HCCs & Their Impact on Value- Based Payments

Transcription

1 Health Care

2 HCCs & Their Impact on Value- Based Payments Presented by: Marla Dumm, CPC, CCS-P, CRC Managing Consultant/BKD HFMA Gulf Coast Winter Institute February 11, 2019

3 1 Overview of Risk Adjustment OUR GOALS FOR TODAY 2 Risk adjustment errors to look out for 3 Documentation guidelines 4 Ways to improve HCC documentation & coding 5 Questions & answers 3

4 Overview of Risk Adjustment Risk adjustment is a process used by CMS/HHS that: Reimburses Medicare Advantage (MA) plans based on the health status of their members. Set target prices (benchmarks) for value-based payment programs such as ACOs and Bundled Payments. Established Commercial Risk Adjustment (CRA) for commercial health plans to stabilize premiums and prevent adverse selection The CMS risk adjustment model measures the disease burden of a given population by using 79 HCC categories, which are correlated to diagnosis codes. Hierarchical Condition Categories (HCCs) are a systematic approach to structuring chronic conditions into distinct categories based on the diagnosis codes. The number of HCCs and affected ICD-10 codes can change from year to year

5 Overview of Risk Adjustment For 2019, CMS added the following categories: Drug Abuse, Uncomplicated, Except Cannabis (HCC 56) Reactive and Unspecified Psychosis (HCC 58) The current CY2018 conditions that mapped to HCC 58 will be renumbered to 59 for CY2019 Personality Disorders (HCC 60) Chronic Kidney disease, Moderate (Stage 3) (HCC 138) Selected Drug and Alcohol poisoning (overdose) (HCC 55) Conditions coded to existing drug/alcohol dependence or abuse/use with complications

6 Overview of Risk Adjustment 70,000+ ICD-10 codes 805 Diagnostic groups 189 Total Condition Categories 79 Hierarchical Condition Categories in current payment model

7 Overview of Risk Adjustment CMS created this system so that patients conditions are coded for the most severe manifestation among related diseases. For example, there are more than a dozen diagnoses that will lead to a heart failure HCC, but payment will only be made for one. There is a trumping logic for related diseases, so that if the patient has metastatic cancer, the provider won t also get payment for the patient s colon cancer. However many HCCs you have, payment is made for the highest of them. For unrelated diseases, HCCs accumulate, so patients can have more than one HCC attributed to them. For example: the physician documents that a male patient suffers from heart disease, stroke, and cancer. Each of those diagnoses maps to a separate HCC. CMS will factor all three HCCs in when making a payment to the MA plan. Some diagnoses reported together such as congestive heart failure and diabetes will generate a higher Risk Adjustment Factor (RAF) value, resulting in higher payments. Not all diagnoses map to an HCC, however, so they will not generate a higher value.

8 Overview of Risk Adjustment Each patient has a RAF score (calculated annually) which impacts reimbursement prospectively. Age, Sex & OREC HCC Codes RAF OREC = Original Reason for Entitlement Code (old age and survivors insurance, disability benefits, end stage renal disease, or combinations)

9 Overview of Risk Adjustment

10 Overview of Risk Adjustment

11 Overview of Risk Adjustment If coding is not to highest specificity, aggregated HCC codes will not capture full risk burden & expected costs If disease burden is under represented, RAFs, financial benchmarks & Per Member Per Month (PMPM) payments will be lower Lower benchmarks make it more difficult to achieve cost savings in shared savings programs Medicare Advantage plans will review HCC scores to determine acuity of patients seen by practices

