Risk Adjustment Purpose and Challenges Explained

Transcription

1 Risk Adjustment Purpose and Challenges Explained For Healthcare Professionals

2 Educa9on provided by: Brian Boyce, BSHS, CPC, CPC-I, CRC, CTPRP CEO, Proprietor & Managing Consultant, ionhealthcare 2

3 No part of this presenta9on may be reproduced or transmi>ed in any form or by any means (graphically, electronically, or mechanically, including photocopying, recording, or taping) without the expressed wri>en permission of ionhealthcare, LLC. 3

4 Course Objec,ves Understand the purpose of the new risk adjustment payment methodology. Understand different how risk adjustment payments and forecas9ng are established Recognize how documenta9on can affect payment and forecas9ng efforts Understand the difference between ICD coding guidelines as they pertain to risk adjustment models Learn how risk adjustment models differ from Fee For Service and other tradi9onal methods 4

5 Public Health The science and art of preven2ng disease, prolonging life, and promo2ng physical health and efficiency through organized community efforts for the sanita2on of the environment, the control of community infec2ons, the educa2on of the individual in principles of personal hygiene, the organiza2on of medical and nursing services for the early diagnosis and preven2ve treatment of disease, and the development of the social machinery which will ensure to every individual in the community a standard of living adequate for the maintenance of health. A defini9on of public health by Edward A. Winslow, a theore9cian and leader of American public health in the first half of the 20 th century,

6 Public Health Controversy Public Health can be controversial Milk producers resisted pasteuriza9on Landlords resisted building codes Individual freedoms vs. improving the community s health (smoking, vapes, guns, etc.) The government has a primary purpose to promote the general welfare of its people, and this includes health and safety The government cannot guarantee this for every individual, but its role is to maximize the health and safety of all 6

7 Paying for Healthcare The 4 main methods of paying for healthcare services include: Out-Of-Pocket Payment Individual Private Insurance Employment-Based Group Private Insurance Government financing 7

8 Fee For Service Issues Fee For Service (FFS) pays providers a specific amount of money for a specific service rendered (by CPT procedure code) FFS is the most commonly used method of reimbursement, but this is changing with risk adjustment FFS payments increase by increasing the number of services, tests, visits, procedures, and duplica9on of services (Note CPT is a registered trademark of the AMA) 8

9 Fee For Service Issues Fee For Service (FFS) creates financial incen9ves: To provide services which are reimbursed at higher rates To invent new services that are billed at higher fees than gold-standard and less costly services Encourages overuse and misuse of services FFS creates a DISINCENTIVE to: Deliver services at a lower or fairer fee structure Provide services that are not reimbursed (care coordina9on, treatment planning, web and e-visits, etc. 9

10 Fee For Service Issues Providers are reimbursed for what was done, with no insight to the quality of care provided Providers can be paid MORE in reimbursements for poor quality which causes added follow up visits, or addi9onal treatments Many payment reform models are looking at ways to adjust payment for pa9ent care based on the pa9ent s need (by diagnosis code); and while including quality of care measures (a>en9on to, and management of chronic condi9ons) 10

11 Capita,on Payment of a fixed amount of money that is paid in advance, usually on a monthly rate, to the MCO (Managed Care Organiza9on) to cover the delivery of all care and health services PMPM = per member, per month Example: Agreed Rate of PMPM 1,000 members = 800, per month for care of all members OR 1,000 members = 9,600, per year for care of all members The Problem? Not all pa9ents have the exact same costs.. Open to waste of health care dollars 11

12 Modified Capita,on Keep current es9mates of average costs PMPM, but a>empt to narrow actual need or costs Based on known diagnoses The pa9ent with mul9ple chronic condi9ons or diagnoses will cost more (and we know approximately how much exactly) than the pa9ent with few problems or diagnoses This enables financial forecas9ng for the necessary funding toward the care of pa9ents in the popula9on group = RISK ADJUSTMENT 12

13 Risk Adjustment (RA) Risk Adjustment is a method of analysis using diagnoses for financial forecas9ng that has been growing in popularity in healthcare Medicaid plans began using Risk Adjustment modeling in 1996 and has con9nued to update that model Medicare Advantage Plans have been using the HCC/ Risk Adjustment model since 2004 and is expanding the program Commercial Plans are now looking at Risk Adjustment as a valuable method to iden9fy and plan for high risk pa9ents 13

