Impact of Risk Scoring And Attribution October 2017 Linda Gates-Striby

Transcription

1 STRATEGIC CODING IN THE ERA OF MACRA: Impact of Risk Scoring And Attribution October 2017 Linda Gates-Striby

2 Disclosures Linda Gates-Striby Nothing To Disclose

3 Increasing Our Focus The coding landscape in physician practices is changing quickly as healthcare shifts towards value-based care and quality payment models. Coding specificity, accuracy, and compliance is having an increasing impact on Medicare reimbursement in the years to come. We MUST pay greater attention to ICD-10 coding. Coders and Clinicians need to understand the specifics required of our new world of value and ensure we are documenting and coding in the most accurate and appropriate manner. Forward thinking practices and coders are already focusing on HCC/RAF and many are beginning CDI type efforts in the outpt environment

4 MACRA Basics Does Anyone Really Understand MACRA?

5 ACC MACRA HUB

6 Registry Participation ACC s PINNACLE Registry or Diabetes Collaborative Registry can help you fulfill MIPS requirements for Quality, Improvement Activities and Advancing Care Information. Free participation Compatible with over 85 EHRs Monthly performance and benchmarking reports

7 Should I Do Anything Different? MIPS and Risk Adjustment HCC coding is the system used for Risk Adjustment under MIPS. Diagnosis codes (ICD-10) are assigned a weight that measures patient acuity. Medicare expects that patients with higher HCC scores will consume more healthcare dollars and have worse outcomes. If 60% of the MIPS score for providers is going to come from risk adjusted quality and resource use scores, it is critically important to accurately reflect the acuity of our patient population. Doing so will help quality and cost scores to accurately reflect the excellent care provided by physicians. Your diagnosis coding is about to become much more important, both for immediate fee-for-service reimbursement and over the following

8 What Are The MIPS Elements? PQRS Program Value Based Modifier Program Meaningful Use Program Medicare Shared Savings Program Merit Based Incentive Program (MIPS) 2017 First Reporting Year, effects 2019 Payments

9 MIPS Financial Impact Page 9

10 Page 10 MIPS Scoring A.K.A. Meaningful Use

11 Page 11 HCC Impact on Sample Contracts National Quality Benchmarks MSSP/ ACO Benchmark Anthem MA (PMPM and Savings)

12 Simplified Version Using an actuarial tool to plug in a person s current health conditions and apply data collected since approximately 2004 about those conditions. Now apply a forecasting perspective to estimate future financial implications, and more importantly, to predict future patient care management needs and plan for potential complications. The thought is to attempt to level the playing field and allow each individual s health to be reflected as it truly is. We each carry a level of risk. The healthiest of us those without any chronic health conditions, are at the lower end of the risk scale. With the addition of some conditions, the risk increases. Add even more conditions and the risk continues to rise and so will that person s health care needs & resource use

13 Diagnosis Coding The New RVU? Consider that CMS and other payors generally use data that is two years behind when they implement changes What we are submitting now is setting us up for payment changes in the future in a number of ways what we don t know for sure is exactly how many ways We need to be as specific as possible and present a true and accurate picture of our patient s severity We need to be thinking about this at each encounter as we never know for sure if we will see the patient again in the year

14 Why Should I Care? For CMS MACRA replaces the flawed SGR and is scheduled to go into effect in 2019 Claims submitted in 2017 will be used in the 2019 implementation Commercial payors such as Anthem, United, Aetna, Cigna, Humana and others are also using claims data to determine their Value or resource use scores for individual providers

15 Where Does Documentation & Coding Fit In? Builds the language to describe overall patient care Creates the connections of independent medical conditions Requires you to bring uniqueness and specificity to each patient encounter Rationalizes coverage for increasing complex patients Objectifies the claim my patients are the sickest Will provide the context to use big data to plan and execute Population Health Predictive Analytics

16 How Does Risk Adjustment Impact You? Risk adjustment facilitates more accurate comparisons by accounting for differences in patient case mix Risk adjustment plays a role in quality rankings by estimating an expected performance on a quality or cost measure based on the case mix and then comparing that estimate to the actual performance. The essential component of these measures is a ratio of actual-toexpected performance, where the expected performance is reflective of the clinical complexity

