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1 How CDI Professionals Can Drive Success With Risk Adjustment Strategies Angela Carmichael, MBA, RHIA, CDIP, CCS, CCS P, CRC Director, HIM Kimberly Hopey, PhD, RN Director, Professional Services J.A. Thomas & Associates/Nuance Communications 1 Learning Objectives At the completion of this educational activity, the learner will be able to: Develop an understanding of risk adjustment, and the CMS HCC methodology Articulate how to "start the conversation" within your organization on deploying HCC strategies and make the case for why CDI pros should drive the HCC program forward Develop successful CMS HCC strategies for inpatient, hospital outpatient, and physician office settings Employ concurrent processes for CDI, HIM, and coding professionals to work in collaboration for success in risk adjustment 2 Risk Adjustment The who, what, where, when, and why 3

2 What Is Risk Adjustment? Risk adjustment is a corrective tool used by actuaries to level the playing field regarding the reporting of patient outcomes, adjusting for the differences in risk among specific patients It is the process of adjusting expected volumes to account for the case mix of the facility or category being compared 4 Why Is Risk Adjustment Important? It s a necessary tool for managed care programs Account for changes in severity & case mix over time Accurately set performance targets (quality & efficiency) Identifies patients for population health initiatives It s relevant Risk adjustment is an important element in VBP It s fair Provide incentives to enroll high cost individuals into managed care programs by ensuring health plans/acos have the resources needed to provide efficient and effective treatment It s prominent Risk adjustment payment methodologies are used across a variety of government (federal & state) private & commercial insurance programs It s here to stay! 5 How Is Risk Adjustment Used? Uses Payment methodology For example: CMS HCCs set Per Member Per Month (PMPM) capitation payments to Managed Medicare plans & ACO Medicare Shared Savings Programs (MSSP) Risk adjusts other payment models HCCs mathematically reconcile the observed rate versus the expected so that the quality of the care can be isolated and understood an important element of Value Based Purchasing For example: The six per capita cost measures and select quality measures included in the 2016 Value Modifier Severity of illness (SOI) during the 90 days preceding the Medicare spending per beneficiary episode in Medicare Spending Per Beneficiary (MSPB) 6

3 How Prominent Is Risk Adjustment? Risk adjustment payment methodologies are used across a variety of government (federal & state) private & commercial insurance programs The four prominent systems: Ambulatory Care Groups (ACGs) Chronic Illness and Disability Payment System (CDPS) (Managed Medicaid) Diagnostic Cost Groups (DxCGs) Hierarchical Condition Categories (HCCs) CMS HCCs (Managed Medicare) HHS HCCs (Managed Commercial in Health Insurance Exchange) 7 What Are Hierarchical Condition Categories (HCCs)? An actuarial tool used to predict healthcare costs Sets capitation payments to health plans to reflect the expected costs of providing care to their members Adjustments consider demographic information (age, sex, eligibility) and health status (diagnoses) Adjusts approximately 40% of the quality metrics used in Value Based Purchasing Alternative Payment Models 8 What Are Hierarchical Condition Categories? HCCs are a form of case mix index (CMI) This form of CMI applies to the patient for the calendar year across both inpatient and outpatient settings HCCs are diagnostic categories that bucket patients into different categories based on demographics and the ICD 10 CM diagnosis codes The categories are designed to group patients that are not only clinically similar but follow similar cost patterns to predict future healthcare costs and allow for quality of care comparisons CMS HCCs are more predictive of readmissions and future costs than MS DRGs 9