14 Popula,on-based Medicine Managing chronic condi9ons across a popula9on of people by trea9ng all with a specific diagnosis with the same gold standards and preventa9ve care measures Healthcare largely manages complica9ons are they arise as opposed to a>emp9ng to prevent them Risk adjustment allows for awareness and ac9on for those in need of disease management 14

15 RA & Affordable Care Act (ACA) The Affordable Care Act calls for a risk adjustment program that aims to eliminate incen9ves for health insurance plans to avoid people with pre-exis9ng condi9ons or those who are in poor health. Risk adjustment ensures that health insurance plans have addi9onal money to provide services to the people who need them most by providing more funds to plans that provide care to people that are likely to have high health costs. Insurance plans then compete on the basis of quality and service, and not on the basis of whether they can a>ract healthy people (Larsen, 2011) 15

16 Affordable Care Act (ACA) Health insurance coverage is a key factor in making healthcare accessible In 1980, 25 million Americans were uninsured, and by 2009, it increased to 51 million (Bodenheimer/Grumbach, 2012) While most people obtain employer plan insurance, those whose employers were not offering insurance, or those who were self-employed, or unemployed were leq to fend for their own health care solu9ons Small increases in family income could disqualify people for Medicaid benefits Between , 29% of the US popula9on (87 Million people) went without health insurance 16

17 Affordable Care Act (ACA) The ACA established several posi9ve movements for uninsured pa9ents. These pa9ents previously cost huge healthcare dollars through ER and hospitaliza9on visits that had to be wri>en off by hospitals and other organiza9ons There are 4 metal categories for pa9ents to choose from based on what they can afford and what plans they think they need There are different plans types such as HMO, PPO, POS, and EPO 17

18 Affordable Care Act (ACA) Metal Level Insurance Pays Pa,ent Pays Catastrophic <60% >40% Catastrophic plans are available to those under 30 years or those over 30 years with a qualifying hardship. Bronze 60% 40% Bronze plans have the lowest premiums (monthly pa2ent cost) but the highest deduc2bles and other out of pocket costs. Silver 70% 30% Silver plans offer the best value for saving on out of pocket costs. Those who qualify for costsharing reduc2ons based on income can have a lower deduc2ble and pay lower out of pocket costs. Best for those who don t expect to use regular medical services and don t take regular prescrip2ons. Gold 80% 20% Gold plans are ideal for those with more expected doctor visits and/or prescrip2ons. Pla,num 90% 10% Pla2num plans have higher monthly premiums, but pay more for costs of care. Ideal for those with regular doctor visits and/or lots of prescrip2ons. 18

19 Affordable Care Act (ACA) The ACA also established that these commercially offered plans must use a risk adjustment method for es9ma9ng opera9ng costs. The costs of popula9on health are across a pa9ent popula9on by HIOS ID (unique issuer ID) number per state. HIOS (Health Informa9on Oversight System) is the federal government s primary data collec9on vehicle for health insurance Exchanges Marketplaces. One func9on of HIOS is to collect data from health plan issuers that want to become cer9fied qualified health plan (QHP) issuers. 19

20 Pay For Performance CMS defines Pay for Performance (P4P) as: The use of payment methods and other incen9ves to encourage quality improvement and pa9ent-focused, highvalue care. Changes are already underway with HEDIS measures and health plans that review other specific quality of care measures Combining reimbursement and financial planning based on what problems the pa9ent has each year along with expected care needs helps to pinpoint a closer accurate payment toward quality care of chronic condi9ons 20

21 Medical Management Improve overall member health which will then reduce costs of care (preventa9ve) Track HEDIS quality measures Track days for inpa9ent stays Create policies for medically necessary Telephonic and other management of pa9ent cases, oqen in areas such as: Cardiology, COPD, Cancer, Transplant, etc. 21

22 Quality & U,liza,on Management Review and inves9gate quality ini9a9ves and monitor health outcomes Analyze cost pa>erns and appropriate use of resources Meets cost projec9ons while ensuring quality of care delivered These values are assisted through risk adjustment review of records to ensure quality is met for specific illnesses and to project u9liza9on needs based on diagnoses 22

