MIPS TIPS What is HCC and How Does It Impact the MIPS Cost Category? Oct. 25, 2018
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1 MIPS TIPS What is HCC and How Does It Impact the MIPS Cost Category? Oct. 25, 2018 Presented by HealthInsight and Mountain Pacific Quality Health Tina Morishima, CPC, Mountain-Pacific Practice Consultant Cathy Nelson, RN, Mountain-Pacific Practice Consultant
2 HealthInsight Our business is redesigning health care systems for the better HealthInsight is a private, non-profit, community based organization dedicated to improving health and health care in the western United States.
3 Mountain-Pacific Quality Health We are the Medicare Quality Innovation Network-Quality Improvement Organization (QIN-QIO) for Montana Guam Wyoming American Samoa Hawaii The Commonwealth of the Alaska Northern Mariana Islands
4 Network for Regional Healthcare Improvement HealthInsight and Mountain-Pacific Quality Health are providing support to practices as subcontractors to NRHI, the Network for Regional Healthcare Improvement.
5 Slide Deck Available Today s slide deck and recording will be made available a few days following the event. Watch your to be notified when they are available or visit to find all past MIPS Tips and QPP webinar recordings.
6 Our Presenters Cathy Nelson, RN Tina Morishima, CPC
7 Polling Question Do you know what HCC and RAF is? Yes No
8 Agenda What are HCCs and RAFs? Case Scenario Describe the MIPS Cost Category Describe how HCCs relate to the MIPS Cost Category measures Total Per Capital Cost Medicare Spending Per Beneficiary
9 Terminology CMS - Centers for Medicare & Medicaid Services HCC - Hierarchical Condition Categories, chronic conditions used to create a risk adjustment methodology RxHCC Some HCC codes adjust risk due to prescription burden of disease RAF Risk Adjustment Factor, assessing the acuity of illness based upon reported ICD-10 codes and demographics ICD-10 International Classification of Diseases, volume 10 MIPS Merit-based Incentive Payment System TPCC Total Per Capita Costs for all attributed beneficiaries MSPB Medicare Spending Per Beneficiary
10 HCC
11 What is HCC? Hierarchical Condition Categories (HCC) Chronic conditions used to create a risk adjustment methodology RxHCC Some HCC codes adjust risk due to prescription burden of disease There are 79 HCC codes in risk adjustment There are over 70,000 ICD-10 CM codes 9,000 ICD-10 map to 79 HCC codes in the risk adjustment model Creates a RAF score for each eligible beneficiary that reflects patient s health conditions
12 Hierarchical Condition Categories 79 Condition Categories examples Diabetes DM with complications HCC 17, 18 Vascular Peripheral vascular disease (PVD) HCC 108 Psychiatric Major depression disorder HCC 58 Kidney Chronic kidney disease, stage 4 (CKD) HCC 137 Substance Abuse Alcohol/Opioid dependence HCC 55
13 What is RAF? Risk adjustment factor is a numeric value assigned by CMS to identify the health status of a beneficiary/enrollee Risk adjustment score is determined by using a combination of demographic information along with disease information to predict future healthcare cost for enrollees Demographic Age, gender, Medicaid status, disability, geography, institutional living status Diseases Diagnoses submitted by providers PCPs, Specialists, Ancillaries, Hospitals, SNFs. PTs etc. CMS requires that a qualified health care provider identify all conditions that may fall within an HCC at least once, each calendar year Risk scores reset each year
14 Interpreting the Risk Adjustment Factor RAF score identifies patient s health status Low RAF score may indicate a healthier population High RAF score may indicate members with increased health risks OR Low RAF score may falsely indicate a healthier population due to: Incomplete and/or inaccurate ICD-10 CM coding Diagnoses are under reported Patients who were not seen annually High RAF score may be inflated due to: Reported diagnoses not documented Over coding (i.e. copying and pasting problem list into assessment and plan)
15 Case Scenario Example 76-year old female Medicaid eligible Diabetes Vascular disease Congestive heart failure Demographics (Age/Sex) High Risk Chronic Conditions Total RAF 1.862
16 RAF Coding Example No condition coded RAF Some conditions coded RAF All conditions coded RAF 76 year old female year old female year old female Medicaid eligible Medicaid eligible Medicaid eligible Diabetes with complications X DM without complications DM with complications Vascular disease X Vascular disease X Vascular disease Congestive heart failure X CHF X CHF isease interaction (DM+CHF) X Disease interaction (DM+CHF) X Disease interaction (DM+CHF) Total RAF Total RAF Total RAF 1.862
17 Patient Care Good documentation = Good patient care
18 HOW IS HCC AND RAF RELATED TO CMS QUALITY PROGRAMS?
19 History 2004 Developed 2013 Value Modifier Program 2017 MIPS Cost Category
20 HCC and RAF: Essential in Today s Payment Models Characterizes Risk Provides patient-centered care Enhances shared savings
21 Overview of the MIPS Cost Category Weighted at 10 percent of your final MIPS score in 2018, 15 percent in 2019 and up to 30 percent by the 2022 performance year Two measures in performance year 2018 Total per capita cost per beneficiary (TPCC) Medicare Spending per beneficiary (MSPB) Performance year 2019 will add episode based measures CMS calculates cost by administrative claims data, rather than provider submitted data Important to understand how CMS uses claims data to calculate your performance in this category to have an impact on your final cost score.
