ICD-10: Don t Let Risk Adjustments Be An Afterthought

Transcription

1 1 ICD-10: Don t Let Risk Adjustments Be An Afterthought Tuesday, October 28, :30-2:30PM PST Presented by: Kim Browning, CHRS, PMP, CHC Executive Vice President, Cognisight, LLC Barb Nutting, RHIT, CCS-P Health Information Director, PACE CNY

2 Today s Agenda ICD-9 to ICD-10 Heat Map Analysis 2 Top 20 HCCs- 3 Different Cuts of Data o o PACE Combined Data for 10 PACE Plans (approx. 40% of PACE participant population) & PACE CNY Specific Data HCCs in the top 20 of at least 2 of the 3 categories Provider and Coder Engagement What PACE CNY is Already Doing to Prep for ICD-10 How PACE CNY Worked the Top 20 s into Their Current ICD-10 Training How PACE CNY gets their Providers Engaged in this Training How Can PACE Programs Use Their Data to Determine Their Top 20 s? Lessons Learned Questions?

3 ICD-9 to ICD-10 Heat Map Analysis (PACE CNY Data) 3 ICD9 to ICD10 ICD9 mapping to ICD10 ICD10 based on ICD9 history ICD10 count based on ICD9 history 2% 21% ICD9 codes that map directly to one ICD10 18%* ICD10 codes that may map to HCC 77% ICD9 codes that map to multiple ICD10 82% ICD10 codes that may not map to current HCC model ICD9 codes that map to no ICD10 *20-25% of all ICD-9 codes currently map to an HCC

4 Top 20 HCCs 4 Top 20 HCCs - 3 Different Cuts of Data Highest Volume/Prevalence in Participants Highest HCC Factor Value Highest Total RAF Weight

5 HCCs that have the Most Volume/Prevalence among PACE participants 5 PACE Combined Data PACE CNY Data 73% HCC HCC Description Members Value Total RAF Weight % of total 108 Vascular Disease % 1 52 Dementia Without Complication % 2 18 Diabetes with Chronic Complications % 3 85 Congestive Heart Failure % 4 51 Dementia With Complications % 5 Top Chronic Obstructive Pulmonary Disease % 6 Major Depressive, Bipolar, and Paranoid 58 Disorders % Chronic Kidney Disease, Moderate (Stage 3) % 8 96 Specified Heart Arrhythmias % 9 75 Polyneuropathy % Hemiplegia/Hemiparesis % Diabetes without Complication % 12 Chronic Kidney Disease, Mild or Unspecified 139 (Stages 1-2 or Unspecified) % Acute Renal Failure % Seizure Disorders and Convulsions % Cardio-Respiratory Failure and Shock % Protein-Calorie Malnutrition % Other Significant Endocrine and Metabolic Disorders % Coagulation Defects and Other Specified Hematological Disorders % Ischemic or Unspecified Stroke % 20 HCC HCC Description Membe rs Valu e Total RAF Weight % of Total 138 Chronic Kidney Disease, Moderate (Stage 3) % Chronic Obstructive Pulmonary Disease % 2 18 Diabetes with Chronic Complications % 3 85 Congestive Heart Failure % 4 96 Specified Heart Arrhythmias % Vascular Disease % 6 52 Dementia Without Complication % 7 51 Dementia With Complications % 8 Chronic Kidney Disease, Mild or Unspecified 139 (Stages 1-2 or Unspecified) % 9 75 Polyneuropathy % Morbid Obesity % Cardio-Respiratory Failure and Shock % Hemiplegia/Hemiparesis % Acute Renal Failure % 14 Pressure Ulcer of Skin with Partial Thickness 159 Skin Loss % Seizure Disorders and Convulsions % 16 Other Significant Endocrine and Metabolic 23 Disorders % Parkinson's and Huntington's Diseases % 18 Atherosclerosis of the Extremities with 106 Ulceration or Gangrene % Angina Pectoris % 20 Top 20