23 Risk Adjustment Enables changes to address quality of care for chronic illnesses Iden9fies Disease Management opportuni9es Iden9fies Quality of Care opportuni9es Iden9fies markers for U9liza9on 23

24 Different Programs, Same Goals Whether Risk Adjustment is being u9lized for Medicaid, Medicare, or Commercial pa9ents, the main ingredients used are Diagnosis Codes (ICD codes) Diagnoses are collected and their specificity drives risk score or categoriza9on The worse, or more serious a condi9on, or diagnosis, the higher the risk scoring Risk Scores either affect incoming payment or the future financial forecas9ng for each pa9ent 24

25 Risk Adjustment Models Medicaid CDPS Model CMS HCC Model HHS HCC Model Hybrid Models 25

26 Various Models in RA There are various systems using Risk Adjustment beyond HCC for Medicare HMO plans. Some of these include: Diagnosis based programs: Chronic Illness and Disability Payment Systems (CDPS) - Medicaid Hierarchical Co-Exis9ng Condi9ons (HCC-C) Medicare Part C Hierarchical Co-Exis9ng Condi9ons (HCC) HHS (ACA/Commercial) Diagnosis Related Groups (DRG) Inpa9ent Adjusted Clinical Groups (ACG) Outpa9ent Prescrip,on based programs: MedicaidRx (UCSD) RxGroups (DxCG) Hierarchial Co-Exisi9ng Condi9ons (HCC-D) Medicare Part D Some add: Pa,ent Func,onal Abili,es (ADL s) 26

27 History of CDPS Model Started in 1996 to tailor current risk adjustment models to be>er apply to Medicaid programs. Development started using claims from disabled beneficiaries informa9on from the Disability Payment System (DPS) from Colorado, Michigan, Missouri, New York, and Ohio by Rick Kronick and associates Update in 2000 to include disabled and TANF (Temporary Assistance for Needy Families) beneficiaries from California, Georgia, and Tennessee. This upgraded program was then renamed the Chronic Illness and Disability Payment System (CDPS) In 2001, Todd Gilmer and associates developed the Medicaid Rx (MRX) using CDPS informa9on. Based on combining from the Chronic Disease Score (CDS) developed by Von Korff and associates and the RxRisk model by Fishman and associates 27

28 History of CDPS Model In 2008, CDPS and MRX models were updated using Medicaid data from 44 states in 2001 and Another model was developed employing both diagnos9c and pharmacy data called CDPS + Rx Data was supplied by CMS from Medicaid Analy9c extract (MAX) data system. MAX data consists of pa9ent-level data files with informa9on on Medicaid eligibility, u9liza9on of services, and payments for services 28

29 Stage 1 Groups in Major Categories (CDPS Model): 1) Psychiatric 2) Skeletal 3) Central Nervous System 4) Pulmonary 5) Gastrointes9nal 6) Diabetes 7) Skin 8) Renal 9) Substance Abuse 10) Cancer 11) Developmental Disability 12) Genital 13) Metabolic 14) Pregnancy 15) Eye 16) Cerebrovascular 17) AIDS/ Infec9ous Disease 18) Hematological 29

30 Hierarchies in CDPS CDPS Categories are Hierarchical within Major Categories: For example: Cardiovascular Category: ( 4 levels) - CARVH includes 3 Stage 1 groups and 7 diagnoses - CARM includes 13 Stage 1 groups and 53 diagnoses - CARL includes 26 Stage 1 groups and 314 diagnoses - CAREL includes 2 Stage 1 groups and 35 diagnoses VH (weight 2.037) = Very High: Heart transplants, valves, etc. M (weight 0.805) = Medium: Heart acacks, etc. L (weight 0.368) = Low: Heart disease, etc. EL (weight 0.130) = Extra Low: Hypertension, etc. * Credit only for most severe form/diagnosis in category. Each higher level takes all other lower diagnoses into considera9on already. 30

