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Risk adjustment factor, RAF
- 1. RAF: Risk AdjustmentFactor Dr. Krutagni Mehta Presenter Dr. Gauvain Kankeu Presenter Dr. Nimesh Khanal Presenter Dr. Dhriti Gupta Writer and Presenter Dr Vinay Patel Director and Presenter J C M I ' S G R A N D T E L E C O N F E R E N C E Clinical Externs, Under supervision of Dr Jean Charles, JC Medical Centers, Fl, USA, September 10th, 2021
- 2. SOURCE: AMERICAN ACADEMYOF PROFESSIONAL CODERS, AAPC Premium 100$ Premium 100$ Insurance Co. What is RISK? Financial risk of profit/loss
- 3. SOURCE: AMERICAN ACADEMYOF PROFESSIONAL CODERS, AAPC Premium 100$ Premium 100$ Insurance Co. What is risk ADJUSTMENT and why? Financial risk of profit/loss Risk selection
- 4. SOURCE: AMERICAN ACADEMYOF PROFESSIONAL CODERS, AAPC Premium 100$ Premium 100$ Insurance Co. risk score (RAF) Health status + Demographics Age, Gender, Occupation HCC code Risk Adjustment Risk Adjustment is a methodology that equates the health status of a person to a number, called a risk score, to predict healthcare costs.
- 5. SOURCE: AMERICAN ACADEMYOF PROFESSIONAL CODERS, AAPC This method puts related medical diagnoses (ICD 10) into groupings based on resource use. CMS (centre for Medicare and Medicaid services) risk adjustment model Uses HCC model for calculating risk score (RAF)
- 6. SOURCE: AMERICAN ACADEMYOF PROFESSIONAL CODERS, AAPC Risk Adjustment Processing System (RAPS:OLD)
- 7. SOURCE: AMERICAN ACADEMYOF PROFESSIONAL CODERS, AAPC
- 8. SOURCE: AMERICAN ACADEMYOF PROFESSIONAL CODERS, AAPC
- 9. Not every diagnosesmaps to HCC! COLLECTIVE ANNUAL ASSESSMENT (ICD-10-CM) FOR MR. JOHN Abdominal pain Tuberculosis Diabetes A sprain Morbid obesity Acute appendicitis Myocardial infarction Hepatitis C HCC CROSSWALK Morbid obesity Diabetes Myocardial infarction SOURCE: AMERICAN ACADEMY OF PROFESSIONAL CODERS, AAPC A sprain Acute appendicitis Abdominal pain Hepatitis C The CMS-HCC model focuses on chronic health conditions likely to affect long-term health expenditures (included in the HCC crosswalk) and purposefully excludes: clinically insignificant diagnoses (e.g. non-diagnostic diagnoses (e.g., a diagnosis of or diagnoses that are definitively treated (e.g.,
- 10. Medicare risk adjustment Rule #1 Hierarchy HCCwithin same Disease state are mutually exclusively SOURCE: AMERICAN ACADEMY OF PROFESSIONAL CODERS, AAPC 17. T2-DM with acute complication 18. T2D with complications 19. T2D without complications Mr. John: Type 2 Diabetes mellitus 1. T2-DM 2. T2-DM with hyperglycemia 3. T2-DM with retinopathy 4. T2-DM with polyneuropathy 5. Diabetes KetoAcidosis
- 11. Medicare risk adjustment Rule #2 HCCfrom different disease states are additive. SOURCE: AMERICAN ACADEMY OF PROFESSIONAL CODERS, AAPC HCC Diagnoses HCC CODE RAF SCORE T2-DM with acute complication 17 a Acute myocardial infarction 86 b Morbid obesity 22 c Demographics d RAF score for Mr. John in the year 2021 a+b+c+d
- 12. CMS-HCC model SOURCE: AMERICANACADEMY OF PROFESSIONAL CODERS, AAPC
- 13. SOURCE: AMERICAN ACADEMYOF FAMILY PHYSICIANS
- 14. SOURCE: AMERICAN ACADEMYOF PROFESSIONAL CODERS, AAPC
- 15. SOURCE: AMERICAN ACADEMYOF PROFESSIONAL CODERS, AAPC
- 16. SOURCE: AMERICAN ACADEMYOF PROFESSIONAL CODERS, AAPC
- 17. SOURCE: AMERICAN ACADEMYOF PROFESSIONAL CODERS, AAPC
- 18. Our task #1 SOURCE:AMERICAN ACADEMY OF FAMILY PHYSICIANS 1. Select not only the diagnosis codes that describe why the patient was seen but also codes for any chronic conditions that affected treatment choices. For example:
- 19. Our task #2 2.If a patient has a serious chronic condition with a manifestation or complication that has its own code, use that code rather than an unspecified code. Hepatitis C: RAF=0 Chronic Hepatitis C: RAF: 0.165 SOURCE: AMERICAN ACADEMY OF FAMILY PHYSICIANS
- 20. Our task #3 3.Report diagnosis codes annually. Status codes: Asymptomatic HIV infection status Quadriplegia and paraplegia BMI 40.0 – 44.9, adult Acquired absence of toes or feet SOURCE: AMERICAN ACADEMY OF FAMILY PHYSICIANS
- 21. Reference 1. HTTPS://WWW.AAPC.COM/RISK-ADJUSTMENT/RISK-ADJUSTMENT.ASPX 2. HTTPS://WWW.AAFP.ORG/FPM/2018/0300/P21.HTML 3.HTTPS://WWW.AAFP.ORG/FPM/2016/0900/P24.HTML SOURCE: AMERICAN ACADEMY OF PROFESSIONAL CODERS, AAPC
- 22. SOURCE: AMERICAN ACADEMYOF PROFESSIONAL CODERS, AAPC
Editor's Notes
- #10 . An ICD code maps to exactly one HCC, but not all ICD codes map to an HCC. Approximately 10,000 ICD-10 codes map to an HCC, but this is just 14 percent of the approximately 69,000 diagnosis codes.3 The CMS-HCC model focuses on chronic health conditions likely to affect long-term health expenditures and purposefully excludes non-diagnostic diagnoses (e.g., a diagnosis of abdominal pain), clinically insignificant diagnoses (e.g., a sprain), or diagnoses that are definitively treated (e.g., acute appendicitis).
- #11 Hurray! You just became a medical coder.
- #21 Dependence on renal dialysisDependence on ventilator statusZ79.4Long term, current use of insulinMonoplegia and hemiplegia colostomy