Understanding Risk Adjustment Hierarchical Condition Categories (HCC) & Importance of Clear Documentation Working smarter not harder!

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1 Understanding Risk Adjustment Hierarchical Condition Categories (HCC) & Importance of Clear Working smarter not harder!

2 Risk Adjustment Overview Health insurance plans participate with Medicare or Affordable Care Act risk pools. Compensation to the insurer is based on the patient s health status thus protecting the insurers against losses due to high risk/cost patients. The Centers for Medicare & Medicaid Services payment for each member is unique based on: Demographic factors (age, gender, other factors). Health Status (diagnosis codes that fall in the HCC model). Health status is determined annually based on submission of diagnosis codes to CMS (facility and professional claim). Problem associated with yearly submission include chronic conditions disappearing from the record over time. Status conditions get overlooked despite their importance. 1

3 Risk Adjustment Overview Continued CMS requires codes be fully supported by documentation in the medical record and diagnosis codes (ICD 10) submitted follow the Official Coding Guidelines. Medical record documentation must support diagnosis codes submitted on claim THIS IS KEY. Complete documentation will also help in assisting providers to meet the requirements for other alternative payment methods such as Stars, HEDIS, MIPS and MACRA. Mandatory CMS and Health and Human Services Audits are called Risk Adjustment Data Validation Audits (RADV). 2

4 HCC Risk Adjustment What are HCCs? Hierarchical Condition Categories are made up of multiple ICD 10 codes for similar diseases. Patients are assigned risk adjustment scores based on HCC diagnoses. Patient demographics + HCC diagnoses = risk score Higher score = higher predicted cost of care = higher reimbursement Predictive modeling: the sicker the patient, the higher the cost of care 3

5 HCC Risk Adjustment How are HCCs captured? HCC Dx must be listed as a visit Dx at least once per calendar year. Face to face visit with an eligible provider (as specified by CMS). Supporting documentation must be in the patient s medical record. 68,000+ Total ICD 10 Codes 9,500+ ICD 10 s in Risk Adjustment 79 HCCs 4

6 Physician Reimbursement vs. Risk Adjustment Historically physician reimbursement was based on: Fee For Service model Based on CPT codes = services and procedures The Risk Adjustment model is based on: ICD 10 CM diagnosis codes (medical conditions) grouped into chronic condition categories known as HCCs. Dx codes are submitted to plan via a claim and forwarded to CMS. Risk Adjustment Factor (RAF) score is a payment methodology used by CMS to reimburse a health plan for the risk of the beneficiaries they enroll for expected costs. 5

7 Impact of HCC Coding on RAF Score Example: Demographic Diagnosis Code and Description Risk Score Female years Base Rate: E11.22 Type II Diabetes with CKD Total Risk Score Additional Diagnosis found and supported in the same medical record: N18.4 CKD Stage J44.9 COPD Revised Risk Score Increase

8 HAP Project Work Retrospective chart reviews Prospective assessments Gap closure projects Internal chart audits (mock audit) Medical record retrieval and ICD 10 coding campaign CMS RADV Audits 7

9 Medical Record Mechanics Patient s name and at least one other identifier (e.g., date of birth or medical record number) is required on every page. Handwritten notes must be legible. Anyone should be able to read notes. Late entries should be identified as such according to CMS guidelines. Never use white out, erase, or obliterate an entry. CMS required signature guidelines. Clear and concise diagnosis documentation needs to be linked to treatment plans. Use approved CMS abbreviations. Use diagnosis verbiage in lieu of diagnosis codes. 8

10 Electronic Medical Record Tips Areas of concern commonly seen in the EMR Examples Copy and paste functions Problem lists Assessment, medications and treatment plans linked Example: Keppra, 250mg refilled for seizure disorder. Electronic signatures Follow CMS signature guideline requirements Include date of signature and provider credentials: MD, DO, NP, PA Electronically signed by: John Smith, M.D., 10/13/2017 9

11 Coding Specificity Choose code(s) that most accurately describe the patients condition. Same amount of detail must be documented in the medical record as is classified in the ICD 10 code. Examples History of cancer vs. current cancer present Include the stage for Chronic CKD Anemia Acute vs. chronic Acute due to blood loss Due to CKD CHF (Congestive Heart Failure) Acute, chronic or acute on chronic Systolic vs. diastolic Systolic and diastolic 10