31 Risk Adjustment is Spreading Risk Adjustment is a method of analysis using diagnoses for financial forecas9ng that has been growing in popularity in healthcare Medicaid plans began using Risk Adjustment modeling in 1996 and has con9nued to update that model Medicare Advantage Plans have been using the HCC/ Risk Adjustment model since 2004 and con9nue to modify the program yearly Commercial Plans are now required to have Risk Adjustment as a method to iden9fy and plan for pa9ents under the ACA (HHS HCC Model) 31

32 Documented Diagnoses Risk adjustment is purely concentrated upon what pa9ents have as current condi9ons instead of what was done or performed on the pa9ent Coders must understand that collec9ng all current diagnoses will affect payments as well as forecas9ng Diagnoses uncollected will be leq with no dollars to manage those condi9ons 32

33 Significance to Providers Providers have familiarity no9ng the seriousness and severity of the pa9ents they treat through the use of E/M procedure codes Higher level E/M codes iden9fy serious encounters, u9lizing more medical decision making, and are reimbursed at a higher rate In Risk Adjustment scenarios, these procedure codes have no significance Instead, specific diagnosis codes communicate the seriousness of medical decision making 33

34 Significance to Providers Using specific ICD Diagnosis Codes will help convey the true seriousness of the condi9ons being addressed in each visit Documen9ng these carefully involves two main focal points: 1 Iden9fying the Diagnosis as a Current or Ongoing problem as opposed to a PMH (Past Medical History) or previous condi9on 2 Choosing the most specific Diagnosis Code while also being sure documenta9on supports it 34

35 Why It Ma\ers For Medicare Advantage Plans 1 Risk Adjustment (RA) iden9fies pa9ents who may need disease management interven9ons and 2 RA establishes the financial allotment allowed from CMS toward the annual care of each pa9ent; with more dollars allocated for those with higher risk scores For Medicaid and Commercial Plans 1 Risk Adjustment (RA) iden9fies pa9ents who may need disease management interven9ons and 2 RA establishes the overall state of the popula9on by aggrega9ng diagnoses; which assists in financial forecas9ng for future medical need 35

36 Risk Adjustment Payment Payments in risk adjustment models take the idea of an HMO PMPM, and apply the monthly value toward known current diagnoses being managed Payment can increase if all current diagnoses are submi>ed properly and can decrease if diagnoses are withheld Each diagnosis must be found as current in at least one face-to face visit by an approved provider to be counted in the model 36

37 How ICD Codes Link to HCC Value Most of the ICD diagnosis codes which are in the models are chronic condi9ons Medicaid CDPS and HHS HCC Models recognize more codes Risk Adjustment is based on adjus9ng the es9mated risk of each pa9ent based on known diagnoses Part C HCC (HCC-C) are those diagnoses which are costly to manage from a medical perspec9ve Part D HCC (HCC-D) are those diagnoses which are costly to manage from a prescrip9on drug perspec9ve Some diagnoses are both tough medically as well as costly for prescrip9on drug management and therefore carry value in both models 37

38 No Condi,ons Coded (Demographics Only) CMS HCC Payment Example Some Condi,ons Coded (Claims Data Only) All Condi,ons Coded (Chart Review by Cer,fied Coder) 76 year old female year old female year old female.468 Medicaid Eligible.177 Medicaid Eligible.177 Medicaid Eligible.177 DM Not Coded DM (no.118 DM with Vascular.368 manifesta9ons) Manifesta9ons Vascular Disease Vascular Disease.299 Vascular Disease.41 not coded without complica9on with complica9on CHF not coded CHF not coded CHF coded.368 No interac9on No interac9on + Disease Interac9on bonus RAF (DM + CHF).182 Pa9ent Total RAF.645 Pa9ent Total RAF Pa9ent Total RAF PMPM Payment for Care Yearly Reserve for Care $452 PMPM Payment for Care $ 5,418 Yearly Reserve for Care $743 PMPM Payment for Care $8,921 Yearly Reserve for Care $1,381 $16,573

39 Financial Forecas,ng HHS and Medicaid models may not have an immediate affected monthly payment, however collec9on of diagnosis codes will affect forecas9ng Plans a>empt to es9mate necessary recourses and plan accordingly for future years The more that is known about pa9ents diagnoses today, the more specific forecas9ng may become If diagnoses are withheld, then there will not be enough money set aside to earmarked in an9cipa9on to treat these illnesses and their possible complica9ons 39

