"Strategies for Enhancing Reimbursement " September 16, 2015

Transcription

1 "Strategies for Enhancing Reimbursement " September 16, 2015

2 Chat box feature Chat Box is available to you to ask questions or make comments anytime throughout today s webinar. Submit to Host and click the send button

3 ACO Announcements Reminders: May Specialty meetings-video available ACO Notifications Save the date 9/22/2015 Primary Care Meeting Save the date 11/4/2015 Specialist Meeting

4 Agenda Payment reform Severity of Risk- Diagnosis coding Examples of Special Code Q&A

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8 Quality Measurement: Domains 33 quality measures are separated into the following four key domains that will serve as the basis for assessing, benchmarking, rewarding, and improving ACO quality performance: 1. Patient/Caregiver Experience 2. Care Coordination/Patient Safety 3. Preventive Health 4. Clinical Care for At Risk Population

9 Quality Metrics Patient Experience Timely appointments Patient rating of MD Access to specialists Care Coordination/ Patient Safety All condition readmissions Ambulatory Sensitive Conditions (eg. COPD/Asthma/Heart Failure) Preventive Health Influenza/Pneumococcal immunizations Depression screening Colon rectal/mammography screening Disease Specific Measures Diabetes/Hypertension/ Coronary Artery Disease 9

10 WHAT ARE HIERARCHIAL CONDITION CATEGORIES (HCC S)

11 CMS Shift in payment methodology CMS has changed the reimbursement strategy from pay for services (based on CPT codes) to a pay for performance (based on severity of illness). The severity of illness is based ICD 9 codes that "paint a picture" for how sick a patient is and Medicare reimburses accordingly. Hierarchal condition categories (HCC) are used to describe severity of illness.

12 What are HCC s? Hierarchical Condition Categories (HCC) This model uses beneficiary demographic characteristics and prior year diagnoses (from fee for service (FFS) claims data) to determine to determine an illness severity index 100% risk adjusted payment model for Medicare Advantage members Based on clinical conditions- Diagnosis codes All conditions are placed into hierarchical categories and a final risk score is calculated for each member

13 What are HCC s? The CMS-HCC model counts only the most severe manifestation among related conditions (not all ICD9 codes are placed into an HCC) There are over 14,000 ICD9 codes which are classified into diagnostic groups. These diseases within these categories are related clinically and with respect to cost Hierarchies are imposed among related CCs, so that a person is coded for only the most severe manifestation among related diseases. All conditions are placed into hierarchical categories and a final risk score is calculated for each member

14 HCC Coding: Why is this important? This index is updated yearly and is what some of our health plan contracts, including our ACO, use to develop our budget. Higher reimbursement for less healthy members; lesser reimbursement for more healthy members The more complex the patient population, the larger the budget needs to be to properly care for these patients. If we don t accurately code, our budget may not meet the needs of our populations, resulting in less opportunity for surplus in our contracts and funding for clinical integration programs for our members going forward.

15 HCC scores Budget established Feedback Loop HCC scores are used in determining our annual budgets Quality Measures are used to determine quality of care provided to the Medicare population Example: (unspecified diabetes) Share in financial results & reinvest in the organization Provide quality care Document for accurate HCC Receive base HCC score=least $$ allowed If patient is more complicated, then the budget expenditures $$ not allotted in the budget are spent on providing quality care Perform well on quality measures Receive set budgets Come under budget

16 Severity of Patient Population Goal - Gather the most accurate severity of risk for the patient population How to acheive- Gathering the most amount of diagnosis codes! Problem: Some practice management system limitations that require providers to enter multiple lines/procedures in order to submit the maximum allowed 12 diagnosis codes

17 Solution.CPT CPT special reports such as insurance forms, more than the information conveyed in the usual medical communications, or standard reporting form. Special code that may already be used for Medical records, workers compensation, etc. Can also be used to report additional diagnosis.

18 How to use How is it used? Submit additional claim lines in order to accommodate the need to send additional diagnoses This can be used in cases where the patient has multiple medical conditions but only has one procedure (E&M) code performed for a date of service.

