ACO/HCC/Coding Presentation

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1 ACO/HCC/Coding Presentation Prepared by Kristin & Sheree Date 5/15/2013

2 CMP ACO Background CMP is participating in the Medicare Shared Savings ACO program (Track 1) which is a 3 year agreement With Track 1 we will have an opportunity to share in savings achieved up to 50%, no penalty if no savings, we need to show 2.5% savings to be able to share those savings The 33 Quality Measures in the ACO metrics determines the % of savings we can share, for Performance Year 1 (PY1) CMS is only looking for us to report those measures, for PY2 some of those measures will be moved to pay for performance Our budget is determined by claims data for Medicare patients attributed to our ACO for the last 3 years which is the CMS-HCC (Hierarchical Condition Category) model

3 Changes to the Payment Model CURRENT: Fee For Service (FFS)- getting paid for each service you perform and bill for regardless of any clinical outcomes CURRENT CMS : Hierarchical Condition Category (HCC) Model that uses beneficiary demographic characteristics and prior year diagnoses (from fee for service (FFS) claims data) to determine program payments FUTURE: Prospective Payment model that will affect all lines of payment. This model uses prior year data to predict future costs Payment is based on formula calculation: CMS Approved base rate X factors associated with HCCs X factors associated with members demographics

4 Hierarchical Condition Category (HCC) Model Background The CMS-HCC model counts only the most severe manifestation among related conditions (not all ICD9 codes are placed into an HCC) There are over 14,000 ICD9 codes which are classified into 805 diagnostic groups which are further aggregated into 189 Condition Categories (CC) which describe a broader set of similar diseases. These diseases within the CC s are related clinically and with respect to cost. Out of those 189 CCs CMS further breaks them into Hierarchical CCs which include the most complex conditions that will determine cost of that member There are a total of 70 HCCs for 2013 and 74 HCCs for 2014

5 Characteristics of the CMS HCC Model: Prospective in Nature: Diagnosis from base year used to predict payment for next year (New enrollee VS. Existing enrollee) Diagnostic Sources: CMS will only consider diagnoses from IP & OP Hospital & Physician Data HCCs/Multiple Chronic Diseases: Base payment for each member based on HCCs and influenced by Medicare costs for Chronic Diseases Disease Interactions: Additional factors applied when hierarchy of more severe and less severe conditions co-exist Demographics: Final adjustment due to age, sex, original Medicare entitlement, disability and Medicaid status

6 HCCs continued. If no chronic conditions are reported within the year then base payment is calculated solely on the demographics Which is why it is important to. - Make sure all patients are seen at least annually - Properly reflect your patients health status which is proven with Dx CODING - Fully assess ALL chronic conditions at least annually - Thoroughly document all conditions evaluated at each visit in the medical record, documentation must show that condition was monitored, evaluated, assessed or treated (MEAT) - Treatment and level of care must be justified - Code to the highest level of specificity and fully utilized the ICD9 coding system If a patient is less healthy but it is not documented, minimal payment will be calculated for that patient who will most likely incur costs higher than what is budgeted

7 Clinical Initiative- Tie Clinical Quality and Diagnosis Together More Specific Provider Documentation Improved Quality Care Improved Disease Management Enhanced Patient Outcomes GOAL!!!

8 Objectives Why is appropriate coding important Where is the focus of improvement What is the process to improve How will this transition to ICD10

9 ICD-10 is COMING. Crossing the border? Before ICD-10 Border Patrol: Where were you born? Traveler: Buffalo, NY Crossing the border? After ICD 10 Border Patrol: Where were you born? Traveler: In operating room 301A on the 3 rd floor of Mercy hospital of Buffalo at 565 Abbott Rd (west side of the road) in Buffalo, NY; Erie County; USA; located at degrees N; deg W; North America in the Western Hemisiphere of the earth; 3 rd planet from the sun in the Milky Way.

10 IMPORTANT for ICD10 There is no one-to-one cross-walk or mapping exists from ICD-9-CM to ICD-10, there may be more (or fewer) ICD-10 codes to describe the same condition or procedure. More specific, detailed ICD-9 Coding will help assist the transition to ICD-10 and suggestion of codes

11 Example #1:

12 Example #2

13 1. Importance of Appropriate Coding Appropriate (accurate and specific) coding and documentation can: Identify complexity of patient population: Severity and historical conditions of your patients are fully accounted for. CMS is adapting fully risk-adjusted payment model explained in earlier slides. Ensure continuity of care: When you or other provider see the patient again, appropriate coding and documentation provide a full picture. More accurate profiling: More accurately identify high-risk patients, plan follow-ups or proactive/preventative care to improve quality. Get a fair share of CMP incentives: Your coding and documentation ensure accurate calculation of current and future CMP incentives that will be distributed to you. (ex. Risk contracts, ACO Shared Savings)

14 2. Focus of Improvement According to historical records and CMS HCC coding guidelines, we identified the following 4 areas for improvement: 1. Unspecified diabetics Patients with only reported on a claim w/o a more specific diabetes dx Elder population tend to have diabetes w/ complications. Document what exactly is the complication. 2. Fallout diagnosis A diagnosis (usually chronic) that was reported on a claim one year, but fell off the following year. Absence of chronic conditions in coding greatly reduces HCC score and reduces payment for the next year. 3. Status codes Supplementary codes, informational in nature. You don t need to treat those conditions, just need to consider them when treating the patient. Appropriate status codes contribute to accurate HCC score. 4. Monitoring for chronic kidney disease (CKD) CKD often gets overlooked and undocumented. Pay close attention to patients w/ hypertension and diabetes