40 Code For All Diagnoses Some coders may confuse E/M guidelines for diagnosis repor9ng as it pertains to the selec9on of the E/M level of service codes When choosing a level of service for E/M, diagnosis codes should only be counted toward the level of service when they are documented how they were evaluated or addressed This is en9rely related to selec9on of level of service for E/M purposes, and does not change the fact that ICD coding guidelines instruct coders to include all comorbidi9es for each encounter 40

41 ICD-9 Guidelines ICD-9-CM: SecQon IV. DiagnosQc Coding and ReporQng Guidelines for OutpaQent Services: H. ICD-9-CM code for the diagnosis, condiqon, problem, or other reason for encounter/visit List first the ICD-9-CM code for the diagnosis, condi2on, problem, or other reason for encounter/visit shown in the medical record to be chiefly responsible for the services provided. List addiqonal codes that describe any coexisqng condiqons. In some cases the first-listed diagnosis may be a symptom when a diagnosis has not been established (confirmed) by the physician. (ICD-9-CM, 2013) K. Code all documented condiqons that coexist Code all documented condiqons that coexist at the Qme of the encounter/visit and require or affect paqent care treatment or management. Do not code condi2ons that were previously treated and no longer exist. However, history codes (V10-V19) may be used a secondary codes if the historical condi2on or family history has an impact on current care 41

42 ICD-10 Guidelines ICD-10-CM: SecQon IV. DiagnosQc Coding and ReporQng Guidelines for OutpaQent Services G. ICD-10-CM code for the diagnosis, condiqon, problem, or other reason for encounter/visit List first the ICD-10-CM code for the diagnosis, condi2on, problem, or other reason for encounter/visit shown in the medical record to be chiefly responsible for the services provided. List addiqonal codes that describe any coexisqng condiqons. In some cases the first-listed diagnosis may be a symptom when a diagnosis has not been established (confirmed) by the physician. (ICD-10-CM, 2013 Dra\) J. Code all documented condiqons that coexist Code all documented condiqons that coexist at the Qme of the encounter/ visit and require or affect paqent care treatment or management. Do not code condi2ons that were previously treated and no longer exist. However, history codes (categories Z80- Z87) may be used as secondary codes if the historical condi2on or family history has an impact on current care or influences treatment 42

43 General RA Guidelines These programs operate on similar rules and guidelines to include: Specific diagnoses must be documented in a face-to-face visit by the trea9ng licensed provider (showing creden9als: MD, DO, PA, NP, OT, CRNA, MSW, and similar master s level providers) and the documenta9on must be signed by the trea9ng provider to be accepted Diagnoses must be clearly stated on the DOS (Date Of Service) as a current problem if audited Diagnoses must be documented each year, ongoing as each year is evaluated without historical context influence 43

44 General Diagnosis Coding Rules Code all current diagnoses that were a part of the medical decision making of the visit Signs and symptoms should never be coded when the reasons for the symptoms are iden9fied. For example, one would not code shortness of breath when a diagnosis of asthma is known, nor heartburn when a diagnosis of GERD is known Old diagnoses which have been treated an no longer exist should not be coded unless there is a history of code that communicates the old condi9on (most of these do not risk adjust, but may be valuable to disease management and suspect logic) Persistent diagnoses such as amputa9ons, Old MI, ostomy, quadriplegia, etc. should be re-documented at least yearly 44

45 Diagnosis Specificity Documenta9on of diagnoses must be specific This is paramount not only for Risk Adjustment programs, but also for ICD-10 implementa9on efforts Comorbidi9es; Cause and effect rela9onships of diagnoses; Loca9on; and Other modifying factors should be clearly documented Examples of commonly under-diagnosed condi9ons are diabetes and hypertension 45

46 The Word Chronic Diagnosis specificity is of paramount importance and in many diagnoses, use of the word chronic can change the chosen diagnosis code (and its subsequent risk value) Examples include (but are not limited to): Chronic Renal Insufficiency vs. Renal insufficiency Chronic Hepa99s B vs. Hepa99s B Chronic Bronchi9s vs. Bronchi9s Chronic cor pulmonale vs. cor pulmonale 46