19 Why is using important? Will provide a more accurate reflection of the overall health of a patient ACO budget based off a patient s HCC score, and a patient s HCC risk score is driven by coding If patients are not coded properly and to the highest specificity then it will negatively impact our budget Less $ budgeted to take care of a potentially sicker population

20 Tamila (Tami) Kaczmarek, CBO, CPC, CMOM Founder & Partner Accessium Billing & Consulting, Inc.

21 99080 Special reporting code Only the diagnosis codes that are pointed to a CPT code are guaranteed to be processed through the payers adjudication systems Note: Each computer system is different with regards to how many ICD codes can be pointed to a specific CPT code. Accessium Billing & Consulting, Inc

22 Example of how to use.. Provider completes a progress note with diagnosis codes with assessments and plans for each. Example: Diabetic Cataract Diabetes w/ophthalmic complications ND DM W/Peripheral Circulatory Disorders 496 COPD Chronic Kidney Disease stage Diabetes w/renal complications V58.67 Long-Term Use of Insulin Sinusitis Acute Cough CPT documented: 99213

23 Example continued Billing would rank diagnosis based on CPT code and prioritize the codes based on highest specificity Pointing Diagnosis to CPT codes and ranking CPT , , 585.4,

24 Medent example of ebill Accessium Billing & Consulting, Inc

25 99213 only CPT used. Only bring in 4 Dx codes

26 Severity of patient only 4 codes.. Pointing Diagnosis to CPT codes and ranking , , 585.4, Total HCC: 0.96 What happens if CPT code is added?

27 99080 added to superbill.more codes come across claim Accessium Billing & Consulting, Inc

28 What difference does it make? Provider completes a progress note with diagnosis codes with assessments and plans for each. Example: Diabetic Cataract Diabetes w/ophthalmic complications ND DM W/Peripheral Circulatory Disorders COPD Chronic Kidney Disease stage Diabetes w/renal complications V58.67 Long-Term Use of Insulin Sinusitis Acute Cough Total HCC: vs.96

29 Accessium Billing & Consulting, Inc

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32 Additional ideas to assist Training providers - coding out to the highest specificity Providing coding tip sheets for reference Report analysis unspecific diagnosis System alerts as reminders for providers Request roster list from payers of HCC < 01.1 Ensuring all diagnosis codes applicable for each service are included on claims (pointed to a CPT code) Ensuring all patients are seen yearly for annual physicals

33 PQRS (Physician Quality Reporting System) Value Modifier In 2017 Medicare will apply the value based payments to all physicians Tiered calculation is based on 3 categories Chart below is for Solo providers and groups with 2 9 Eligible Providers Cost/Quality Low quality Average quality High Quality Low cost * +2.* Average cost * High cost *an additional +1.0 if reporting measures and average beneficiary risk score in the top 25 percent of all beneficiary risk scores Every eligible provider must participate in the PQRS to avoid up to -2% penalty to 1-9 providers and -4% penalty to 10+

34 Think about the budget: CMS funds the managed payers on average $10,000 a year for an Average 65+ patient & High risk patient would be $25,000. Your patient population example: Total patient 500 Total Expense 100 listed as High risk based on a >1.1 score Budget: $ 6,500, *25,000 = $ 2,500,000 Total Expense 400 listed as High risk based on a <1.1 score 400*10,000 = $ 4,000, listed as High risk based on a >1.1 score Budget: $8,000, *25,000 = $ 5,000, listed as High risk based on a <1.1 score 300*10,000 = $ 3,000,000 Do you have the true illness of your patient population accurately claimed & accounted for? Accessium Billing & Consulting, Inc

35 Why is this important? If no encounter data (or non specific) is submitted in a year (ie. 2014) then minimum payment is calculated for that member in 2015 Which is why it is important to. - Properly reflect your patients health status which is proven with Dx CODING- Use Make sure all patients are seen at least annually and that ALL chronic conditions are assessed when possible - Thoroughly document all conditions evaluated at each visit in the medical record, documentation must show that condition was monitored, evaluated, assessed or treated (MEAT) - Treatment and level of care must be justified - Code to the highest level of specificity and fully utilized the ICD9/ICD10 coding system If a patient is less healthy but it is not documented, minimal payment will be calculated for that patient who will most likely incur costs higher than what is budgeted

36 QUESTIONS??

37 Announcements Next Lunch & Learn: 10/21/2015 Topic:"Quality Improvement-Measuring practice performance " Reminders: May Specialty meetings-video available Save the date 9/22/15- Primary Care Meeting Save the date 11/4/15 Specialist Meeting ACO Notifications Sheree M Arnold ACO Clinical Transformation Specialist sarnold@chsbuffalo.org (716)