RISK ADJUSTMENT CONCEPTS AN INTRODUCTION AND DISCUSSION

RISK ADJUSTMENT CONCEPTS AN INTRODUCTION AND DISCUSSION HFMA Maine Chapter Physician Practice Management Seminar March 16, 2017 AGENDA Risk Adjustment How Risk Adjustment Works Comprehensive Annual Visits Traditional vs Risk Adjustment Coding Clinical Documentation Barriers Coding Challenges The Future of Risk Adjustment 2 1

THE WHO, WHAT, WHY, HOW AND WHEN OF RISK ADJUSTMENT WHO is subject to risk adjustment Health Plans Medicare Advantage Plans, Health Insurance Exchanges, others Hospitals, Physician Practices WHAT does it do Redistributes funds from plans with lower-risk enrollees to plans with higher-risk enrollees WHY does it do it To protect against adverse selection and risk selection Adverse-only sicker patients get insurance coverage Risk-Insurers try to make products unattractive to sicker patients with expensive health conditions HOW does it do it Actuarial risk based on enrollees individual risk scores lower risk equates to lower payments WHEN did this happen For Medicare Advantage, way back in 1997. For the health insurance exchanges, mandated by the ACA, in 2014 going forward 3 WHAT IS RISK ADJUSTMENT? A prospective payment methodology utilizing: Prior year diagnoses to predict future costs The premise that the average risk score is 1.0 A methodology to adjust payment to health plans based on: Certain demographics Age, gender, socioeconomic status, disability status, insurance status Actual health status of an enrollee Diagnosis code(s) Place of service code Patient-specific conditions ocommunity, Institutional, ESRD 4 2

WHY IS RISK ADJUSTMENT IMPORTANT? Complete and accurate reporting allows providers to: Improve the overall patient healthcare evaluation process Improve communication with a patient s healthcare team Identify the composite picture of a patient s health status Reinforce self-care and prevention strategies Coordinate care in a collaborative manner Avoid potential drug-drug/disease interactions 5 WHY IS RISK ADJUSTMENT IMPORTANT? Meet required CMS obligations which include Use all diagnosis coding guidelines/standards in medical record documentation Report all conditions and diagnosis codes that exist on the date of an encounter Participate in CMS Medicare Recovery Audit Contractor (RAC) and Risk Adjustment Data Validation (RADV) Audits. 6 3

HOW DOES IT WORK? CMS $ FERAS RAPS EDS Medicare Advantage Organization $ Claims Diagnoses Medical Records Providers, Facilities, Coders, CDI 7 ACCEPTABLE PROVIDER SPECIALTIES ALL DIAGNOSES THAT ARE REQUIRED FOR THE RA MODELS AND RENDERED AS A RESULT OF FACE-TO-FACE VISITS MUST BE COLLECTED BY MA ORGANIZATIONS. 8 4

COMMON CHARACTERISTICS OF RISK ADJUSTMENT MODELS The final result, no matter what risk adjustment model is used and no matter the individual scoring process: An overall risk score is calculated for each and every patient, and; Final risk scores are always affected by known diagnoses Diagnosis codes carry value and are generally cumulative Risk scores can be grouped by patient population or together to identify the risk of an entire health plan Inaccurate risk scores from over/under coding can have dramatic financial impacts On a health plan s payments On a provider s payments On the ability to adequately care for patients with certain conditions 9 CMS-HCCS (USING DIABETES AS AN EXAMPLE) All ICD-10-CM codes map to a Diagnostic Group (DxG) Each DxG is a specified medical condition or set of conditions Ex. Type 2 DM with Diabetic Nephropathy DxGs combine into Condition Categories (CCs), which describe a broader set of similar, clinically related diseases, with similar treatment/management cost Ex. Type I DM with Acute Complications CC would also include Type II and Secondary DM with hyperosmolarity, ketoacidosis or coma Hierarchies imposed with related CCs, thus HCCs Diabetes with Acute Complications-HCC17 Diabetes with Chronic Complications-HCC18 Diabetes without Complications-HCC19 10 5