4 Introduction to Medicare Part A, B, C, & D Medicare is a federal health insurance program Medicare consists of 4 parts Part A IP hospital care (LTAC & SNF), home health & hospice Part B Doctor services, office visits, screenings, therapies, preventive services, OP hospital, emergency care, ambulance, medical/surgical supplies, and durable medical equipment Part C (Medicare Advantage/CMS HCCs) Part A & B services Additional services such as coverage for extra dental, vision, hearing, and preventive services and some optional supplement services (e.g., gym memberships and exercise classes) Part D (RxHCCs) Pharmacy benefits Includes plans with varying out of pocket requirements 10 The Medicare Payment Spectrum Traditional Pure FFS Pay by service Silo based Some VBP No risk ACO Mixed payment FFS +/ shared savings All Part A&B Quality incentive Limited risk Patients can self refer MA Pay for population Full capitation All Part A&B Quality bonus Full risk PCP must refer Payment & delivery system integration 11 Diagnosis Sources: Provider Types Diagnoses documented by select provider types are appropriate for coding and reporting for MA coding MD or DO OD = doctor of optometry DC = doctor of chiropractor DDS = doctor of dental surgery DO = doctor of osteopathy DPM = doctor of podiatry All nurse practitioners, certified nurse specialists, CRNAs Physician s assistants Therapists; speech, physical, occupational (except respiratory ) Licensed clinical social worker or clinical social worker Certified wound care and/or ostomy nurse Note: This is not an exhaustive list 12

5 13 Diagnosis Sources: Provider Settings Acceptable provider settings for CMS HCCs Short term (general & specialty) hospitals Critical access hospitals Children s hospitals Long term hospitals Rehabilitation hospitals Psychiatric hospitals Religious non medical healthcare institutions Community mental health centers Federally qualified health centers Rural health clinics (freestanding & provider based) IP & OP services OP services only Non covered settings: Hospital inpatient swing beds, freestanding ambulatory surgery centers, skilled nursing facilities, intermediate care facilities, respite care, hospice, home health care, freestanding renal dialysis facilities Non covered services: Ambulance, lab, radiology, DME, prosthetics, orthotics, supplies Note: This is not an exhaustive list 14 CMS HCC Risk Adjusted Payment Model CMS HCC (Medicare) overview 3 programs: ICD 10 CM codes: 9,548 Medicare Advantage 42% are CCs Dual Demonstration 16% are MCCs Medicare MSSP for ACOs 42% are neither CC or MCC 3 models: HCCs: 79 Model 22 (current) HCC range: Model 21 for PACE & ESRD Accepted provider types: Budget/payment mechanism Specified by CMS Funded by CMS Data linkages: Applied to each individual Not tied to a particular procedure Used to calibrate monthly MA: Claim based, home premiums assessments, & retrospective PMPM payment from CMS review Patients pay monthly premium ACO: Claim based only Medicare Advantage plans on average received about $9,900 per person in

6 Comparing HCCs to MS DRGs: Differences MS DRGs More than 1 HCC can be assigned per encounter No sequencing involved Not all diagnoses map to an HCC Procedures not included Various provider types & specialties documentation can be used Various settings involved CMS HCCs Only 1 assigned per IP discharge Sequencing is a critical component All appropriate principal diagnoses map to a MS DRG Procedures can impact assignment Code only from physician documentation with few exceptions Only applicable to IP care 16 Deploying HCC Strategies in Your Organization 17 Managing CMS HCC Opportunities Determine scope & depth of opportunity Varies based on patient population/insurance type Does your organization offer their own provider sponsored Medicare Advantage plan? (aka Medicare HMO ) Does your organization receive incentives from insurers offering a Medicare Advantage Plan if you improve risk scores? Is your facility part of an accountable care organization (ACO)? 18

7 Pertinent Guidelines Payment methodology CMS HCCs, HHS HCCs, CDPS, etc. Sub models Rate year risk factors & mapping tables Code sets ICD 10 CM Official Coding Guidelines Coding conventions Official Coding Guidelines published by the National Center for Health Statistics Coding Clinic published by the American Hospital Association CMS Risk Adjustment Participant s Guide 19 What Type of Conditions Map to a CMS HCC? High cost medical condition (current cancer, heart disease, hip fracture) Highest weighted: HIV, sepsis, opportunistic infections & cancers Acute, chronic, status codes, etiology & manifestation Hip fracture, COPD, status amputation of great toe, diabetic neuropathy Common conditions, rare conditions, conditions that can be cured, non curable, congenital and acquired, but Must be current & impact the encounter in terms of requiring either Monitoring, evaluation, assessment, or treatment Diagnoses are excluded from mapping when They do not predict future cost (e.g., appendicitis) There is a high degree of discretion or variability in diagnosis, diagnostic coding, or treatment (e.g., symptoms, osteoarthritis) Diagnosis codes from lab, radiology, and home health claims are not used because they are not reliable and may indicate rule out diagnoses 20 HCC Strategies Across the Care Continuum 21

