ACOFP 55th Annual Convention & Scientific Seminars. How Complicated is Your Panel? Effective Risk Coding in Primary Care. Alison Mancuso, DO, FACOFP
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1 8 ACOFP 55th Annual Convention & Scientific Seminars How Complicated is Your Panel? Effective Risk Coding in Primary Care Alison Mancuso, DO, FACOFP
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3 How Complicated is Your Panel?: Effective Risk Coding in Primary Care Alison Mancuso DO FACOFP Associate Professor & Vice Chair Residency Program Director RowanSOM Department of Family Medicine Learning Objectives Understand how risk adjusted coding impacts utilization measurement in quality programs Be able to use appropriate risk coding for common chronic conditions in Family Medicine Effectively utilize documentation guidelines in risk coding 1
4 Evolution of Medicine: Recent Past Fee For Service Episodic Care Not focused on Outcomes or Cost Evolution of Medicine: Current 2
5 Evolution of Medicine: Future Attributed Lives Quality Based Payments & Shared Savings Quality and Utilization Goal: HIGHEST QUALITY at lowest cost Some patients legitimately cost more Multiple Comorbidities Rare Diagnoses Cancer Treatment Non-adjusted model: these patients penalize their providers 3
6 Quality and Utilization How Do Carriers Know Patients? Office Visits Hospitals/Facilities Claims Data Radiology Medications/DME Laboratory 4
7 How to Account for a Sicker Panel Our claims = communication of the complexity of the patient with the carrier Carriers will adjust expected cost based on complexity! Risk Adjustment Coding Developed 1997; Implemented 2003 Risk Adjustment & Hierarchical Condition Category (HCC) Utilizes health conditions and demographics to assign a score 9000 ICD-10 codes map to 79 HCC Codes 5
8 Risk Adjustment Factor (RAF) Measure of relative risk of specific patient Demographics + HCC Coefficients (total)+ Disease Interactions = Risk Score (Risk Adjustment Factor) Risk Score (Risk Adjustment Factor) Lower expected cost 1 Higher expected cost 6
9 RAF Example 75 year old female E87.7 Volume Overload (0) E11.9 DM (.102) N18.9 Renal Insufficiency (0) Risk score of year old female I50.22 Chronic left sided systolic congestive heart failure (0.323) E11.22 Type 2 Diabetes with diabetic chronic kidney disease (0.318) N18.4 Chronic Kidney Disease, stage IV (0.237) Risk score of Additional.377 in disease interactions = Documentation Must-Haves Date of Service Patient Name & Date of Birth Evaluation Statement Provider Signature/Credentials Providers must use legible handwriting (if not using EMR) and avoid unusual abbreviations 7
10 Documentation Must-Haves MEAT-C Monitored/Managed Evaluated Addressed/Assessed Treated Considered in Care Documentation Examples Are Present & Stable At Each Visit- Document Conditions that: Are Managed on Therapy Require Observation Require Referral for Management Influence decision making in care 8
11 Documentation Chronic & Active Conditions Document ANNUALLY Note Chronicity & Severity Document associated complications/conditions Forever Codes Document ANNUALLY Examples: Amputation, Transplant, Alcoholism in Remission Maybe Forever : Ostomy, Cirrhosis, Paraplegia/Quadriplegia 9
12 Documentation: History of only appropriate for inactive conditions Examples: Cancer with completion of treatment and no recurrence = History of Cancer Stroke: follow up outside of hospital = History of Stroke Document any known deficits/sequelae as active Combining Codes Diabetic Manifestations Hypertensive Renal Disease Document causal relationship Infections Document type of infection AND organism (if known) 10
13 DIABETES HCC Diabetes (200 ICD-10 Codes) Document status, causal relationships, and treatment plan HCC17: Diabetes with Acute Complications Ketoacidosis, Hyperosmolarity, Coma HCC18: Diabetes with Chronic Complications Nephropathy, Neuropathy, Retinopathy, Peripheral Vascular Disease HCC19: Diabetes without Complications 11
14 Case Example 65 y/o Male with DM and CKD Stage 4 (GFR 28) E11.22: Type II DM with Diabetic Chronic Kidney Disease (0.318) N18.4: Chronic Kidney Disease, Stage IV (0.237) HCC Coefficient: CARDIOVASCULAR DISEASE 12