17 RAF - Risk Adjustment Factor What Do We Mean By RAF? Used to access the clinical complexity of a patient and predict the burden of illness for individuals and populations Acts as a multiplier when calculating CMS payments in a year Factors into bidding and payment of MA plans Focuses on identification, management, and treatment of chronic conditions Additional Resources Better Analytics Encourages Regular Management Provides a payer with additional resources to manage the health of a riskier population More accurate coding leads to improved practice modeling and stratification of a population Encourages regular outreach to patients who aren t coming in regularly but may need follow-up

18 How Are Payments Or Expected Costs Calculated?

19 HCC Hierarchical Condition Category 101 The Least You Need To Know Model Is Here To Stay In One Form Or Another Goes To A Blank Slate Every Calendar Year Subject To Data Validation Sampling The HCC & RAF Connection 79 to 3,000 The HCC model has been the basis for reimbursement to MAO plans since Due to it s proven success in predicting resource use it is now being used to determine much more and by more payors. The CMS model is accumulative a patient can have more than one HCC category assigned to them. Some categories override others and there is a hierarchy of categories. The HCC must be captured using claims data every 12 months. The HCC must be documented and supported in the medical record and this can be subject to a data validation review The plan must submit the one best medical record that supports the patient s HCC scoring if identified for validation. Patients with multiple HCCs in a single category will be scored at the highest level *Additional risk is scored when certain conditions coexist When multiple conditions are present in the same patient a higher score will be used. i.e. CHF & COPD or CHF and CRF

20 Sample Encounter And The Accumulative Impact Sample Patient - Mickey M HPI Mickey comes in for a follow up of his CHF. He also has DM and CRF stage IV. A/P 1.Chronic Systolic HF Currently Stable, to continue current dose of Lasix 2.Type II DM and Stage IV CKD Stable, scheduled to HCC/RAF see nephrologist Scoring in 2 weeks This pt has 3 HCC categories, all three codes risk adjust and would represent an accumulative scoring. This Pt s RAF Score would be.960 Financial Metrics If the anticipated monthly cost was $850 this now becomes $850 x.960 = $1,666 All 3 conditions result in an extra $816 per month + $9,792 Reporting CHF only would provide an extra $312 per month +$3,744 Add l for 12 months

21 What If Mickey Also Had A Skin Ulcer? HCC Condition RAF Score HCC 157 HCC 158 Pressure ulcer of skin with necrosis through to muscle tendon or bone Pressure ulcer of skin with full thickness skin loss What Does Coding Correctly Mean? A patient with HCC 157 will be spending $2,168 more each month (2.551 X $850) A patient with HCC 158 will spend $1,165 more per month (1.371 X $850) HCC 161 HCC 162 Chronic ulcer of skin except pressure.549 Severe skin burn or condition.422 A patient with HCC 161 will spend only $466 more per month (.549 X $850) and A patient with HCC 162 will spend only $358 more per month (.422 X $850).

22 Documentation & Coding

23 Humana Offer

24 Don t Miss Chronic Conditions DM & complications CHF COPD A Fib Morbid Obesity HTN & complications (HTN alone does not have a RAF score) Major Depression PVD Malnutrition Use ICD-10 Appropriately I.E. as specific as possible Provider s role is to accurately capture the conditions that are treated, managed, or impact care Coded conditions must be documented i.e. MEAT manage, evaluate, assessment, treatment plan Accurate coding and documentation is critical to risk scoring and our future

25 What Does And Does Not Risk Adjust Does CKD stage IV & V Morbid Severe Obesity Angina, Unstable Angina Complete AV Block ASCVD with intermittent claudication Seeing a pattern? Does Not CKD Stage I, II, and III Obesity Unspecified Chest Pain AV Block 1 st or 2 nd degree ASCVD unspecified Don t code to a greater degree than you document!