8 Common Challenges Medical record requirements Documentation Mapping diagnoses Clinical support for each mapping diagnosis Coding Billing/reporting Compliance with all guidelines 22 What Kind of Documentation Do We Need? Diagnoses must be documented there can be no assumptions Coders cannot interpret labs Coders cannot assume a diagnosis based on meds provided or orders Diagnoses must be documented to the highest level of specificity Increases the likelihood of mapping (Example: Depression) Increases the likelihood of the condition mapping to a higher weighted HCC (Example: Diabetes) Diagnoses must be documented in a part/section/document coders are permitted to code from We can t code current conditions from problem lists, medical history, or super bills Supporting clinical documentation for all reported diagnoses, aka MEAT Monitor, Evaluate, Assess, Treatment 23 Where Is the MEAT? Ensure MEAT is met M = Monitoring E = Evaluation A = Assess/Address T = Treatment Only 1 element of MEAT is required to support a diagnosis not all 4 2 elements is better 3 elements is better still MEAT can be found in any section of the patient record 24

9 MEAT for the Chronic Condition Monitor Signs, symptoms, disease progression, disease regression Evaluate Review of test results, medication effectiveness, response to treatment ( stable, improving, exacerbation, worsening, poor ) Assess/address Ordering tests, discussion, review records, counseling Treatment Referral, medication(s), planned surgery, therapies, other modalities Examples: CHF symptoms well controlled with Lasix and ACE inhibitor. Will continue current medications. Major depression recurrent episode. Patient continues with feelings of hopelessness and anhedonia despite current regiment of Zoloft 50 mg daily. Will increase dose to 100 mg daily and monitor. 25 Common CMS HCC Diagnoses/Code Families Diabetes Atrial fib/flutter/pat COPD CHF Long term use of insulin PVD Rheumatoid arthritis BMI > 40/morbid obesity Cardiomyopathy Angina Cor pulmonale Epilepsy/convulsions Parkinson's Major depression Bipolar disorder Acute renal failure/esrd/ckd/stage 4 or higher Aortic atherosclerosis/abdominal aortic aneurysm Malignant neoplasm of prostate or breast 26 CDI Processes Across the Care Continuum Inpatient setting DRGs + CMS HCCs Hospital outpatient setting Outpatients in a bed Provider office setting Greatest opportunity Focus on PCP first Collaboration & workflow is critical Data analytics improve scalability 27

10 Common Challenges: Inpatient Setting Are you reviewing Medicare Advantage & ACO member admissions? Analyze the HCC tables to ensure you are capturing all conditions that map to a CMS HCC and meet reporting criteria Severity of illness & risk of mortality clarifications are critical to HCC success but they alone are not enough Approximately 58% of diagnoses that map to a CMS HCC are CCs/MCCs too but that leaves 42% that are not Develop CDI, coding, and abstraction policies for riskadjusted contracts 28 Common Challenges: Hospital Outpatient Setting Emergency department, observation, outpatient surgery: Think beyond medical necessity or reason for encounter Encourage documentation of all comorbid conditions to capture disease burden Chronic diseases treated on an ongoing basis may be reported as many times as the patient receives monitoring, evaluation, assessment, or treatment. If the condition impacted medical decision making (MDM), report it for that DOS. Documentation should specifically link manifestations to their etiology Ensure diagnosis coding is accurate, complete, & consistent Develop coding and abstraction policies for risk adjusted contracts Invest in outpatient coder education and professional development 29 Common Challenges: Physician Office Greatest risk area is the physician office Documentation, coding, billing, & medical record deficiencies Improving coding alone will only get you so far Approximately one third of the opportunity requires CDI remedy Who is performing the coding? Ensure coding is accurate, complete, & consistent Problem focused visits should include diagnoses that meet the MEAT criteria Think beyond evaluation & management (E/M) & chief complaint (CC) Ensure members are seen at least once annually New patient & annual wellness visits are a great opportunity to capture chronic non resolving diagnoses Even with great documentation, coding, & billing, you are not protected from compliance reviews Eradicate medical record deficiencies 30

