column

8 Metastatic Cancer and Acute Leukemia 9, 10, 11, 12

9 Lung and Other Severe Cancers 10, 11, 12

10 Lymphoma and Other Cancers 11, 12

11 Colorectal, Bladder, and Other Cancers 12

17 Diabetes with Acute Complications 18, 19

18 Diabetes with Chronic Complications 19

27 End-Stage Liver Disease 28, 29, 80

28 Cirrhosis of Liver 29

46 Severe Hematological Disorders 48

54 Drug/Alcohol Psychosis 55

57 Schizophrenia 58

70 Quadriplegia 71, 72, 103, 104, 169

71 Paraplegia 72, 104, 169

72 Spinal Cord Disorders/Injuries 169

82 Respirator Dependence/Tracheostomy Status 83, 84

83 Respiratory Arrest 84

86 Acute Myocardial Infarction 87, 88

87 Unstable Angina and Other Acute Ischemic Heart Disease 88

99 Cerebral Hemorrhage 100


Examples of Disease Hierarchies

Only one diagnosis per category is used in the risk score calculation. Example: If both angina and AMI are reported in one year, only

the AMI is scored as it is at a higher level of specificity within the heart category.

Diagnosis Code Description CMS-HCC

Risk Adjustment Factor

I20.0 Unstable angina 87 0.258

I21.4Non-ST elevation (NSTEMI) myocardial infarction 86 0.275

CMS-HCC Description86 Acute Myocardial Infarction87 Unstable Angina and Other Acute

Ischemic Heart Disease88 Angina Pectoris


Risk Adjustment Factor

Each member is assigned a Risk Adjustment Factor (RAF) RAF is a numeric value assigned by CMS to identify the health

status of a patient. Prospective

Uses historical diagnosis as a measure of health status to predict future expense. Data from 2016 will be used to predict cost in 2017.


Risk Adjustment Factor (cont’d)

Demographic Information (incl. age

and gender)

Medicaid Status

Disability Status Disease Burden• Chronic Condition(s)• Disease Interactions

Components

Documentation and Coding


Acceptable Physician Specialty Types

* Indicates that a number has been skipped. ** Effective 2017 Dates of Service


Sources of Documentation

Inpatient hospital (stays longer than 24 hours) Outpatient hospital Face-to-Face provider visits include:

MDs, DOs, DPM, DCs, ODs, PAs, NPs, CNSs, Nurse-midwives and independently practicing PTs

No face-to-face visit is required for anatomical pathology services

Excluded - SNFs, Free-Standing Renal Dialysis Facilities, Hospice, Clinical Lab, Diagnostic Radiology, Ambulance, DME, Prosthetics and Orthotics, and Free-Standing Ambulatory Surgery Centers


Documentation Is Important!

Patient name and date of service must appear on all pages of the record.

Encounter must be based on a face-to-face visit. Condition(s) must be documented in the medical record

and be clear, concise, consistent, complete and legible. Acceptable provider’s signature, credentials, and date of

authentication must be appended.


Shared Responsibility of RiskManagement

Physician• Complete, concise

documentation• Document ALL co-existing

conditions that impact care/treatment

• Link treatment/plan to conditions• Impact on RAF score

Coders• Know ICD-10-CM Guidelines• Review from the body of the note• Assign accurate, complete

diagnosis codes• Query when in doubt• Impact on RAF score


Helpful Acronyms

T = Treatment A = Assessment M = Monitor/Medicate P = Plan E = Evaluate R = Referral

M = Monitor E = Evaluate A = Assess/Address T = Treatment

• Can be found in any section of the patient record• Ensure there is at least one element of the above acronyms documented

for each coded condition

A MT P E R M E A T


MEAT Examples

Monitor - order labs or diagnostic test/radiology Evaluate - review labs or radiology results and physical

exam Assess - condition described as stable or improving Treatment - referral to a specialist, ordering or refilling

medications, surgery

Note: Examples for TAMPER are similar


Documentation and Coding Goals

For each patient: Health status assessment:

Report all current diagnoses to the highest level of specificity. Assess and report all chronic conditions no less than once a

year. Accurate and comprehensive documentation of the various

categories of diagnoses of a patient over a year creates an appropriate risk score.

Medical record must support ICD-10-CM codes reported on the encounter form or claim.


Documentation and Goals Coding (cont’d)

Example of specific reporting rules: Chronic diseases can continue to be reported on an on-going

basis as long as receiving treatment and care for the condition. Diagnoses that receive care and management during the

encounter can be reported. Diagnoses that have resolved or are no longer treated should

not be listed. Malignancy can be reported as long as receiving active

treatment. Do not code problem list diagnoses that have been resolved. Do not code conditions that were previously treated and no

longer exist. History codes may be used as secondary codes if the historical

condition or family history has an impact on current care or influences treatment.