HIGH LEVEL EXAMPLE OF A CMS PAYMENT TO A PLAN No Diagnoses Reported Some Diagnoses Reported All Diagnoses Reported 68 year old male.300 68 year old male.300 68 year old male.300 Dual eligible.192 Dual eligible.192 Dual eligible.192 Type 2 DM, not coded Type 2 DM, no complications.097 Type 2 DM with other skin ulcer.346 Congestive Heart Failure, not coded Congestive Heart Failure, not coded Congestive Heart Failure, coded.355 Disease interaction (DM+CHF).205 Risk Adjustment Factor.492.589 1.398 PMPM base payment $814 PMPM base payment $814 PMPM base payment $814 PMPM for this patient $401 PMPM for this patient $479 PMPM for this patient $1,138 Annual payment $4,806 Annual payment $5,753 Annual payment $13,656 11 COSTLY, CHRONIC DISEASES HCC Model made up of ICD-10-CM codes that typically represent costly, chronic diseases such as Diabetes Chronic Kidney Disease End Stage Liver Disease Renal Failure Congestive Heart Failure Chronic Obstructive Pulmonary Disease Malignant neoplasms Ongoing Chronic Conditions Multiple Sclerosis Parkinson s and Huntington s Disease 12 6

CAPTURE THE CHRONIC CONDITIONS! The slate is wiped clean on January 1 EVERY YEAR Amputations grow back! COPD patients have healthy lungs! Diabetes patients have superb pancreases! All kidneys function flawlessly! Colostomy patients have a perfect colon! Get the picture? IF YOU DON T DOCUMENT AND CODE THE CONDITION, YOU LOSE! 13 HOW CAN YOU HELP ENSURE IDENTIFICATION OF CHRONIC CONDITIONS? Through Comprehensive Annual Visits Sometimes called comprehensive physical exams Medicare COVERS these under MA Plans And not to be confused with the Medicare Annual Wellness Visit Provides personalized prevention plan services through a health risk assessment Medicare COVERS these under both FFS and MA Plans 14 7

COMPREHENSIVE ANNUAL VISITS Once a year process to evaluate, document and submit all relevant diagnoses Promotes quality of patient care Ensures screening tests are performed Assesses chronic conditions on an ongoing basis Allows for accurate risk score calculations Important if chosen for data validation audits 15 COMPREHENSIVE ANNUAL VISITS Why are these taking on such importance? They are a perfect opportunity to diagnose and capture all chronic illnesses at least once each calendar year So Medicare pays the MA Plan for these what s in it for me? 16 8

COMPREHENSIVE ANNUAL VISITS Some plans are offering incentives/supplemental payments to physicians to ensure these are completed annually Capture twice, not just once Some plans provide pick lists showing prior diagnoses of chronic conditions that a patient has been treated for Some plans provide templates or other lists of chronic conditions to help ensure their capture 17 BEYOND ANNUAL VISITS RISK ADJUSTMENT VS TRADITIONAL DOCUMENTATION AND CODING 18 9

RISK ADJUSTMENT Traditional Coding (Fee For Service) Clinical Documentation Improvement (CDI) Risk Adjustment Coding Ambulatory (Outpatient) Clinical Documentation 19 TRADITIONAL CODING VS RISK ADJUSTMENT CODING Outpatient and Inpatient Coding Physician based coders Bill for physician s work and overhead Assign CPT, HCPCS and ICD-10-CM codes Codes are tied directly to physician reimbursement CMS-1500 Claim Form Hospital based coders Bill for technical component of services provided Assign CPT, HCPCS, ICD-10-CM and ICD-10-PCS codes ICD-10 codes are used to assign a Medicare severity diagnosis-related group (MS-DRGs) for reimbursement UB-04 Claim Form Risk Adjustment Coding Focus on diagnosis coding for all encounter types Office visits Outpatient facility visits Inpatient admissions Focus on learning ICD 10 CM codes Disease process and interactions Pathophysiology Hierarchical Condition Categories (HCC) Be familiar with common medications Be familiar with documentation barriers Building relationships between coding and CDI 20 10

REMEMBER Medicare has advised that the overarching criterion for code selection should be medical necessity: It would not be medically necessary or appropriate to bill a higher level of evaluation and management service when a lower level of service is warranted. (CMS Manual System, Pub 100 4, Ch. 12, Sub Sec 30.6.1A) Documentation in History, Exam & Medical Decision Making should consistently support medical necessity. 21 DOCUMENTATION PRINCIPLES/REQUIREMENTS What is it and why do we do it? Basic Requirements The medical record records facts, findings, observations about a person s health history, including past/present illnesses, examinations, tests, treatments and outcomes Should be a chronological document of the care of the patient Can reduce the hassles associated with claims processing and serve as a legal document 22 11