6 HCCs with the Highest HCC Factor Value 6 PACE Combined Data PACE CNY Data 30% HCC HCC Description Membe Value rs Total RAF % of total Top 20 HCC HCC Description Memb ers Value Total RAF % of Total Top 20 8 Metastatic Cancer and Acute Leukemia % 1 82 Respirator Dependence/Tracheostomy Status % 2 Atherosclerosis of the Extremities with Ulceration 106 or Gangrene % 3 46 Severe Hematological Disorders % 4 70 Quadriplegia % Pressure Ulcer of Skin with Full Thickness Skin Loss % Pressure Ulcer of Skin with Partial Thickness Skin Loss % Pressure Pre-Ulcer Skin Changes or Unspecified Stage % Pressure Ulcer of Skin with Necrosis Through to Muscle, Tendon, or Bone % Major Organ Transplant or Replacement Status % 10 Amyotrophic Lateral Sclerosis and Other Motor 73 Neuron Disease % 11 9 Lung and Other Severe Cancers % End-Stage Liver Disease % Paraplegia % 14 Amputation Status, Lower Limb/Amputation 189 Complications % Respiratory Arrest % Lymphoma and Other Cancers % Aspiration and Specified Bacterial Pneumonias % Protein-Calorie Malnutrition % 19 8 Metastatic Cancer and Acute Leukemia % 1 Atherosclerosis of the Extremities with 106 Ulceration or Gangrene % 2 46 Severe Hematological Disorders % 3 70 Quadriplegia % Pressure Ulcer of Skin with Necrosis Through to Muscle, Tendon, or Bone % Pressure Ulcer of Skin with Full Thickness Skin Loss % Pressure Ulcer of Skin with Partial Thickness Skin Loss % Pressure Pre-Ulcer Skin Changes or Unspecified Stage % 8 73 Amyotrophic Lateral Sclerosis and Other Motor Neuron Disease % 9 9 Lung and Other Severe Cancers % End-Stage Liver Disease % Paraplegia % 12 Amputation Status, Lower 189 Limb/Amputation Complications % Respiratory Arrest % Lymphoma and Other Cancers % 15 Aspiration and Specified Bacterial 114 Pneumonias % Protein-Calorie Malnutrition % Dialysis Status % Acute Renal Failure % Dementia With Complications % 20

7 HCCs with the Highest Total RAF Weight 7 PACE Combined Data PACE CNY Data 76% HCC HCC Description Membe Value Total rs RAF % of total 51 Dementia With Complications % 1 52 Dementia Without Complication % 2 85 Congestive Heart Failure % 3 18 Diabetes with Chronic Complications % Vascular Disease % 5 Top Chronic Obstructive Pulmonary Disease % 6 Major Depressive, Bipolar, and Paranoid 58 Disorders % Hemiplegia/Hemiparesis % 8 96 Specified Heart Arrhythmias % Acute Renal Failure % Polyneuropathy % Chronic Kidney Disease, Moderate (Stage 3) % Protein-Calorie Malnutrition % 13 Pressure Ulcer of Skin with Partial Thickness 159 Skin Loss % 14 8 Metastatic Cancer and Acute Leukemia % 15 Septicemia, Sepsis, Systemic Inflammatory 2 Response Syndrome/Shock % Parkinson's and Huntington's Diseases % Atherosclerosis of the Extremities with Ulceration or Gangrene % Pressure Pre-Ulcer Skin Changes or Unspecified Stage % Pressure Ulcer of Skin with Full Thickness Skin Loss % 20 HCC HCC Description Membe rs Valu e Total RAF % of Total 51 Dementia With Complications % Chronic Obstructive Pulmonary Disease % 2 85 Congestive Heart Failure % 3 18 Diabetes with Chronic Complications % 4 52 Dementia Without Complication % Pressure Ulcer of Skin with Partial Thickness Skin Loss % Atherosclerosis of the Extremities with Ulceration or Gangrene % Vascular Disease % Chronic Kidney Disease, Moderate (Stage 3) % 9 96 Specified Heart Arrhythmias % Acute Renal Failure % 11 Pressure Ulcer of Skin with Full Thickness 158 Skin Loss % Polyneuropathy % Hemiplegia/Hemiparesis % 14 Chronic Kidney Disease, Mild or Unspecified 139 (Stages 1-2 or Unspecified) % Morbid Obesity % Parkinson's and Huntington's Diseases % Cardio-Respiratory Failure and Shock % Septicemia, Sepsis, Systemic Inflammatory Response Syndrome/Shock % 19 Rheumatoid Arthritis and Inflammatory Connective Tissue Disease % 20 Top 20

8 Top 20 HCCs Continued 8 Top 20 HCCs- 3 Different Cuts of Data You ll need to react to all 3 in order to maximize your results.

