Risk Adjustment. Here s What You ll Learn:

Transcription

1 Risk Adjustment Chandra Stephenson, CPC, CIC, COC, CPB, CDEO, CPCO, CPMA, CRC, CCS, CPC-I, CANPC, CCC, CEMC, CFPC, CGSC, CIMC, COBGC, COSC Program Director- Certification Coaching Organization Here s What You ll Learn: What risk adjustment (RA) is The purpose of RA Where RA originated Which plans are RA plans Why understanding RA coding is essential How RA differs from traditional coding Why there are an increasing number of RA plans 1

2 What is Risk Adjustment? Risk: (Insurance) A situation where the probability of a variable (such as burning down of a building) is known but when a mode of occurrence or the actual value of the occurrence (whether the fire will occur at a particular property) is not. Adjustment: Adoption of new fiscal and monetary policies... The objective is to correct the balance of payments imbalance by transferring labor and capital from uncompetitive sectors of the national economy to the ones that can compete in the global marketplace. What the Purpose of RA? Level Payment & Expectations Patient A Patient B Patient C Patient D Healthy Diabetes Diabetes Diabetes Retinopathy Retinopathy CKD III 2

3 Where did RA Plans Originate? Medicare Part C - Medicare Advantage Plans HCC HCCRx Drug Hierarchical Condition Categories Hierarchical Condition Categories - Prescription Medicaid Managed Care Plans ACG CDPS CDPS-MH CRG DCG DPS ERG PRG Which Plans are RA Plans? Ambulatory Care Groups Chronic Illness and Disability Payment System CDPS - Mental Health Clinical Risk Groups Diagnostic Cost Groups Disability Payment System Episode Risk Groups Pharmacy Risk Groups ACA Market Plan Managed Care Plans HHS-HCC Health & Human Services HCC 3

4 Why Do I Need to Understand RA? How is RA Different? Traditional FFS Plans Risk Adjustment Plans Federally Funded Plans Paid per enrollee/beneficiary Diagnoses drive payment Acuity Demographics Age Gender Location Additional requirements Consistently request documentation Quarterly 4

5 Is RA Really Increasing? Here s What You ll Learn: Acceptable documentation for RA: Acceptable provider types Acceptable sources of documentation Documentation essentials Progress note/soap note reading Coding Pearls Common coding errors made in coding for RA 5

6 Acceptable Provider Types Acceptable Sources of Documentation Covered Facilities HOSPTIAL INPATIENT AND OUTPATIENT DATA Short-term (general and specialty) hospitals Religious Non-Medical Health Care Institutions Long-term Hospitals Rehabilitation Hospitals Children s Hospitals Psychiatric Hospitals Medical Assistance Facilities/Critical Access Hospitals Community Mental Health Centers Federally Qualified Health Centers Rural Health Clinic (Free-Standing & Provider-Based) Non-Covered Facilities* HOSPITAL INPATIENT DATA Skilled Nursing Facilities (SNFs) Hospital Inpatient Swing Bed Components Intermediate Care Facilities Respite Care Hospice HOSPITAL OUTPATIENT DATA ONLY Free-standing Ambulatory Surgical Centers (ASCs) Home Health Care Free-standing Renal Dialysis Facilities Non-Covered Services Laboratory Services Ambulance Durable Medical Equipment, Prosthetics, Orthotics, Supplies Radiology Services 6

7 Documentation Essentials Data Elements used in CMS-HCC Risk Score Calculation: Age Sex Disability Original Reason for Entitlement (OREC) Medicaid Status Institutionalization Frailty Minimum Elements Required: HIC (Health Insurance Claim) number Provider Type From and Through Dates of Service Diagnosis Code(s) CMS Alpha Suffix Descriptions: A = beneficiary B = spouse C = children D = divorced spouse, widow, widower Signatures Documentation Essentials A compliant handwritten signature is legible and includes the clinicians credentials If the signature is illegible, it can be made compliant by having the clinicians name and credential pre-printed on the form. This may be in the letterhead or in the form of a signature block on the form EMR/EHR must clearly be authenticated, digitally signed, or electronically signed by the provider Other Patient name, DOB, and DOS must be on each page Medical record must be complete and legible Only standard medical abbreviations should be used Late entries/addendums can be made to clarify confirmed diagnoses and must be dated/timed. 7