12 Outpatient ICD 10 Do s and Don ts DO CODE conditions that are: Definitive Confirmed In the absence of an established diagnosis, code signs and symptoms, abnormal labs and test results DO NOT CODE conditions that are: Suspected Ruled out (R/O) Questionable Likely/most likely Probable/possible Inconclusive Uncertain Consistent with Working diagnosis using / or vs 11

13 Coding Additional Diagnoses Outpatient/Clinic Visits: Code all documented conditions that coexist at the time of the encounter and require or affect patient care, treatment, or management. DO NOT code conditions that were previously treated and no longer exist unless you re using a history code. Examples of when to report additional diagnoses: Clinically evaluated Therapeutic treatment Diagnostic procedures Requires monitoring 12

14 E/M & HCC E & M To count toward MDM and E&M level, condition must be directly assessed and treated during visit Accurately document condition(s) you are treating Add to visit Dx HCC Condition does NOT need to be directly treated during visit to count toward HCC, as long as one aspect from MEAT is documented For example: Document how condition affects your treatment: Diabetes well controlled, able to proceed with surgery Document condition status and/or refer to another provider: Diabetes stable, advised to follow up with PCP Also add to Visit Dx 13

15 Common Conditions Requiring Improvement Diabetes (complications) Cancer (active cancer vs. history of) Pulmonary (asthma & COPD) Cardiology (myopathies & CHF) Morbid obesity vs. obesity Vascular disease Rheumatoid arthritis Atrial fibrillation and flutter Myocardial Infarction CVA 14

16 Significant Frequently Overlooked Conditions Must Be Documented Annually Transplant status Current ostomies Amputations Dialysis status Long term use of insulin Alcohol use or dependence Drug use or dependence 15

17 HCC Requirements must reflect at least one element of MEAT ME A T MONITOR Signs and symptoms, disease process (e.g., HgbA1c 5.5 or lipids within normal limits) EVALUATE test results, meds, patient response to treatment (e.g., amputation or ostomy site w/o infection, appears clean and dry) ASSESS/ADDRESS/REFER ordering tests, patient education, refer to other provider (e.g., DM stable and well controlled and/or refer to nephrologist) TREAT/PLAN meds, therapies, procedures, modality (e.g., continue insulin; taking Fosamax for osteoporosis and/or plan bone density study) 16

18 Case Study Reason for Visit Follow up: Diabetes, Hypertension, Back Pain [Patient] is a pleasant 55 y.o. male who presents to clinic today for a follow up on chronic medical problems including HTN, DM, Hyperlipidemia, hypothyroidism, morbid obesity, and bipolar disorder. No changes in medical conditions or medications since the last office visit. Pt admits to being compliant with all his current medications. Patient recently came back from Kansas after being there for about 2 weeks. He says he hasn't seen his psychiatrist since January but he has an appointment to see them soon. He was supposed to have some lab work done for his psychiatrist almost 3 months ago but he's not been able to do it yet. The patient reports stable mood for the last few months. He admits to not checking his sugar regularly but he is compliant with his medications. He has never seen a podiatrist but claims that his feet are fine and he does check them himself. He reports having an appointment to see an eye doctor soon. The patient reports a fairly sedentary lifestyle. He does not leave the house very much and does not have an exercise plan. He reports a good appetite and admits to gaining some weight. He's currently still smoking daily and is not ready to quit. He does cough and increase mucus production on occasions but denies any shortness of breath or chest pain. He otherwise has no acute complaints at this time. Bipolar Disorder Diabetes Mellitus Morbid Obesity 17

19 Case Study Reason for Visit Follow up: Diabetes, Hypertension, Back Pain Assessment & Plan: Type 2 diabetes mellitus without complication, without long term current use of insulin (CMS HCC) Patient compliant with medications but does not check blood glucose regularly. M. Ophthalmologist appointment scheduled; diabetic foot exam done during visit; check A1C; A Comprehensive Metabolic and Lipid Profile; continue with Metformin. T Bipolar 1 disorder (CMS HCC) Patient follows with psychiatrist; compliant on medications; reports stable mood; will check Valproic acid level. A M Morbid Obesity (CMS HCC) Encourage diet and exercise; patient admits to a sedentary lifestyle and does not appear ready for change; will continue to advise and encourage lifestyle modification. A 18