DOCUMENTATION FORMAT S Subjective The patient s statement about their health, including symptoms. How the patients describe their problem or illness. O Objective The provider assesses and documents the patient illness using observation, palpation, auscultation, and percussion. Data obtained from examinations, lab results, vital signs, etc. A Assessment Evaluation and conclusion made by the provider. Listing of the patient s current condition and status of all chronic conditions. How the objective data relate to the patient s acute problem. P Plan Course of action. Next steps in diagnosing problem further, prescriptions, consultation referrals, patient education, and recommended time to return for follow up. 23 DOCUMENTATION PRINCIPLES/REQUIREMENTS Patient care can vary from visit to visit, although the diagnosis may be the same, the treatment plan(s) can change The fact that a patient has an underlying condition or chronic problem is only significant if it impacts the encounter on that day MEAT Monitor, Evaluate, Assess, Treat 24 12

ASSIGNING CODES USING PRIOR ENCOUNTERS CODING CLINIC, THIRD QUARTER 2013 PAGES: 27-28 EFFECTIVE WITH DISCHARGES: SEPTEMBER 10, 2013 Documentation for the current encounter should clearly reflect those diagnoses that are current and relevant for that encounter. Conditions documented on previous encounters may not be clinically relevant on the current encounter. The physician is responsible for diagnosing and documenting all relevant conditions. A patient's historical problem list is not necessarily the same for every encounter/visit. It is the physician's responsibility to determine the diagnoses applicable to the current encounter and document in the patient's record. When reporting recurring conditions and the recurring condition is still valid for the outpatient encounter or inpatient admission, the recurring condition should be documented in the medical record with each encounter/admission. However, if the condition is not documented in the current health record, it would be inappropriate to go back to previous encounters to retrieve a diagnosis without physician confirmation. 25 ICD 10 CM CODING GUIDELINES SECTION IV. DIAGNOSTIC CODING AND REPORTING GUIDELINES FOR OUTPATIENT SERVICES G. ICD 10 CM code for the diagnosis, condition, problem, or other reason for encounter/visit List first the ICD 10 CM code for the diagnosis, condition, problem, or other reason for encounter/visit shown in the medical record to be chiefly responsible for the services provided. List additional codes that describe any coexisting conditions. In some cases the first listed diagnosis may be a symptom when a diagnosis has not been established (confirmed) by the physician. I. Chronic diseases Chronic diseases treated on an ongoing basis may be coded and reported as many times as the patient receives treatment and care for the condition(s) J. Code all documented conditions that coexist Code all documented conditions that coexist at the time of the encounter/visit, and require or affect patient care treatment or management. Do not code conditions that were previously treated and no longer exist. However, history codes (categories Z80 Z87) may be used as secondary codes if the historical condition or family history has an impact on current care or influences treatment. 26 13

ICD-10 DOCUMENTATION CONCEPTS LEVEL OF SPECIFICITY IMPORTANT FOR RISK ADJUSTMENT Type Timing Caused by/contributing factors Symptoms/Findings/ Manifestations Localization/Laterality Anatomy Associated with Severity Episode Remission status History of Morphology Complicated by External Cause Activity Place of Occurrence Loss of Consciousness Substance Number of Gestations Outcome of Delivery BMI 27 DOCUMENTATION AND CODING IS KEY Medical Decision Making Chronic conditions that impact care and treatment planning Allows for better management of patient Complete diagnosis coding Included in quality management programs Accurate diagnosis reporting/complete clinical documentation Accuracy of member s risk score Reduces potential request of medical records Reduces risk of claims audit Minimize administrative burden 28 14

TO RISK ADJUSTMENT It is the responsibility of the health care provider to produce accurate and complete documentation and clinical rationale, which describes the encounter with the patient and the medical services rendered, to adequately substantiate the use of the most appropriate ICD 10 CM code(s) according to the Official Guidelines for Coding and Reporting. Medicare Advantage Organizations are ultimately responsible for the accuracy of the data submitted to CMS. Providers are the source of this reported data 29 TO RISK ADJUSTMENT 1. Medical record does not contain a legible signature with credentials. All dates of service must be signed (with credentials) and dated by the provider. Within an EHR, each note must be authenticated, which means Electronically signed by, Authenticated by, Approved by, Completed by, Finalized by,, or Validated by, and include the practitioner s name and credentials and the date signed. Electronic signatures must be password protected and used only by the physician/provider. Medical records that do not contain date or lack an acceptable physician signature (or if reviewer is unable to determine who evaluated the patient) will not be reviewed during RADV process. 30 15

TO RISK ADJUSTMENT 31 TO RISK ADJUSTMENT 2. General Documentation Legibility Reviewers must be able to read what is written. Ultimate responsibility lies with provider to review notes, including dictated or electronic records, for accuracy 32 16