15 HCC: Arrhythmias Atrial Fibrillation Atrial Flutter Ventricular Fibrillation Sick Sinus Syndrome Document: Persistent vs Paroxysmal Treated or Not HCC: Atherosclerosis Native Coronary Artery Coronary Artery Graft Document: Type Association with Angina (stable v unstable) HCC: Chest Pain Unstable Angina Angina Pectoris with Documented Spasm Document: Treatment and Response 13
16 HCC: Acute Myocardial Infarction ST-Elevation MI (STEMI) Non-ST-Elevation MI (NSTEMI) Document: Date (Acute = 4 weeks) Location Initial vs Subsequent Event HCC: Heart Failure Acute or Chronic/ Systolic or Diastolic Document: Type Cause 14
17 HCC: Cardiomyopathy Most Types HCC: Aneurysm & Dissection Most Types Document: Type Location Cause Diseases Associated with CM Document: Location Ruptured vs Non-Ruptured Non-HCC Cardiovascular Conditions Hypertension Valvular Disease Bradycardia Tachycardia Palpitations These may be associated with other HCC conditions, so they are still important to document 15
18 Always Code Tobacco ICD-10 with Cardiovascular Diseases if applicable RENAL DISEASE 16
19 Renal Disease HCC Dialysis Status Acute Renal Failure CKD Stage IV CKD Stage V Document: Chronicity Cause Stage Requirement for Dialysis or Transplant If CKD and HTN occur together Case Example 72 y/o Female with stable CHF and Renal Impairment now with stable GFR of 27 I50.22 Chronic L-Sided CHF (0.323) N18.4: Chronic Kidney Disease, Stage IV (0.237) HCC Coefficient:
20 Case Example 76 y/o Male with HTN, on Hemodialysis I12.0 Hypertensive CKD with Stage V CKD/ESRD (0.237) Z99.2 Renal Dialysis Status (0.422) HCC Coefficient: CANCERS 18
21 HCC: Active Cancers All Active Cancers have HCC History of do NOT Document: Location Histology/Cell Type (if known) Primary v Secondary Metastatic v in situ Treatment If patient declines treatment or unable to tolerate treatment: active cancer 51 y/o Male three years s/p total prostatectomy for T2N0M0 adenocarcinoma Case Examples 68 y/o Female with Left Sided Breast Cancer, s/p total mastectomy, currently on tamoxifen Z85.46: Personal Hx of Malignant Neoplasm of Prostate (0.0) C50.912: Malignant Neoplasm of Unspecified Site of Left Female Breast (0.146) HCC Coefficient: HCC Coefficient:
22 BEHAVIORAL HEALTH HCC: Behavioral Health Depression Bipolar Disorder Schizophrenia Alcohol Related Disorders Drug-Related Disorders Document: Chronicity Severity Initial vs Recurrence 20
23 45 y/o Female, going to AA, sober for 5 years Case Examples 24 y/o Male, previously treated for depression, with new depressive symptoms F10.21 Alcohol Dependence NOS in Remission (0.383) F33.0: Major Depressive Disorder, Recurrent, Mild (0.395) HCC Coefficient: HCC Coefficient: NEUROLOGIC CONDITIONS 21
24 HCC: Neurologic Conditions Acute Stroke* Acute TIA* TIA and CVA Without Residual Deficits Residual Deficits Document: Residual/Persistent Complications or Deficits * Acute CVA/TIA should only be coded during acute care setting Case Example 88 y/o Female with persistent R sided hemiplegia from CVA 3 years prior I Hemiplegia/hemiparesis affecting right dominant side (0.538) HCC Coefficient:
25 PULMONARY CONDITIONS HCC: Pulmonary Conditions Chronic Obstructive Pulmonary Disease Chronic Obstructive Asthma (not Asthma NOS) Chronic Bronchitis Emphysema Bronchiectasis Document Presence of: Hypoxemia Hypercapnia Acute/Chronic Respiratory Failure Tracheostomy Status O2 Dependence Ventilator Dependence 23
26 Case Examples 75 y/o Male with longstanding COPD J44.9 COPD NOS (0.328) HCC Coefficient: y/o Male with longstanding COPD on chronic oxygen via nasal canula J44.9 COPD NOS (0.328) J96.11 Chronic Respiratory Failure with Hypoxia (0.302) HCC Coefficient: DISEASE INTERACTIONS 24
27 Added to the HCC Coefficient Congestive Heart Failure CHF & CKD (0.226) CHF & COPD (0.186) CHF & DM (0.151) CHF & Arrhythmias (0.103) Cancer & Immune Disorder (0.877) Respirator Dependence & COPD (0.330) Substance Abuse & Psychiatric Disorder (0.187) Conclusions Proper coding for Complexity increases Attributed Risk Increased Attributed Risk improves Utilization Metrics Medicine is moving towards 100% Value Based Care Get credit for the complexity of your panel! Always use best documentation practices! 25
28 Questions 26
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