Risk Adjustment and Hierarchial Condition Category Coding and Auditing
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1 December 2, 2016 Risk Adjustment and Hierarchial Condition Category Coding and Auditing Risk Adjustment (RA) and Hierarchical Condition Category (HCC) coding is a payment model mandated by CMS in 1997, which was implemented in This model identifies individuals with serious or chronic illness and assigns a risk factor score to the person based upon a combination of the individual's health conditions and demographic details (called the Risk Adjustment Factor or RAF). The individual's health conditions are identified by the International Classification of Diseases - 10 (ICD -10) diagnoses that are submitted by providers on incoming claims. There over 9000 ICD-10 codes that map to 79 HCC codes in the RA model. As outlined in the Medicare Managed Care Manual, "CMS administers risk adjusted payments to Medicare Advantage (MA) organizations..." CMS requires documentation in the patient's medical record by a qualified health care provider to support the submitted diagnosis(es). Documentation must support the presence of the condition and clearly support the provider's assessment and plan for management of the condition. As a NAMAS member, you'll receive access to monthly webinars for CEUs (including those hard to find CPMA CEUs!), a subscription to BC Advantage magazine, discounts on products and NAMAS training events, and much, much more! We offer 4 membership levels- choose the one that best suits your needs! Click Here to View NAMAS Membership Levels and Benefits For added convenience, NAMAS accepts PayPal, PayPal Credit, quarterly and monthly payments of membership dues. The chronic conditions that are current and managed must be reported (and supported by the documentation for that date of service) at least once each calendar year for CMS to continue to "count" that condition towards the patient's overall risk level.
2 The Official ICD-10 coding guidelines state that a condition must exist at the time of the encounter and affect the patient's care, or be actively managed AND be documented through the History of Present Illness (HPI), the Physical Exam, and the medical decision making. Each reported diagnosis should be documented in an assessment and a plan of care. According to CMS a simple list of "assessed" conditions alone would not support the diagnosis(es) reported without showing that the condition is current (active) at the time and/or evaluation and treatment for each condition. M.E.A.T. is an acronym used to describe factors that support the ICD-10 code(s) chosen. Please see below for the acronym description and what they mean: M = Monitor (signs, symptoms, disease progression, disease regression) E = Evaluate (test results, medication effectiveness, response to treatment) A = Assess/Address (ordering tests, discussion, review records, counseling) T= Treat (medications, therapies, other modalities) Some common issues to be aware of when coding or auditing for support of reported diagnosis(es): Code to the highest level of specificity. This can affect support for the risk factor if unspecified or generic codes are used. Coding of "history" as current: anything that is not supported as active at the time of the face-to-face encounter, such as "resolved" or "history of" conditions, should not be reported. Conditions and manifestations need to be clearly linked with such terms as "due to" "because of" etc. According to ICD-10, some conditions have a presumed cause and effect relationship such as hypertension and CKD (ICD-10 Section 1; 9. A.2.). Always code to the highest level of documented specificity. Chronic Conditions: don't overlook documented and supported chronic conditions that affect the patient's care and management. Our onsite or online training program will not only prepare you to sit for the medical auditing certification test, but will prepare you for a career as a medical auditor. As a bootcamp attendee, you will receive the NAMAS Auditor's Resource & Prep Guide, 16 AAPC CEUs, AND a 1 year NAMAS membership! Our next onsite bootcamp will be: December 5-6: Orlando, FL We've also added additional online Saturday classes to our calendar Click Here to Learn More About The NAMAS Medical Auditing BootCamp Weekly Tip Sponsor The Association for Rural Health Professional Coding offers education, certification, training and resources for rural health coders. Visit ARHPC at the 8th Annual Auditing & Compliance Conference in Orlando, FL NAMAS Calendar of Events Be on the lookout for more information and services from NAMAS regarding coding and auditing for Risk Adjustment HCCs! This Week's Audit Tip Written By: Michelle West, CPC, CEMC, CPMA, CRC Michelle is a Senior Compliance
3 Consultant for our parent organization, DoctorsManagement Source: Medicare Managed Care Manual; Chapter 7; Risk Adjustment Click the image above to view our monthly calendar Upcoming Webinars NAMAS is proud to present the following webinars in November There's Still Time to Register for the NAMAS 8th Annual Auditing & Compliance Conference in Orlando, FL! The Art & Science of Networking Speaker: Debbe Childress December 5, 2016 Dates: Pre-Conference: Tuesday, December 6, 2016 Conference: Wednesday, December 7- Friday December 9, 2016 Venue: Loews Portofino Bay Hotel, Orlando, FL Attend the ONLY conference designed for medical auditors and compliance professionals! Earn Over 20 AAPC CEUs good toward Core A, CPMA, CPCO & CEMC certifications Select your conference sessions from a variety of concentrated tracks, including: Physician-Based Auditing, E&M Auditing, Facility Auditing and Physician-Based Compliance! Learn from the best speakers in the business, network with your peers and our group of exhibitors 2017 CPT Updates for the Auditor Speaker: J. Paul Spencer December 13, 2016 The Practice Manager's Role in Maintaining Compliance Speaker: Doug Graham December 20, 2016 E&M Encounter Review Speaker: Shannon DeConda December 17, 2016 NAMAS Members: Watch your for Registration Links Non-Members: namas@namas.co to learn how to attend these webinars Our 8th Annual Conference Has Gone Green! We're proud to be a paperless conference, offering attendees the opportunity to download their session 2016 Salary Survey
4 handouts electronically prior to conference NAMAS Conference Speaker Spotlight Each year, NAMAS collects data from auditors about their employment as auditors. Please take a few moments to complete our survey. Entering your address at the end of the survey will enter you into a drawing for a chance to win one of several prizes: $100 Visa Gift Card $25 Starbucks Gift Card and our GRAND PRIZE is a scholarship to attend our 9th Annual NAMAS Auditing & Compliance Conference! Click the image above to complete the survey. This survey will close on March 15, 2017 and winners will be selected and contacted by a NAMAS representative. Our weekly auditing & compliance tip s are available to anyone who could benefit from this information. If you know someone who would like to receive these s, invite them to sign. Click the image above to be added to our list!
5 Sample what a NAMAS membership can offer you with our FREE 1-month LITE trial membership Register for our 1-month free trial LITE membership and experience a sample of what a NAMAS membership has to offer - NO Credit Card Information Needed! Too Many Audits Stacking Up? During your trial, you'll receive access to weekly webinars for a chance to earn CEUs, weekly auditing and compliance tips, and even a sample of BCAdvantage magazine! Click the image above to get your 1-month free trial membership today! In This Issue Let our team help with the backlog & keep you current! DoctorsManagement & NAMAS employ Senior Management Auditors with no less than 10 years of experience. Our team can perform your audits or offer hands-on assistance to your auditing team. Risk Adjustment and HCC Coding NAMAS 8th Annual Conference Speaker Spotlight-Michelle West Become a NAMAS Member Medical Auditing BootCamp ARHPC Calendar of Events Upcoming Webinars 2016 Salary Survey Receive These Tips FREE Trial Membership We are available to assist with: Valuation Audits Pre-Bill Audits Retrospective Audits Customized Training To schedule your audit or training, contact NAMAS at or via at namas@namas.co Copyright All Rights Reserved.
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