9 3 Different Cuts of Data Recap (PACE CNY Data) 9 We have identified the Top 20 HCCs in all 3 Categories Highest Volume/Prevalence in Participants = 73% of risk factor Highest HCC Factor Value = 30% of risk factor Highest total RAF Weight= 76% of risk factor

10 HCCs in Top 20 of at least 2 of the 3 categories (PACE CNY Data) 10 HCC HCC Description Patients Value Total RAF Top 20 Total RAF Top 20 HCC Value Top 20 Patients 51 Dementia With Complications Chronic Obstructive Pulmonary Disease Congestive Heart Failure Diabetes with Chronic Complications Dementia Without Complication Pressure Ulcer of Skin with Partial Thickness Skin Loss Atherosclerosis of the Extremities with Ulceration or Gangrene Vascular Disease Chronic Kidney Disease, Moderate (Stage 3) Specified Heart Arrhythmias Acute Renal Failure Pressure Ulcer of Skin with Full Thickness Skin Loss Polyneuropathy Hemiplegia/Hemiparesis Chronic Kidney Disease, Mild or Unspecified (Stages 1-2 or Unspecified) Morbid Obesity Parkinson's and Huntington's Diseases Cardio-Respiratory Failure and Shock

11 Provider and Coder Engagement 11 To be successful, provider and coder engagement is mission critical If your providers aren t documenting properly you will lose traction with your clinical profiling and corresponding reimbursement In addition, your coders will also need to be well versed with the ICD-10 codes in order to capture what the providers are documenting

12 What PACE CNY Is Already Doing To Prep For ICD Hired two reimbursement positions credentialed coders Completed ICD-10 training for all coding staff o Training started taking place prior to change in ICD-10 deadline Where do we have diagnoses data stored already? Worked with various software vendors (EMR, finance, etc.) are they ready for testing? Provider queries based on increased ICD-10 documentation requirements.

13 How PACE CNY Worked The Top 20 s Into Their Current ICD-10 Training 13 Shared the data analysis with our Medical Director to get buyin for training objectives Comparing highest HCC volume and highest HCC value reports against data from PDAC (PACE Data Analysis Center) what participants have those HCCs? Focusing on those participant records first is the documentation sufficient for increased ICD-10 requirements?

14 How PACE CNY Worked The Top 20 s Into Their Current ICD-10 Training (cont.) 14 PACE CNY Raw Data - Top 20 HCC's Based on Prevalence HCC HCC Description Patients Value Top Chronic Kidney Disease, Moderate (Stage 3) Chronic Obstructive Pulmonary Disease Diabetes with Chronic Complications Congestive Heart Failure Specified Heart Arrhythmias Vascular Disease Dementia Without Complication Dementia With Complications Chronic Kidney Disease, Mild or Unspecified (Stages 1-2 or Unspecified) Polyneuropathy Morbid Obesity Cardio-Respiratory Failure and Shock Hemiplegia/Hemiparesis Acute Renal Failure Pressure Ulcer of Skin with Partial Thickness Skin Loss Seizure Disorders and Convulsions Other Significant Endocrine and Metabolic Disorders Parkinson's and Huntington's Diseases Atherosclerosis of the Extremities with Ulceration or Gangrene Angina Pectoris

15 How PACE CNY Worked The Top 20 s Into Their Current ICD-10 Training (cont.) 15 PACE CNY Raw Data - Top 20 HCC's Based on HCC Factor Value HCC HCC Description Patients Value Top 20 8 Metastatic Cancer and Acute Leukemia Atherosclerosis of the Extremities with Ulceration or Gangrene Severe Hematological Disorders Quadriplegia Pressure Ulcer of Skin with Necrosis Through to Muscle, Tendon, or Bone Pressure Ulcer of Skin with Full Thickness Skin Loss Pressure Ulcer of Skin with Partial Thickness Skin Loss Pressure Pre-Ulcer Skin Changes or Unspecified Stage Amyotrophic Lateral Sclerosis and Other Motor Neuron Disease Lung and Other Severe Cancers End-Stage Liver Disease Paraplegia Amputation Status, Lower Limb/Amputation Complications Respiratory Arrest Lymphoma and Other Cancers Aspiration and Specified Bacterial Pneumonias Protein-Calorie Malnutrition Dialysis Status Acute Renal Failure Dementia With Complications

16 How PACE CNY Gets Their Providers Engaged In This Training 16 Medical Director Buy In!!! Existing monthly provider meetings HCC of the Month Started individual meetings between providers and reimbursement staff Track and trend provider queries provide reports broken down by provider and by type