TO RISK ADJUSTMENT CODING 3. Reporting signs and/or symptoms Appropriate when the treating provider has not established a definitive diagnosis. Few signs/symptoms impact risk score; those that do tend to be reported during inpatient stay. Examples: SIRS, sepsis, shock, convulsions, post-traumatic seizure, Coma scale ratings 33 TO RISK ADJUSTMENT CODING 4. Uncertain diagnoses Uncertain diagnoses in the inpatient setting, which are uncertain at the time of discharge are not a reportable diagnoses for Risk Adjustment purposes. Risk adjustment is based on final/confirmed diagnoses. Consistent with is not acceptable documentation to establish a diagnosis in the outpatient setting. More common in outpatient setting for provider to incorrectly, based on coding guidelines, report diagnosis when condition not definitively established. This can be identified with internal coding validation. 34 17

TO RISK ADJUSTMENT CODING Acceptable Wording Unacceptable Wording Outpatient Services Evidence of Component of Element of Early Underlying Consistent with Probable Likely Possible Presumed Suspect Rule out Questionable Appears to be 35 TO RISK ADJUSTMENT 5. Highest level of specificity was not selected/reported based on the narrative in the record. Knowledge gaps by provider in ICD-10-CM code set EHR limitations Providers selecting first code from drop down menu or key word search fails to locate intended code May negatively impact risk adjustment score 36 18

TO RISK ADJUSTMENT 6. Higher level code was selected/reported than can be substantiated with the provider documentation in the record. Selection of code vs. documentation to support code Providers should use terms in their narrative such as acute, chronic, recurrent, major, remission, etc. in support of diagnoses on claim 37 TO RISK ADJUSTMENT 7. Documentation does not demonstrate MEAT principles. Long list of diagnoses under assessment, without evidence of impact on current encounter does not support MEAT. Does ordering labs and review of medication list validate the diagnosis? 38 19

TO RISK ADJUSTMENT 8. Chronic conditions or status codes are not documented at least once yearly, preferably twice. Diagnosis will disappear if not submitted at least once annually. 39 TO RISK ADJUSTMENT CODING 9. Provider use of history of when condition is acute or chronic and requiring treatment and management. Discourage provider use of this terminology unless condition truly historical in nature. History of COPD, without evidence in the encounter of how this condition affects the management, care, or treatment of the patient, should not be reported. (OIG Report, 2012-Paramount Care, Inc., a MA organization) 40 20

TO RISK ADJUSTMENT 10. Reporting no more than 4 ICD 10 CM diagnosis codes Truncated diagnosis fields (Many EHR or coding systems only allow four) Historical reporting practice Tendency to underreport valid diagnosis codes 41 TO RISK ADJUSTMENT 11. Failure to report manifestation codes, additional codes based on instructional notes. Providers are generally not well versed in coding guidelines and conventions. Do not expect providers to know that HTN and CKD can be reported with combination code-requires education! 42 21

TO RISK ADJUSTMENT CODING 12. EMR unable to identify codes submitted in prior years or from other providers because they do not incorporate claims data. Some MA organizations create processes and monitor data of current member s previously submitted codes for use in easily identifying which conditions should be addressed annually and for patient risk stratification for care management. 43 TO RISK ADJUSTMENT CODING 13. Problem lists can be a problem! Easily become outdated Governance and ownership Not acceptable source for documenting a current condition 44 22

OPPORTUNITIES TO ADDRESS CLINICAL DOCUMENTATION BARRIERS Provider Concerns & Vulnerabilities Understanding of Coding Guidelines EHR Barriers Time Constraints and other Reporting Requirements What s in it for me? Prevention / Solution Implement chart review process (internal and external provider documentation review); general vs. specific audit of missing diagnoses Assess documentation/data quality-cdi opportunities Work with EHR vendor/it department to optimize software for physician documentation Communicate through feedback and ongoing education 45 CHALLENGES IN RISK ADJUSTMENT CODING Providers are not coders and coders are not providers Unfamiliar with rules and regulations Selecting a code that looks right Limited to no access to Coding Clinic Prevention / Solution Never assume your education is complete Discuss trends Create a professional development plan for each team member Attend local coding meetings and conferences (local/national) Cross-train 46 23