8 Progress Note/SOAP Note Subjective: refers to subjective observations that are verbally expressed by the patient, such as information about symptoms. Objective: objective observations, which means factors which can be measured, seen, heard, felt, etc; physical examination; results of diagnostic tests, such as lab work and x-rays can also be reported in the objective section of the SOAP notes. Assessment: the diagnosis or condition Plan: how the provider is going to address the patient s problem ( Key Coding Concepts & Pearls HIV status Insulin dependent Protein-calorie malnourished Alcohol/Drug dependent Tracheostomy/Vent/Respirator Long-term oxygen Renal dialysis Noncompliance Major organ transplant Artificial opening Amputee CHF CKD COPD CVA/Stroke Dementia Depression DVT HTN DM Neoplasms Ulcers Pulmonary embolism 8

9 Top 10 Medicare RA Coding Errors 1. The medical record does not contain a legible signature with credentials 2. The electronic health record (EHR) was unauthenticated (not electronically signed) 3. The highest degree of specificity was not assigned the most precise ICD code to fully explain the narrative description of the symptom or diagnosis in the medical chart 4. A discrepancy was found between the diagnosis codes being billed vs. the actual written description in the medical record. If the record indicates depression, NOS (311 Depressive disorder, not elsewhere classified), but the diagnosis code written on the encounter claim is major depression ( Major depressive affective disorder, single episode, unspecified), these codes do not match; they map to a different HCC category. The diagnosis code and the description should mirror each other. Top 10 Medicare RA Coding Errors 5. Documentation does not indicate the diagnoses are being monitored, evaluated, assessed/addressed, or treated (MEAT) 6. Status of cancer is unclear. Treatment is not documented 7. Chronic conditions, such as hepatitis or renal insufficiency, are not documented as chronic 8. Lack of specificity (e.g., an unspecified arrhythmia is coded rather than the specified type of arrhythmia) 9. Chronic conditions or status codes aren t documented in the medical record at least once per year 10.A link or cause relationship is missing for a diabetic complication, or there is a failure to report a mandatory manifestation code 9

10 M.E.A.T. M = Monitored Signs, symptoms, disease progression / regression E = Evaluated Review test results, medication effectiveness, response to treatment A = Assessed/Addressed Ordering tests, discussion, review records, counseling T = Treated Referral(s), medication(s), planned surgery, therapy(s), other modalities content/uploads/2016/01/the-coders-playbook-for-success-with- Risk-Adjustment-Payment-Methodologies-AAHIMA-.pdf Risk Score Calculator 10

11 Example 1 Assessment/Plan states: 1. Hypertensive CKD, Stage 3 Stable, labs reviewed and medications refilled 2. CAD Continue statins and return to clinic in 3 months for follow up and labs Example 1 Assessment/Plan states: 1. Hypertensive CKD, Stage 3 Stable, labs reviewed and medications refilled I12.9 Hypertensive chronic kidney disease stage 1-4 or unspecified 2. CAD Continue statins and return to clinic in 3 months for follow up and labs I25.10 Atherosclerotic heart disease of native coronary artery without angina pectoris 11

12 Example 1 Example 2 Assessment states: 1. Hypertensive CKD, Stage 5 or End Stage 2. Aortic atherosclerosis Plan states: 1. CKD, Stage 3 2. Hypertension 3. Aortic atherosclerosis per patient report, awaiting confirmation testing 4. Diabetes 12

13 Example 2 Assessment states: 1. Hypertensive CKD, Stage 5 or End Stage I12.0,??? 2. Aortic atherosclerosis I70.0 Plan states: 1. CKD, Stage 3 N Hypertension I Aortic atherosclerosis per patient report, awaiting confirmation testing I Diabetes E11.22 Example 2 13

14 Example 2 Wrap Up RA is not new RA varies from plan to plan and state to state RA enrollment is increasing THERE IS A NEED FOR CODERS WHO UNDERSTAND RISK ADJUSTMENT! 14

15 Contact Info THE END Thanks For Attending 15