11 Common CDI Clarifications in PCP Office Morbid obesity Major depression Diabetes & manifestations COPD CHF Peripheral artery disease Opioid dependency uncomplicated 31 Commonly Unreported Diagnoses Do not report conditions that were previously treated & no longer exist However do report the following status/conditions when they meet the reporting criteria for the encounter (aka MEAT ): BMI over 40 Long term use of insulin Ostomy status or attention to ostomy Amputation status Asymptomatic HIV Transplant status Dependence on dialysis or respirator Monoplegia & hemiplegia 32 The Power of CDI & the Impact on Risk Scores Patient risk score is a composite of the demographic RAF + disease RAF. Risk adjustment factor (RAF) reflects the age, sex, eligibility status, beneficiary type, risk model, &disease burden of the patient. CMS HCC Example for V22 PY Based on Bid Rate of $750 PMPM/$9,000 yr. 33

12 Concurrent Processes Drive Success 34 A New Year A Clean Slate A New Year A Clean Slate Only CMS HCC mapping diagnoses submitted on claims from specific settings as a result of a face to face encounter with a qualified practitioner during the calendar year(s) under consideration will influence the member s risk score Each January 1 starts a clean slate and the documentation of the mapping diagnoses must be documented & billed again to influence the risk score If not we call this falling off 35 Why More Really Is Better Even though each mapping diagnosis only needs to be reported once in the calendar year, during a RADV you are able to submit up to 5 DOS to support any 1 HCC Even if the diagnosis is documented clearly & coded correctly a medical record deficiency could make the encounter invalid Stack the deck in your favor! Your goal is to report each mapping diagnosis as often as it meets reporting guidelines 36

13 Medical Record Requirements Two patient identifiers on each page of every document: Example: Patient s name, date of birth, medical record number Date of service (complete month/day/year & legible) Face to face encounter with acceptable type provider & setting Acceptable provider signature, with credential Legibility: Documentation, signature, & credentials must be legible to the auditor validating the risk score Documentation should be clear, concise, consistent, complete, & legible 37 The Balancing Act: Managing Opportunity & Risk In the reporting of disease burden via claims or retrospective submission, mistakes are common and trigger billions of dollars in improper payments every year, mostly overcharges CMS HCC data validation error rates: CMS HCC error rate approximately 33% OIG results indicate even higher error rates 2006 PY extrapolated results for overpayments indicated $3 billion in overpayments 38 Compliance Risk Adjustment Data Validation (RADV) annual audits are supposed to keep the industry honest Two types; national & targeted Applicable to Medicare Advantage & Medicare Shared Savings Program for ACOs Regulated by CMS and performed annually CMS contracts with coders to perform these annual reviews Financial impact: Payment recovery, if applicable Results may be extrapolated against total enrollment False Claims Act violation triple damages plus $5,500 to $11,000 per claim penalties OIG Work Plan since 2012 (Part C & D) RAC reviews Part D claims & is expected to add Part C claims to their SOW in near future 39

14 Top 10 RADV Risks 1. Lack of two patient identifiers & date of service on every page of the assessment form 2. Lack of an acceptable provider signature 3. Lack of code specificity as compared to the written description in the medical record 4. A discrepancy between the codes billed & the actual written description in the medical record 5. Lack of MEAT to support billed diagnosis 6. Status of cancer is unclear 7. Chronic conditions are not documented as chronic (e.g., viral hepatitis) 8. Lack of specificity (e.g., an unspecified arrhythmia is coded rather than the specific 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 causal relationship is missing for a diabetic manifestation, or there is a failure to report a mandatory manifestation code 40 Thank you. Questions? Angela.Carmichael@nuance.com Kimberly.Hopey@jathomas.com In order to receive your continuing education certificate(s) for this program, you must complete the online evaluation. The link can be found in the continuing education section at the front of the program guide. 41