20 Summary Physicians should have a face to face visit with member annually to evaluate and document chronic conditions. Accurate coding results in identification of diseases and enhances medical planning. Risk adjustment factors are dependent on complete documentation and proper coding (reminder: use MEAT method) 19

21 Summary continued Adherence to accurate coding and documentation requirements increases compliance with several value based programs making a win/win situation for all. Reach out to your educator with questions or to request additional training. Providing Highly Reliable Care is Everyone s Goal 20

22 Tips-Acute Myocardial Infarction Acute Myocardial Infarction (AMI) Poor Better STEMI VS. NSTEMI, Type 1 4 Artery involved Acute or history Older than 4 weeks is a history Less than 4 weeks is acute Urgent Care/ Emergency Room Troponin level Patient is seen in the office today for chest pain, history of myocardial infarct. She states that it has been ongoing for 3 days. EKG came back negative and I ve discussed the patients diet and the need to remove acidic foods from her daily intake. Patient is to continue her use of aspirin daily and will follow up with me in 3 months unless she needs to be seen prior to that. (Warning: this is a very detailed note but the time of the AMI is not clear.) Patient is seen in the office today for chest pain, history of myocardial infarct 5 months ago. She states that the pain has been ongoing for 3 days. EKG came back negative and I ve discussed the patients diet and the need to remove acidic foods from her daily intake. Patient is to continue her use of aspirin daily and will follow up with me in 3 months unless she needs to be seen prior to that. 21

23 Tips-Atrial Fib/Flutter Atrial Fib/Flutter History or current Specify the type of A fib (I.e. paroxysmal or persistent etc.) Specify the type of atrial flutter (i.e. typical or type1 vs. atypical or type 2) Treated with medication Following with cardiology Pacemaker or ablations Poor Better Patient followed up with physician for her annual wellness exam. The physician documented that the member has COPD and A fib. Member is feeling well, needed a refill on her inhalers for COPD and will be seeing her cardiologist in 3 months. Patient followed up with physician for her annual wellness exam. The physician documented that the member has COPD and A fib per EKG. Member is feeling well, needed a refill on her inhalers for COPD and will be seeing her cardiologist in 3 months. Her A fib is currently stable. 22

24 Tips-Cancer Cancer Active Cancer diagnosis Historical Cancer diagnosis (use a Z code) Behavior: Malignant (primary, secondary, in situ) Benign (uncertain or unspecified behavior) Site and Laterality Complications or associated conditions Adjuvant therapy Prophylactic treatment Chemotherapy or Radiation Poor Reason for visit: follow up of metastatic breast cancer. History of lumpectomy and adjuvant therapy. Overall patient is doing quite well. Better (Warning: Does the patient have breast cancer currently or do they have a history since the lumpectomy is historical.) Reason for visit: follow up of breast cancer. History of lumpectomy in 2003 and adjuvant therapy was completed in Patient started Arimidex 11/10/2005 and completed treatment after 5 years in Overall patient is doing quite well and will have a mammogram prior to next appointment. Currently the patient is without evidence of disease. ( shows that the condition is no longer active and only a historical condition) 23

25 Tips-Cerebral Vascular Accident Cerebral Vascular Accident (CVA) Poor Better Facial droop Sequela (Hemiparesis or Dysphasia) Current vs. History Wheelchair Emergency room / Urgent care Administration of clot dissolving medication Patient had a stroke and is having difficulty with hemiparesis since the occurrence. Patient is looking better but asked to follow up with rehabilitation and physical therapy. Current diagnosis is CVA (Warning: the patient is most likely not having a CVA in the office right now. It sounds only to be symptoms of the previous CVA. Code the Sequela {late effect} of a CVA which is the hemiparesis.) Patient had a stroke and is having difficulty with hemiparesis since the occurrence last month. The patient is looking better but asked to follow up with rehabilitation and physical therapy. Current diagnosis is Hemiparesis due to the CVA. ( specifies the timing of the stroke which is historical, while the hemiparesis is a result of the stroke and still current.) 24