12 Overview of Risk Adjustment All Conditions Coded Accurately Some Conditions Coded Accurately No Conditions Coded 76 year old female year old female year old female Medicaid eligible Medicaid eligible Medicaid eligible Diabetes w/ vascular complications Diabetes w/o vascular complications Diabetes w/o vascular complications Vascular disease w/ complications Vascular disease w/o complications Vascular disease w/o complications CHF CHF CHF Disease Interaction (CHF + DM) Disease Interaction (CHF + DM) Disease Interaction (CHF + DM) Total RAF Total RAF 1.15 Total RAF PMPM Payment $1,873* PMPM Payment $863* PMPM Payment $484* Annual Payment $22,473 Annual Payment $10,350 Annual Payment $5,805 *PMPM assumed at $750 per month Calculation: Total RAF * PMPM = Adjusted Monthly Payment for beneficiary

13 Overview: HCC Rationale RADV Audit

14 Overview: HCC Rationale

15 Overview: HCC Rationale

16 Top HCC Risk Adjustment Errors: Documentation Medical record does not contain legible signature or authentication Discrepancy exists between diagnosis codes & written description Documenting breast cancer post treatment, in remission (Z85.3)(HCC weight 0) but coding acute breast cancer upper inner quadrant, right, female (C50211)(HCC weight 12) Documenting very obese (E66.9) (HCC weight 0) instead of morbidly obese (E66.01)(HCC weight 22) Medical record does not indicate diagnosis is being monitored, evaluated, addressed or treated (MEAT) Documentation does not reflect a face-to-face encounter with an eligible provider (i.e., physician, non-physician practitioner)

17 Top HCC Risk Adjustment Errors: Coding Highest degree of specificity not assigned to most precise ICD-10 code to fully reflect narrative description of the symptom/diagnosis in chart History of coding used when the condition is still active TIP: Provider education may be required on use of history of language for active or chronic conditions Examples: Coding Asthma (J45.909)(HCC weight 0) instead of Chronic Obstructive Asthma (J44.9)(HCC weight 111) Coding for history of COPD (Z87.09)(HCC weight 0) instead of COPD controlled with Advair (J44.9)(HCC weight 111)

18 HCC Risk Adjustment Coding Errors: False Claims Liability Actions The United States Department of Justice released news of a $270 million repayment agreement with HealthCare Partners Holdings, LLC (d/b/a DaVita Medical Holdings) on October 1, 2018 The organization disclosed that internal coding policies and provider education were implemented that resulted in improper diagnosis code assignment for a particular spinal condition that obtained inflated payments for the organization The organization also inappropriately captured historical diagnoses in order to increase Medicare payments This action resulted in an inaccurate mapping of risk scores and associated risk adjustment factor calculations by the managed care plan Source: Department of Justice Office of Public Affairs, Justice News, Monday, October 1, 2018, Medicare Advantage Provider to Pay $270 Million to Settle False Claims Act Liabilities

19 Top HCC Risk Adjustment Errors: Chronic, Active Conditions Status of primary or metastatic cancer Lack of documentation of chronic for conditions such as renal insufficiency Coexisting or comorbidity conditions not documented or left out of clinical documentation A link or casual relationship not documented resulting in failure to capture mandatory manifestation code Example chronic, active conditions to be coded annually: Diabetes Amputations Transplants HIV CHF COPD Beware of the CMS annual Miracle Cure. Risk adjustment is reset each year, so chronic conditions not reported are considered cured. Diagnoses actively managed need to make it onto a claim so CMS is notified.

20 Documentation & Coding Guidelines Coders will look for MEAT to support the diagnosis Monitor Signs, symptoms, disease progression/regression Evaluate Test results, medication effectiveness, response to treatment Assess/Address Treat Ordering tests, discussion, counseling, review records Medications, therapies, other modalities Coding diagnoses to highest specificity leads to most accurate severity of illness and higher RAF scores

21 Documentation & Coding Guidelines The presenting diagnosis should not be the only diagnosis on a claim when capturing HCC eligible conditions ICD guidelines state to also code for other comorbidities during each encounter (if documented) Medicare guideline: Code all documented conditions which coexist at the time of the visit that require or affect patient care or treatment The Treatment Plan should link conditions to medications DO NOT code conditions previously treated, but no longer exist DO NOT code conditions that are differential or being ruled out