CHALLENGES IN RISK ADJUSTMENT CODING Missed Diagnoses vs. Extra Diagnoses Common coding errors Medical record documentation supported additional code(s) Reporting of additional code(s) was required based on the official coding guidelines Documentation supported different code(s) compared to those reported Documentation did not support diagnosis or not provided for code reported Prevention / Solution Ensure internal policies and procedures are up to date Implement QA process (internal and external coder validation review) Ongoing education/discussion 47 CHALLENGES IN RISK ADJUSTMENT CODING Expecting traditional coders to code accurately for RA Status codes often overlooked Coding CVA in the office setting Coding acute, severe, past illnesses as if they were current conditions Cancer coding (malignancy vs personal history of, multiple primary sites when patient has metastatic disease) Not coding long standing disease Coding conditions as current vs. history of Prevention / Solution Provide education on the who, what, why Establish team players, groups, and resources 48 24

CHALLENGES IN RISK ADJUSTMENT CODING Relying solely on EHR Assuming software developed to code accurately Code descriptions not matching code assignment Inaccurate code mapping Inclusion and exclusion information not included Updates incomplete or not timely Unspecified or NEC used as default codes Limited fields for diagnoses reporting Prevention / Solution Keep in mind the purpose of an EHR Rely on your skills and documentation supporting visit Work with vendors to ensure updates and field capabilities 49 WHAT SHOULD I DO Review opportunities to improve Clinical Documentation Review internal processes to standardize coding practices Review internal processes to identify most common documentation, coding and billing errors Remediate incomplete/ incorrect coding 50 25

WHAT SHOULD I DO Internal / External Review Coder HCC Pass % HCC Added % HCC Deleted % HCC Changed Combined Coders (less than 5 claims) 8 80% 1 10% 0 0% 1 10% 18 58% 13 42% Coder 1 71 89% 6 8% 3 4% 0 0% 87 61% 56 39% Coder 2 37 73% 7 14% 6 12% 1 2% 55 50% 55 50% Coder 3 44 92% 1 2% 2 4% 1 2% 71 58% 52 42% Coder 4 60 83% 2 3% 9 13% 1 1% 87 48% 93 52% Coder 5 36 62% 2 3% 15 26% 5 9% 45 38% 75 63% Coder 6 94 81% 8 7% 11 9% 3 3% 120 50% 121 50% % ICD 10 Pass % ICD 10 Fail Total: 350 80% 27 6% 46 11% 12 3% 483 51% 465 49% % 51 LET S SUMMARIZE 52 26

RISK ADJUSTMENT IS NOT NEW Some form of Risk Adjustment has been around since 1997. BUT With the arrival of the Affordable Care Act in 2010, there is an increased awareness, because All of the health insurance exchanges require a risk adjustment component for payment. Hence, the increased interest. And then ACOs and APMs MACRA and the MIPS And so on. 53 THE STAKES ARE GETTING HIGHER Organizations are under increasing pressure to get it right Accurate reporting of patient risk scores is paramount OIG Work Plan focus RAC focus Transition from RAPS to EDS The final transition to 100% EDS is 2020 Expected to be a much stricter filter than what is being used today Industry experts believe as much as a 3.5% risk score negative impact for some plans Expected to eliminate RAPS submissions completely 54 27

ENCOUNTER DATA SYSTEM (EDS) Plans will likely transition their focus to encounter data as payment transition evolves Complete and accurate submissions Vendor edits Claim edits Year EDS RAPS 2016 10% 90% 2017 25% 75% 2018* 50% 50% 2019 75% 25% 2020 100% *The 2018 advance notice released on February 1, 2017 proposes to hold the transition in 2018 to 25%/75% 55 SHIFTING FOCUS Under FFS, diagnoses have little meaning related to reimbursement Payment is driven by level of E&M code A diagnosis is included to confirm the medical necessity of services rendered Higher E&M codes mean a more complex encounter with higher level of medical decision making and increased reimbursement Not so in the risk adjustment world where the diagnosis drives reimbursement No real significance related to CPT codes in risk adjustment (at least not currently) omoving away from physician specialty to CPT code driven Diagnosis codes establish the complexity of the patient s health status, medical decision making and ultimately, the reimbursement 56 28

WHAT S IN THE FUTURE? The Crystal Ball tells us Increased use of risk adjustment methodologies at the payer level Increased risk adjusted contracts with providers Risk adjustment refinements at ACO and other APMs Introduction of MIPS (and first data collection period is FFY2017) for providers Implementation of OP CDI programs STAY TUNED.. 57 QUESTIONS? THANK YOU! GINA HOBERT, MBA, CHC, CPC-I, CEMC, CPMA, CRC SENIOR MANAGER GHOBERT@BNNCPA.COM 207/791-7149 58 29