26 Tips-Congestive Heart Failure Congestive Heart Failure (CHF) Poor Better Acute, chronic, acute on chronic Diastolic, Systolic, or combined Due to or associated with other conditions (i.e. htn., HIV, abuse) Labs (electrolytes, CBC, Bun, AST) Tests (EKG, Chest X ray, Echocardiogram) Medications (Lasix) Symptoms: Weight gain, edema, or shortness of breath Patient was seen in the office for leg swelling which was getting progressively worse. PMH mentions congestive heart failure. Assessment for encounter was peripheral edema, abnormal cardiac function test, elevated BNP and heavy tobacco use. (Warning: Signs and symptoms along with past medical history make the condition look current, however the provider never confirmed or elaborated on the diagnosis of congestive heart failure.) Patient was seen in the office for leg swelling which was getting progressively worse. Heart sounds are barely audible. PMH mentions congestive heart failure. Assessment for encounter was peripheral edema, abnormal cardiac function test, elevated BNP and heavy tobacco use (counselled to stop), acute on chronic diastolic CHF confirmed. Planordered an Echocardiogram and chest x ray., increase Lasix dosage. ( stated acute on chronic diastolic heart failure with an increase in Lasix dosage. Provider requested the patient stop smoking due to COPD.) 25

27 Tips-COPD COPD With exacerbation Medications used to control disease process Tobacco dependence Oxygen use Accompanied by infection (identify the infection) Accompanied by other disease (i.e. with asthma, chronic bronchitis etc.) Poor Patient seen for follow up with Major Depressive Disorder. History noted Hypertension, Gerd, Hypothyroidism and COPD. Plan is to follow up with psychiatrist and continue to take antidepressants. (Warning: Multiple conditions noted and some chronic but only documented in the past medical history with no mention if it currently effects the patient. CMS guidelines prohibits coding solely from Problem or Medication list s. Furthermore, there is no treatment or management for the other diseases listed in the history) Better Patient seen for follow up with Major Depressive Disorder. History noted Hypertension, Gerd, Hypothyroidism and COPD. Based on today s spirometry results, prescription given to patient to refill his inhaler of Symbicort for COPD and Synthroid for hypothyroidism. Continue to monitor blood pressures daily and bring back the values to your next appointment. Return to office in 6 weeks. Plan is to follow up with Psychiatrist and continue to take anti depressants. (Some of the conditions that were only a history before are treated and viewed as current since they have a treatment plan like medication or are being monitored like the hypertension) 26

28 Tips-Diabetes Diabetes Type I or II Manifestations/complications due to diabetes Diabetes due to drug or chemical Other type of diabetes Control: poor, inadequate, out of control due to hypoglycemia or hyperglycemia Use of insulin or other medications Poor Patient was admitted to the emergency room with dehydration & dizziness with a blood sugar level of 743. He forgot to take his morning insulin and has gained 25 lbs. to his 350 lb. frame over the last 3 months. A1C was 9.6. He is admitted and diagnosed with AKI and CKD as well as hyperglycemia. Better (Warning: does not mention the diagnosis of diabetes, the stage of CKD, or the fact that he may be morbidly obese) Patient was admitted to the emergency room with dehydration & dizziness with a blood sugar level of 743. He forgot to take his morning insulin and has gained 25 lbs. to his over 350 lb. frame during the last 3 months. A1C was 9.6. He is admitted and diagnosed with DM type 2 with CKD stage III, AKI, and hyperglycemia. Patient is morbidly obese with BMI of

29 Tips-Morbid Obesity Morbid (severe) Obesity Poor Better Diagnosis of overweight or obesity with a BMI over 40 Severe or Morbid Obesity diagnosis Exercise plan Diet plan Weight loss surgery Dietician often referred BMI Patient was seen at the providers office for dyspnea and skin rash. He is 6 2 and weighs 427 lbs. (BMI 54.8). Severe aches and pains noted, patient says he has been taking extra strength Tylenol daily for months. Suggest starting a 2200 calorie diet and talking to a surgeon. (Warning: The diagnosis of Morbid Obesity is not stated in this document.) Patient was seen at the providers office for chronic dyspnea due to pulmonary hypertension and pannus yeast infection. He is 6 2 and weighs 427 lbs. (BMI 54.8). Severe backache and knee pain noted which are symptomatic of his osteoarthritis. Suggest starting a 2200 calorie diet for morbid obesity. Prescriptions written and consult for weight loss surgery to help improve symptoms of pulmonary hypertension and other co morbid conditions. (Note: The diagnosis was specifically stated with supporting documentation to back it up.) 28