26 MEAT

27 Documentation & Coding Guidelines Per ICD-10 Official Guidelines for coding and reporting Code all documented conditions that coexist at the time of the encounter/visit, and require or affect patient care treatment or management. Access all conditions that coexist that day are treated, managed, & affect patient care Consider, document and report the disease as accurately as possible use specificity codes Ensure you are addressing and reporting/coding these conditions at least once per calendar year

28 Capturing Comorbidities Is Essential In our Fee-for-Service model we have gotten used to making sure a diagnosis justifies medical necessity for the CPT codes on a claim. Many practices stop short of documenting and capturing comorbidities that show complicated medical decision making, treatment plans, and more accurately reflect the condition of the patient. These comorbidities have not been required for proper reimbursement, and many practices say that they do not always code comorbidities In contrast the majority of practices indicate that their physicians do a good job of documenting these comorbidities in the note. The change may not be one of documentation, but more of a coding change that is needed. Practices who want to more accurately reflect patient acuity need to do a better job of coding comorbidities

29 29 Documentation Guidelines Chronic condition is stable will continue with current treatment regime Chronic condition now requires the following changes in management. Chronic condition is being managed by specialist and the patient is scheduled for follow up on More is More? Statements such as this will support your consideration on that visit, and adding the code to your claim. This could also support a risk element in your medical decision making **

30 Top Conditions That Are Represented in HCC Categories and RAF Scores Diabetes with complications Morbid obesity Multiple cancers Cirrhosis & end stage liver disease Protein-calorie malnutrition Rheumatoid Arthritis Drug and Alcohol dependence Major depressive, Bipolar, & paranoid disorders Quadriplegia & paraplegia CHF Acute MI Unstable angina & acute Ischemic disease Atrial flutter and fib Vascular disease with complications COPD CKD stage 4, 5, dialysis status Parkinson s Cerebral palsy Hemiplegia/hemiparesis

31 Sample Code Reports

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35 The Coding Path To Readiness? Continue to educate and reinforce with providers the importance of accurately coding the patient s condition(s) Identify providers with high use of unspecified codes and low use of typical chronic conditions Share individual provider RAF scoring patterns Begin to monitor high cost of care numbers per provider and rule out underlying coding issues Build accurate HCC profiles on assigned patients Get patients in for their annual wellness visits (PCP) Reaffirm old dxs Establish appropriate new dxs Clarify & code disease interactions & relationships Specify the unspecified as soon as you know

36 Areas To Review Show current state of disease process for accurate reporting: Acute, chronic, compensated, decompensated, exacerbated If ruled out/resolved, state it Cause of condition should be reported, if known Show relationship in diagnoses to other disease process through linking conditions, providing linking terms between diagnoses, such as: With Due to Caused by Secondary to

37 Helpful White Paper

38 More Resources HCC University excellent resource with lists of all HCC categories and weight of each code available for download CMS MACRA webinar series ( Patient-Assessment-Instruments/Value-Based- Programs/MACRA-MIPS-and-APMs/Quality-Payment- Program-Events.html) MGMA MACRA Resource Center (

39 CMS Attribution Of Beneficiaries The Value-Based Payment Modifier (Value Modifier) Program evaluates the performance of solo practitioners and groups, as identified by their Medicare Taxpayer Identification Number (TIN), on the quality and cost of care they provide to their Medicare Fee-for-Service (FFS) beneficiaries. The Centers for Medicare & Medicaid Services (CMS) disseminates this information to TINs in confidential Quality and Resource Use Reports (QRURs). For each TIN subject to the Value Modifier, CMS also uses these data to calculate a Value Modifier that adjusts the TIN s physicians Medicare Physician Fee Schedule payments upward, downward, or not at all, based on the TIN s performance. In assessing performance on several of the quality and cost measures included in the QRUR and Value Modifier, CMS uses a two-step attribution process to associate beneficiaries with TINs during the year performance is assessed. The attribution methodology determines which beneficiaries are included in the calculation of each TIN s quality and cost performance and payment adjustment under the Value Modifier.