47 Past Medical History (PMH) The different ways providers document PMH or historical diagnoses is challenging for coders and auditors reviewing medical records Some providers use PMH as a true list of old diagnoses, while others use this as a combined list of historical and current problems This documenta9on disparity is also oqen seen in the chief complaint or HPI (History of Present Illness) 47

48 Documenta,on Ma\ers Lack of documenta9on may leave diagnosis codes which are current to me missed from the risk adjustment equa9on These missed diagnosis codes are not reimbursed or forecasted The missed diagnoses also affect pa9ent care by poten9ally leaving pa9ents out of disease management programs offered by the health plans when they are not aware of the diagnoses 48

49 Documenta,on Tips Avoid homegrown abbrevia9ons Document all cause and effect rela9onships Include all current diagnoses as part of the current medical decision making and carry them to the final assessment of the encounter Each note needs a date, signature, & creden9al (MD, DO, NP, PA, etc.) Document history of heart a>ack, any amputa9ons, hypoxia, status codes, ostomy, etc., when factual Only document diagnoses as history of or PMH when they no longer exist or are a current condi9on 49

50 Conflic,ng Documenta,on Providers some9mes document conflic9ng statements, for example: Normal pedal pulses leq and right & BKA 3 years ago Acute Pancrea99s in Past Medical History & in Assessment Acute Renal Failure & CKD Stage II in Assessment Hyperthyroidism in ROS & Hypothyroidism in Assessment Breast Cancer in Past History & Refill of Femara in Assessment Prostate Cancer in Assessment & Radical Prostatectomy in PMH with no current treatment 50

51 Changes in Models Models change yearly and the universal suppor9ng factor will be provider documenta9on Pressure ulcers changed to only have value in 2014 if they are stage 3 or higher, where they previously always counted- thus documenta9on of staging of these ulcers became paramount Old MI was dropped as a Part C and carries Part D value only 51

52 Changes in Models Many lung disease that previously had no C value now carry Part C value Many nephri9s codes that had Part C value were dropped to Part D value only CKD codes correla9ng to Stages 4, 5, and 6 (ESRD) carry Part C value & Part D value, but all other CKD (Stages 1-3) only carry part D value. Hypoxemia and asphyxia were dropped altogether with no C or D value Chronic pancrea99s con9nued to carry C value, but many other pancrea99s codes only carry Part D value 52

53 Cer,fied Coders Role 1. Find legible face-to face encounters with chronic condi9ons documented and signed by an acceptable provider 2. Include all Chronic Condi9ons that are part of the Medical Decision Making Process including any chronic condi9on that is under current treatment whether it is the main reason for the visit or not 3. Past Medical History, Review Of Systems, Exam, Assessment & Plan are all por9ons of the record that may have valuable condi9ons documented 4. Any record within the calendar year works for the en9re year, so if you do not find an acceptable first record, keep looking throughout the set 53

54 Documenta,on for RA & ICD-10 Many documenta9on efforts for risk adjustment simultaneously assist for coding in ICD-10-CM Making strides to improve documenta9on through specificity and clarity helps iden9fy valuable 9me spent by providers and Iden9fies pa9ents in need of disease management programs 54

55 3 Small Steps to Take Now 1. Begin to document laterality, specifying leq or right whenever applicable 2. Begin to document manifesta9ons clearly I. Things which are clinically intui9ve are not allowed to be assumed by coders II. Complica9ons & manifesta9ons need to be documented 3. Begin to separate diagnoses which are truly historical as opposed to those which are current I. Current diagnoses carry value as part of Medical Decision Making II. PMH (Past Medical History) Lists should only contain diagnoses which have been treated and no longer exist 55

56 Ques,ons/Feedback 56

57 Contact Brian Boyce, BSHS, CPC, CPC-I, CRC, CTPRP CEO, Proprietor, and Managing Consultant 2112 W. Laburnum Avenue, Suite 109 Richmond, VA Medical Record Audit and Review - Physician Prac9ce Op9miza9on - Leadership Mentoring Healthcare Educa9on and Networking for Pa9ents and Professionals - Risk Adjustment 57