30 Tips-PVD PVD Associated or due to other disease (i.e. DM) Diminished pulses and or hair loss on legs or feet Amputations Complications (i.e. intermittent claudication or ulceration) ABI values/ ultrasounds Often noted by Podiatry Medications like Pletal Poor Better Patient was seen for a consult following low back and leg pain. He s taken gabapentin, pregabalin, narcotics and tramadol without adequate, sustained relief. Also uses a cane for ambulation. Feet are always cold, letting them hang down while sitting helps with the pain in his legs. I am concerned for additional vascular cause, specifically insufficiency given vascular claudication symptoms, cold feet, and lack of palpable pulses. Due to vascular concerns, I will refer the patient to a vascular doctor. (Warning: is missing diagnosis of PVD.) Patient was seen for a consult following low back and leg pain. He s taken gabapentin, pregabalin, narcotics and tramadol without adequate, sustained relief. Also uses a cane for ambulation. Feet are always cold, letting them hang down while sitting helps with the pain in his legs. I am concerned for additional vascular cause, specifically insufficiency given vascular intermittent claudication. Symptoms include cold feet, and lack of palpable pulses. Due to vascular concerns, I am prescribing a trial of papavarine injection today and referring the patient to a vascular doctor for care of his PVD. I am also recommending exercise (i.e. walking). (Specificity of claudication present as well as the diagnosis of PVD.) 29

31 Tips-Rheumatoid Arthritis Rheumatoid Arthritis Poor Better Be specific for example: Juvenile rheumatoid arthritis Associated conditions with disease (i.e. polyneuropathy, endocarditis etc.) Use of medications such as pain killers, anti inflammatory, steroids and narcotics Site and Laterality Patient was seen in the office last month and given a script and directions on how to use Orencia for their arthritis. Patient is feeling better so we will continue with treatment. Follow up in 3 months (Warning: what type of arthritis and what body part is affected is not clear.) Patient was seen in the office last month and given a script and directions on how to use Orencia for juvenile rheumatoid arthritis in her right knee. Patient is feeling better so we will continue with Orencia treatment. I still recommend the patient follow up with rheumatology in 3 months for ongoing care and treatment of her juvenile rheumatoid arthritis. (Here the type of arthritis, site affected, and follow up plan are more clearly defined.) 30

32 Coding and Resources CMS Resources CMS Official Coding Guidelines CMS SIGNATURE GUIDELINES and Guidance/Gucmsidance/Transmittals/2017Downloads/R713PI.pdf Coding Organizations AAPC AHIMA Coding Questions for HAP 31

33 HCC Glossary Acronym ACO CMS HCC MEAT RADV RAF Description Accountable Care Organization: a group of health care providers who provide care to an assigned group of patients, including reviewing patients medical records and sharing information to coordinate care with the goal of improving quality and lowering cost. Centers for Medicare & Medicaid Services: federal agency that administers the Medicare program and works in partnership with state governments to administer Medicaid, the Children s Health Insurance Program (CHIP), and health insurance portability standards. Hierarchical Condition Category: a component of the CMS risk adjustment model that predicts future health expenditures based on demographics and health status via ICD 10 codes. HCC categories comprise multiple ICD 10 codes, grouped by similar diseases. Monitor, Evaluate, Assess, Treat: a component of CMS HCC documentation requirement whereby the medical record must demonstrate the condition was Monitored, Evaluated, Assessed, or Treated to support billing a HCC ICD 10 code. Risk Adjustment Data Validation: This is a process of verifying diagnosis codes submitted for payment through the use of supporting medical record documentation. The purpose is to ensure risk adjusted payment integrity and accuracy. Risk Adjustment Factor: a score comprised of patient demographic values, ICD 10 diagnoses and other normalization factors which is then used to adjust future payments and/or quality measures for Medicare, Medicare Advantage and Affordable Care Act plan patients. 32

34 hap.org