Common Risk AdjustmentCoding and Documentation Errors

Missing legible signature and credential Electronic Medical Record (EMR) was not electronically

authenticated Diagnosis code was not documented or coded to the

highest degree of specificity Face-to-face visit documentation does not demonstrate

how a chronic condition is being managed, evaluated, assessed or treated (MEAT) or treated, assessed, monitored/medicated, planned, evaluated, referral (TAMPER).


Common Risk AdjustmentCoding and Documentation Errors (cont’d)

Documentation for cancer status and treatment is unclear.

Chronic conditions are not documented. Annual documentation of chronic and status conditions

(e.g., amputations, artificial openings, aortic aneurysms and aortic atherosclerosis).



History - means the condition is no longer present or the patient no longer has the condition. Errors with documentation of history include:

Coding a past condition as active Coding history of when the condition is still active It is appropriate to use “history of” with status conditions such

as amputations Discrepancy of diagnosis between what is billed and

what is documented in the EMR. Examples include: CKD unspecified N18.9 - does not risk adjust CKD stage 4 N18.4 - does risk adjust



Providers report just the first-listed or principal diagnosis and not all diagnoses that require care and treatment: Main reason for visit Co-existing acute conditions Chronic conditions

Atrial Fibrillation, CHF, COPD, CKD, RA, DM Care provided Conclusion and diagnoses



Failure to specify type of arrhythmia. Stage of chronic kidney disease not documented. Stage of decubitus ulcers is not documented. Failure to document the BMI for morbid obesity.


Documentation Tips

Chronic conditions affect the management of the patient, even when the patient is presenting with a straightforward illness that would appear unrelated to the chronic condition.

“History of” conditions are informational unless it is documented how the patient’s care was impacted by that history. Only document diagnoses as “history of” or “PMH” when they no

longer exist or are not a current condition. Conditions can only be coded/reported if there is

documentation that the condition has affected the patient’s treatment and management on that particular encounter.


Documentation Tips (cont’d)

Document all cause and effect relationships.

Include all current diagnoses as part of the current medical decision making and document them in the note on every visit.

Document history of heart attack, status codes, etc.


Sample Risk Adjustment Data Validation(RADV) Audit Checklist

Check for Yes Is the record from the correct calendar year for the payment year being audited ( i.e., for

audits of 2017 payments, validating records should be from calendar year 2016) Is the record for the correct enrollee? Is the patient’s name documented on all pages of the medical record? Is the date of service present for the face to face visit? Is the record from a valid provider type? (e.g. hospital inpatient, hospital outpatient,

physician office) Is the record legible? Does the record contain a signature from an acceptable provider specialty? Are there valid credentials and/or is there a valid provider specialty documented on the

record? If the outpatient/provider record does not contain a valid credential and/or signature, is there

a completed CMS-Generated Attestation for this date of service? Is there a diagnosis on the record? Does documentation indicate the diagnoses are being monitored, evaluated,

assessed/addressed, or treated (MEAT)? Does the diagnosis support an HCC? Does the diagnosis support the requested HCC?

Impact on Payer Revenue


Background

Risk adjustment is used to compute premium revenue from CMS to Payers for Medicare Advantage and ACA Marketplace members.

RAFs are determined each year. Note: RAFs are reset each year to zero.

RAFs are computed for Part C (Medical) and Part D (Pharmacy)

Driven predominately from diagnosis (ICD-10) coding in both facility and ambulatory settings


Impact

Appropriate coding and documentation leads to impactful care management based on accurate patient profile

Compliance risk is minimized with appropriate coding and documentation under CMS’ RADV audit of Payers

RAFS have a direct impact on CMS Revenues paid to Payers (see example below)

Example: Diabetic with or without Neuropathy

Without Neuropathy

With Neuropathy

Premium Revenue $800 $800

Risk Adjustment 0.118 0.368

Adjusted Premium Revenue $94.40 $294.40


Summary

2017 Office of Inspector General (OIG) Work Plan “Risk Adjustment Data – Sufficiency of Documentation Supporting Diagnoses”

Using specific ICD-10 diagnosis codes will help convey the true seriousness of the conditions being addressed on each visit.

Documentation includes: Identifying the diagnosis as a current or ongoing problem, as

opposed to a past medical history or previous condition. Choosing the most specific diagnosis code while also being sure

it is supported in documentation.


HCC: Critical Element of Risk Management


HCC: Critical Element of Risk Management (cont’d)


Questions?

PERSHING YOAKLEY & ASSOCIATES, P.C.800.270.9629 | www.pyapc.com

Carine Leslie, RHIA®, CCS®, AHIMA-Approved ICD-10-CM/PCS TrainerSenior Staff, Healthcare Consulting

[email protected]

Robert Paskowski, CPAPrincipal, Healthcare Consulting

[email protected]

mailto:[email protected]

mailto:[email protected]

Surviving the Healthcare World of Risk Adjustment

Healthcare

Transcript of Surviving the Healthcare World of Risk Adjustment