22 Medicare Spending Per Beneficiary Medicare Spending Per Beneficiary (MSPB). This measure includes Medicare Part A and Part B claims submitted for services from three days prior to 30 days after an inpatient hospitalization and attributes all of these costs to the physician with the most (plurality of) Part B charges during the period from the patient s inpatient admission to discharge date.
23 Calculation of MSPB
24 MSPB Calculation Example Sum of Ratio = Payment-standardized observed Expected MSPB Costs HCCs incorporated in Expected Costs
25 RAF Coding Example No condition coded RAF Some conditions coded RAF All conditions coded RAF 76 year old female year old female year old female Medicaid eligible Medicaid eligible Medicaid eligible Diabetes with complications X DM without complications DM with complications Vascular disease X Vascular disease X Vascular disease Congestive heart failure X CHF X CHF isease interaction (DM+CHF) X Disease interaction (DM+CHF) X Disease interaction (DM+CHF) Total RAF Total RAF Total RAF 1.862
26 Total Per Capita Cost (TPCC) Total Per Capita Cost (TPCC). The TPCC measure is a measure of all Medicare Part A and Part B costs for patients attributed to the individual clinician with the most allowed charges for E&M services other than inpatient hospital, emergency department, and skilled nursing visits during the 2018 performance period.
27 Calculation of TPCC
28 Example Calculation for TPCC HCC/RAF are incorporated in Expected Cost calculation
29 Scoring the Cost Performance Category Must meet or exceed the case minimum for the cost measure TPCC=20 MSPB=35 If only one can be scored, the score is equally weighted average of the scored measures If neither measure can be scored, reweighted to quality category
30 Summary HCC coding is an accurate representation of the patient s health status The cost category weight is increasing and will have a greater impact year to year Cost category is the hardest to change and least understood. HCC brings more clarity to the health care system and helps bring reimbursement in line with quality and value
31 Resources Cost Performance Category Fact Sheet MIPS Total Per Capita Cost for All Attributed Beneficiaries MIPS Medicare Spending Per Beneficiary
32 How to Ask a Question
33 Questions This material was prepared by HealthInsight, the Medicare Quality Innovation Network-Quality Improvement Organization for Nevada, New Mexico, Oregon and Utah, under contract with the Centers for Medicare & Medicaid Services (CMS), an agency of the U.S. Department of Health and Human Services. The contents presented do not necessarily reflect CMS policy. 11SOW- D
34 Please Fill Out Our Evaluation An evaluation link for this session is currently being place in the chat. Please take a few minutes before you leave the meeting today to fill out an evaluation and help us improve our offerings.
35 Assessment Get customized support for your practice by filling out a short assessment HealthInsight: Mountain-Pacific:
36 CMS Learning Modules CMS has created several learning modules aimed at helping you understand and succeed in the QPP program. You can find those modules here:
37 For More Information Contact a QPP Expert in Your State Mountain-Pacific Quality Health Please contact us for assistance! QualityPaymentHelp@mpqhf.org Montana Amber Rogers arogers@mpqhf.org (406) Wyoming Brandi Wahlen bwahlen@mpqhf.org (307) Alaska Preston Groogan pgroogan@mpqhf.org (907) Region/Senior Account Manager Sharon Phelps sphelps@mpqhf.org (307) Hawaii and Territories Cathy Nelson cnelson@mpqhf.org (808) Visit us online at
38 For More Information Contact a QPP Expert in Your State HealthInsight QPP Support Call: qpp@healthinsight.org Web: Nevada Aaron Hubbard Call: ahubbard@healthinsight.org New Mexico Ryan Harmon Call: rharmon@healthinsight.org Oregon Seema Rathor Call: srathor@healthinsight.org Utah Sandra DeBry Call: sdebry@healthinsight.org
39 HealthInsight and Qualis Health In April 2018, HealthInsight and Qualis Health announced a formal merger, combining the two organizations and operations across the U.S. Both HealthInsight and Qualis Health have been engaged in health care quality consulting and providing quality improvement services for more than 40 years. If you are a practice in Washington or Idaho and are seeking QPP support please contact: Idaho Deanna Graham Call: deannag@qualishealth.org Washington Jeff Sobotka Call: jeffs@qualishealth.org
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