17 Coding Definitions of Chronic Kidney Disease Staging Chronic kidney disease, stage I Some kidney damage; normal or slightly increased GFR (>90) Reimbursement staff will not query for this condition Chronic kidney disease, stage II Kidney damage with mild decrease in GFR (60-89) Chronic kidney disease, stage III Kidney damage with moderate decrease in GFR (30-59) Chronic kidney disease, stage IV Kidney damage with severe decrease in GFR (15-29) Reimbursement staff will query for diagnosis of hyperparathyroidism, either primary or secondary to renal disease. The diagnosis of hyperparathyroidism will add an additional HCC weight of Chronic kidney disease, stage V Kidney failure with GFR value of less than 15. Reimbursement staff will query for diagnosis of hyperparathyroidism, either primary or secondary to renal disease. End stage renal disease Chronic kidney disease requiring chronic dialysis Reimbursement staff will query for dialysis status if documentation is not present Documentation of dialysis status will add an additional HCC weight of Things/documentation to remember with CKD Interpretation of stages based on GFR results are different for African-American individuals. There needs to be linkage between the CKD diagnosis and certain other diagnoses when present (i.e. HTN, diabetes). Even if there are no interventions around the CKD (participant is on end-of-life, CKD is a lower stage) the diagnosis still needs to be assessed at least every 6 months at the reassessment along with the other chronic conditions. Reimbursement staff will query for changes in stages for accurate assignment of diagnoses codes. 17

18 Hemiparesis/Hemiplegia HCC model category 100 =.437 weight For Risk Adjustment it s important to document all of the patients chronic conditions during his/her initial, annual and six month reassessment visits. A chronic condition that has health implications but may be over looked is hemiplegia or hemiparesis. Being as specific as possible about the participants condition in your documentation is key. Diagnoses in the assessment should be written clearly so the coders can match them with the correct ICD-9 code. Here are a few things to remember when documenting hemiplegia/hemiparesis: 1. Does the condition affect the dominant side of the participant? 2. Is the condition due to a previous CVA? 3. Is the condition due to an old spinal cord injury etc? 4. It is not enough to list in the condition Past Medical History alone, you must also document the condition in the Assessment and Plan as well as state the status and any treatment directed at the condition. Examples of appropriate documentation for hemiplegia/hemiparesis: Hemiplegia of dominant side due to previous CVA, stable. ICD-9 code , (HCC 100), weight.437 Hemiparesis due to old spinal cord injury, stable. ICD-9 code (HCC 100),.437 If it wasn t documented it wasn t done. 18

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20 Query Reason Statistics

21 How Can PACE Programs Use Their Data To Determine Their Top 20 s? To Determine Top 20 HCCs Based on Prevalence & Weight: Find the community weights for each HCC in the 2012 Announcement o Plans/MedicareAdvtgSpecRateStats/Announcements-and- Documents.html 21

22 How Can PACE Programs Use Their Data To Determine Their Top 20 s? (cont.) 22 Find the number of members with each HCC from the Part C Risk Adjustment Model Output Data (MODD) or Part C Risk Adjustment Model Output Report (MODR) o The Model Output Data file layout is contained in the Plan Communication User Guide (PCUG) Appendices: Systems/CMS-Information- Technology/mapdhelpdesk/Plan_Communications_User_Guide. html Screenshots on next 2 pages

23 How Can PACE Programs Use Their Data To Determine Their Top 20 s? (cont.) You need your Model Output Data (MODD): (Screenshot): 23 Recommendation: convert to excel and label columns fastest way to get to prevalence

24 How Can PACE Programs Use Their Data To Determine Their Top 20 s? (cont.) You also need your Part C Risk Adjustment Model Output Report (MODR): (Screenshot): Participant 1 24 Participant 2 HCCs

25 How Can PACE Programs Use Their Data To Determine Their Top 20 s? (cont.) Now that you have the data: 25 Step 1: to determine prevalence: find the total numbers of HCCs; sort in descending order Step 2: to determine HCC factor value: Take HCCs that apply to your participants; include the applicable HCC factor values (weights); sort in descending order Step 3: to determine the highest RAF weight: take the number of participants with HCCs x HCC weights; sort in descending order Please note, the analysis does not include participants with institutional status, interactions or disease/disabled interactions

26 Lessons Learned 26 Keep HCC information for providers brief just what they need to know to improve Data is in many places be familiar with all of your databases data can be anywhere!

27 Questions 27 Kim Browning, CHRS, PMP, CHC Executive Vice President, Cognisight, LLC Barb Nutting, RHIT, CCS-P Health Information Director, PACE CNY Thank you!