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Surviving the Healthcare World of Risk Adjustment

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PYA Principal Bob Paskowski and Senior Staff Consultant Carine Leslie presented a webinar for the Georgia chapter of the Healthcare Financial Management Association Friday, December 16, 2016.

The presentation is tailored for coders in ambulatory/Medicare Advantage settings, providers participating in Medicare Advantage or other risk-based healthcare plans, and leaders in providers’ managed care contracting departments. The webinar is titled “Surviving the Healthcare World of Risk Adjustment.”

The webinar addresses:

• Principles of the Medicare Advantage risk-adjustment model from Medicare Advantage Hierarchical Condition Categories and other risk-based healthcare plans;
• Strategies for reducing compliance risks;
• Methods for accurately, completely, and consistently capturing and documenting a patient’s disease burden to promote effective care management and to reflect the proper risk score.

Published in: Healthcare
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Surviving the Healthcare World of Risk Adjustment

  1. 1. Friday, December 16, 2016 10:00am EST GEORGIA CHAPTER – HEALTHCARE FINANCIAL MANAGEMENT ASSOCIATION Surviving the Healthcare World of Risk Adjustment
  2. 2. Prepared for Georgia Chapter – Healthcare Financial Management Association Page 1 About the Speakers Robert Paskowski, CPA – Principal, Healthcare Consulting With 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 Consulting Carine 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).
  3. 3. Prepared for Georgia Chapter – Healthcare Financial Management Association Page 2 Agenda
  4. 4. Hierarchical Condition Categories (HCC) and Risk Adjustment Factor (RAF)
  5. 5. Prepared for Georgia Chapter – Healthcare Financial Management Association Page 4 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
  6. 6. Prepared for Georgia Chapter – Healthcare Financial Management Association Page 5 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
  7. 7. Prepared for Georgia Chapter – Healthcare Financial Management Association Page 6 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 I21.4 Non-ST elevation (NSTEMI) myocardial infarction 86 0.275 CMS-HCC Description 86 Acute Myocardial Infarction 87 Unstable Angina and Other Acute Ischemic Heart Disease 88 Angina Pectoris
  8. 8. Prepared for Georgia Chapter – Healthcare Financial Management Association Page 7 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.
  9. 9. Prepared for Georgia Chapter – Healthcare Financial Management Association Page 8 Risk Adjustment Factor (cont’d) Demographic Information (incl. age and gender) Medicaid Status Disability Status Disease Burden • Chronic Condition(s) • Disease Interactions Components
  10. 10. Documentation and Coding
  11. 11. Prepared for Georgia Chapter – Healthcare Financial Management Association Page 10 Acceptable Physician Specialty Types * Indicates that a number has been skipped. ** Effective 2017 Dates of Service
  12. 12. Prepared for Georgia Chapter – Healthcare Financial Management Association Page 11 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
  13. 13. Prepared for Georgia Chapter – Healthcare Financial Management Association Page 12 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.
  14. 14. Prepared for Georgia Chapter – Healthcare Financial Management Association Page 13 Shared Responsibility of Risk Management 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
  15. 15. Prepared for Georgia Chapter – Healthcare Financial Management Association Page 14 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
  16. 16. Prepared for Georgia Chapter – Healthcare Financial Management Association Page 15 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
  17. 17. Prepared for Georgia Chapter – Healthcare Financial Management Association Page 16 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.
  18. 18. Prepared for Georgia Chapter – Healthcare Financial Management Association Page 17 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.
  19. 19. Prepared for Georgia Chapter – Healthcare Financial Management Association Page 18 Common Risk Adjustment Coding 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).
  20. 20. Prepared for Georgia Chapter – Healthcare Financial Management Association Page 19 Common Risk Adjustment Coding 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).
  21. 21. Prepared for Georgia Chapter – Healthcare Financial Management Association Page 20 Common Risk Adjustment Coding and Documentation Errors (cont’d)  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
  22. 22. Prepared for Georgia Chapter – Healthcare Financial Management Association Page 21 Common Risk Adjustment Coding and Documentation Errors (cont’d)  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
  23. 23. Prepared for Georgia Chapter – Healthcare Financial Management Association Page 22 Common Risk Adjustment Coding and Documentation Errors (cont’d)  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.
  24. 24. Prepared for Georgia Chapter – Healthcare Financial Management Association Page 23 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.
  25. 25. Prepared for Georgia Chapter – Healthcare Financial Management Association Page 24 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.
  26. 26. Prepared for Georgia Chapter – Healthcare Financial Management Association Page 25 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?
  27. 27. Impact on Payer Revenue
  28. 28. Prepared for Georgia Chapter – Healthcare Financial Management Association Page 27 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
  29. 29. Prepared for Georgia Chapter – Healthcare Financial Management Association Page 28 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
  30. 30. Prepared for Georgia Chapter – Healthcare Financial Management Association Page 29 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.
  31. 31. Prepared for Georgia Chapter – Healthcare Financial Management Association Page 30 HCC: Critical Element of Risk Management
  32. 32. Prepared for Georgia Chapter – Healthcare Financial Management Association Page 31 HCC: Critical Element of Risk Management (cont’d)
  33. 33. Prepared for Georgia Chapter – Healthcare Financial Management Association Page 32 Questions?
  34. 34. PERSHING YOAKLEY & ASSOCIATES, P.C. 800.270.9629 | www.pyapc.com Carine Leslie, RHIA®, CCS®, AHIMA- Approved ICD-10-CM/PCS Trainer Senior Staff, Healthcare Consulting cleslie@pyapc.com Robert Paskowski, CPA Principal, Healthcare Consulting bpaskowski@pyapc.com

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