40 If You Have Seen One Form of Attribution.. CMS Attribution Basics Attribution Depends on Who Provides Plurality of Primary Care Services Medicare uses a two-step process for determining which patients are tied to a provider and who will constitute the spending-per-beneficiary and claims-based-quality-measure denominators. Medicare is now aligning the methods used in ACO patient attribution with the VBPM patient attribution This is intended to create consistency between Medicare s Value- Based Payment initiatives. Beginning in 2017 CMS is also reviewing APPs such an NP, PA, CNS in the equation for Plurality of Services Team Based Care

41 Medicare s 2 Step Approach Step 1 Step 1: Beneficiaries are assigned to the primary care provider (whether physician, NP, PA, or CNS) who provided the plurality of primary care services to the patient, as measured by allowed charges i.e. E/M visits. But what if they were not seeing a PCP? Step 2 Step 2: Beneficiaries are assigned to the practice whose non-primary care providers (i.e. specialists) provided the plurality of primary care services to the patient, as measured by allowed charges again E/M visits But wait there s more: Primary Care Services may include services that a specialist provides, but which are unrelated to the conditions and events that Medicare is tracking.

42 Who Are You Accountable For? Specific Patient Names Are Available You don t have to guess - review your QRUR report- it lists all of the patient s Shows your total patient cost and from where Were these episodes you controlled? Are there other provider costs that are hurting your score? This can be an eye opening experience! Take The Time To Do Deeper Dive The data is based on Medicare claim data If there are providers not in your network this may be one of the only ways you will see their costs You may see the patient has providers they are seeing that you were never made aware of The ACC has provided extensive web sessions on how to use your QRUR reports What About The PCP Provider? Is There A PCP Provider? One thing specialists can do is consider confirming that the patient has a PCP If they have a PCP make sure they are seeing them at least once per calendar year Finding out a patient with COPD for example is assigned to you can actually signify a gap in care and no one may be managing that condition. A quick review may not only avoid attribution errors but could lead to better patient outcomes all around around

43 Metrics Are Patient Centered One way to help with appropriate attribution is is to ensure the PCP provider is conducting and billing for the Medicare Annual Wellness visit This can help ensure that the patient stays connected to the PCP both clinically and through the attribution process This also provides an opportunity to ensure that chronic conditions are addressed and hopefully coded and billed once per calendar year (HCC & RAF Scoring This also provides an opportunity to ensure that chronic conditions are addressed and hopefully coded and billed once per calendar year (HCC & RAF Scoring) In a P4P world it doesn t always matter if you are the specialist or the PCP - you need to know what care your patients are receiving. You simply can t stop with providing the best possible care in your field and sending patients out the door.

44 If You Remember Nothing Else.. The claims we are submitting in 2017 will be used in the 2019 implementation How many patients have you already seen this year that you might not see again before year end? Did you code to the specificity you should have? Did you report the chronic conditions you evaluated that impacted your decisions?

45 2017 Claims Can Determine Your Fate Don t Get Caught Off Guard

46 PINNACLE and Diabetes Collaborative Registries 2017 Ohio-ACC Annual Meeting

47 PINNACLE: Largest outpatient CV registry in the U.S. Over 50 million records from 12 million unique patient lives todate ACC2017 Founded in 2008 with more than 9,000 providers submitting data from 3000 office locations * Data as of August 2017

48 Diabetes Collaborative Registry Footprint to date 7232 contracted providers from 2531 practice locations across 47 states in the United States N = 1,278 sites with signed contracts * many are practices with multiple geographic locations Confidential. Not for Distribution. (c)2017 As of August 2017

49 Registry Participation ACC s PINNACLE Registry or Diabetes Collaborative Registry can help you fulfill MIPS requirements for Quality, Improvement Activities and Advancing Care Information. Free participation Compatible with over 85 EHRs Monthly performance and benchmarking reports

50 QCDR Participation As a QCDR, the registries submit data for the MIPS Quality category, which accounts for 60 percent of the overall MIPS score. You can also earn bonus points for reporting additional outcome and high priority measures! It s easy to use and simplifies MIPS reporting. Data is captured seamlessly through the electronic health record, and the ACC transmits it to CMS for you. Avoid penalties for non-participation in MIPS by making reporting easy and convenient.

51 Merit-based Incentive Payment System (MIPS) Reporting Quality (60% score) 19 measures available ACC will submit on behalf or providers with consent Improvement Activities (15% of score) 7 Registry Favorites Self-attestation tool via dashboard Advancing Care Information (25% of score) Self-attestation tool via dashboard

52 Successful Reporting Approved by CMS as QCDR for program years 2017, 2016, 2015 and PQRS Reported for over 2200 providers including: 26 Group Practices 16 measures available

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