15 2.1 Unspecified Diabetes Members with only reported on a claim without a more specific diabetes diagnosis Action Plan: Identify correct coding opportunities for patients with Diabetic co morbidities Tie into the CI program looking at Quality Measures for Diabetes. Use EMR to create reports to identify these patients w/ unspecified DM dx Use Coding Tree for DM to show the breakdown of the 4 th and 5 th digit as reference to code accurately

16 2.1.a Unspecified Diabetes Unspecified diabetes with out more specified diagnosis Disease code (Diabetes) th digit- Complication Common Complications with Diabetes: Renal complication 250.4x Ophthalmologic manifestations 250.5x Neurological manifestations 250.6x Peripheral circulatory disorders 250.7x Other specified manifestations 250.8x 5 th digit Severity type 2 or unspecified, not state as uncontrolled 1-type 1, not stated as uncontrolled 2-type 2 or unspecified type, uncontrolled 3-type 1, uncontrolled

17 How much does it matter?? HCC Risk Score HCC Diabetes with no complications $400 HCC X D. w/ophthalmic manifestations HCC X-3X D. w/acute complications HCC X D. w/neurologic manifestations HCC X D. w/renal or peripheral circulatory manifestations $1,800 Note: Some categories have a hierarchy, (such as diabetes) in such categories, only the highest HCC would count

18 2.2 Fallout Diagnosis The most frequent (and most costly) fallout diagnoses are complex chronic conditions (ie. diabetes w/ complications.) Action plan: Ensure all patients have at least one visit annually. Follow-up w/ patients who have not been seen and address condition and add the code to claim Use reports in EMR to identify these patients For patients coming in for annual physical, report full history of diagnoses and consider those in treatment plan. For Medicare patients coming in for acute visit, schedule more than 15min; address existing chronic conditions. Tie into CI program- Managing Ambulatory Sensitive Conditions Tie into PCMH-Population Management and Open Access

19 2.3 Status Codes Conditions that occurred in the past that could significantly impact present medical management Informational only to identify that patient had at some point and it was taken into consideration at that visit for what they were presenting with/being treated for Action Plan: Tie into CI Program-Quality Measures for Diabetes, CAD/IVD, & CHF Top Status Codes- Amputation Transplant Dialysis Ostomy *Need to be on claim only when appropriate *CMP will work on creating Status Code tool relating to the top 5 status codes for our providers

20 2.4 Monitoring for CKD Diabetes and Hypertensive patients that have no diagnosis of CKD but two GFR s under 60 Action Plan: Tie into CI program-diabetic Quality Measures Use EMR to create reports to identify patients with dx of DM and Hypertension with two GFR results under 60 Review patients on reports and add the diagnosis of CKD if appropriate and there is proper documentation Use EMR to create alerts for patients who have a dx of DM and Hypertension to review their GFR results Add the status code for Kidney Dialysis (if appropriate)

21 3. Process for Improvement 2013 Clinical Integration Program 2013 Clinical Integration Program-Utilization Measures Include: Care Pathways Adherence, 30 Day readmission rates, Ambulatory Sensitive Conditions Referral agreements used with Specialist include co management. Did the specialist add a more specific code to diagnose the patient? Problem list updated to help code more specifically? Patients with co-morbidities (high risk) involved in care management programs, 30 day readmission rates are reduced. 8 Ambulatory Sensitive Conditions included in program. 3 are related to Diabetes (2 specific to complications of DM) and 1 to Heart Failure. As these groups are managed, the PQI (Prevention Quality Indicator) scores will be reduced.

22 3. Process Improvement 2013 Clinical Integration Program 2013 Clinical Integration Program Quality Measures Chronic Conditions managed include: Diabetes, CAD/IVD, CHF Quality Measures from EMR uploaded reports include data such as : HbA1C, LDL, BP, GFR. Cycle reports can be referenced and filtered to help code more specifically. What defines Uncontrolled Diabetes vs. Stable Diabetes?-If Stable, when was the last office visit? Was Diabetes managed and on that day s assessment? Care Team Approach: Daily huddles to discuss chronic patients on schedule regardless of visit type. Will their chronic condition be considered or addressed? If so How? Enhanced documentation will lead to more specified coding.

23 ACO Model: A Feedback Loop HCC scores are used in determining our annual ACO budget Provide quality care Metrics are used to determine quality of care provided to the ACO population Example: (unspecified diabetes) Share in the savings & reinvest in the organization Document for accurate HCC Receive base HCC score=less $$ If patient is more complicated, then the budget $$ not allotted in the budget are spent on providing quality care <$$ left eligible for shared savings score well on the quality measures Come under budget Receive MCR-set budget

24 4. Tips from Top Performing Practice Internal Audits: Perform internal coding audits on a regular basis (monthly/quarterly) on a sample of charts to ensure accurate coding Use an internal certified coder and use an outside agency Use reports/alerts in your EMR *Some EMRs do not have the ability, CMP will assist practices with that Use coding cheat sheets/coding trees to assist in more specified coding *CMP will assist in providing those tools If practice does not have a certified coder try to set up training sessions *CMP can recommend resources Utilize Problem List Create Favorites for ICD 9 Codes when selecting assessment

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