22 Ways to Improve Documentation & Coding Provider Engagement Initiatives Proactive education around HCCs Provider involvement in problem list & other form development Care plan review Embed HCC Management Tools in Workflows Accessible to providers at point of care Goal is to allow for informed decision making without additional clicks Aids providers in productivity without sacrificing efficiency

23 Ways to Improve Documentation & Coding: Problem Lists Patient Problem Lists Include diagnoses for each patient encounter Support care, documentation, billing & HCC scoring Documentation Compliance Avoid auto-population Keep up-to-date & comprehensive for every patient TIP: Categorize current, active conditions versus resolved or historical signs, symptoms or conditions to avoid improper reporting Re-document chronic conditions every 12 months

24 Ways to Improve Documentation & Coding: Problem Lists CMS instructs: Evaluate the conditions listed in a problem list against medical record documentation for consistency on a case by case basis Do not report pertinent negatives or resolved conditions Lists of ICD10 codes are not acceptable Lists documented by the patient are not acceptable Problem lists without clear dates are not accepted HCC Coding Tip: Validation should be performed prior to assigning ICD-10 codes directly from problem lists Source: Centers for Medicare & Medicaid Services (CMS), Contract-Level Risk Adjustment Data Validation Medical Record Reviewer Guidance

25 Ways to Improve Documentation & Coding: HCC Scoring Audits Baseline HCC Capture Data Audit previous year s billing & documentation to identify potential gaps Helps to identify HCC opportunity & engage stakeholders, as needed

26 HCC Scoring Audit Overview Samples from each provider obtained & reviewed Patient medical records Provider documentation Billing records Baseline HCC score for each patient & provider identified Certified coding staff identify opportunities for HCC scoring & overall coding improvement opportunities HCC score impact FFS revenue impact Report back to practice outlining findings, recommendations & impact to HCC scores & revenue

27 Valuable HCC Links CMS 2017 Risk Adjustment Fact Sheet Payment/PhysicianFeedbackProgram/Downloads/2015- RiskAdj-FactSheet.pdf CMS Risk Adjustment Methodology White Paper Other-Resources/Downloads/RA-March-31-White-Paper pdf CMS General Risk Adjustment Information Plans/MedicareAdvtgSpecRateStats/Risk-Adjustors.html

28 References The American Journal of Managed Care, Vol. 24, No.1, Electronic Health Record Problem Lists: Accurate Enough for Risk Adjustment?, Timothy J. Daskivich, MD, MSHPM, Geren Abedi, MD, MS, Sherrie H. Kaplan, PhD, MPH, Douglas Skarecky, BS, Thomas Ahlering, MD, Brennan Spiegel, MD, MSHS, Mark S. Litwin, MD, MPH, and Sheldon Greenfield, MD American Academy of Professional Coders (AAPC), Top 10 Medicare Risk Adjustment Coding Errors, Carol Olson, CPC, CPC-H, CPC-I, CEMC, CCS, CCS-P, CCDS ICD10 Monitor, May 22, 2018, CMS Issues RADV Blueprint for Handling Flawed Documentation, Sheri Poe Bernard, CCS-P, CPC, CRC, CDEO Becker s Hospital CFO Report, 10 Most Common Medicare Risk Adjustment Coding Errors, April 15, 2013 Centers for Medicare & Medicaid Services (CMS), Contract-Level Risk Adjustment Data Validation Medical Record Reviewer Guidance Adjustment-Data-Validation-Program/Other-Content-Types/RADV-Docs/Coders-Guidance.pdf CMS, Advance Notice of Methodological Changes for Calendar Year (CY) 2019 for the Medicare Advantage (MA) CMS-HCC Risk Adjustment Model, December 27, 2017

29 Questions?

30 Thank You!

31 For more information: Marla Dumm// Managing Consultant // //