Diagnosis Coding is About to be Much More Important. Matthew Menendez

Transcription

1 Diagnosis Coding is About to be Much More Important Matthew Menendez

2 Agenda What is CMS doing with MACRA? What is an HCC code and why should I care? Brief MIPS overview How does risk adjustment impact MIPS? Diagnosis coding is about to change again How are my clients handling this? Q&A?

3 Question 1 HCC codes were originally used for Risk Adjustment in which program: A. Value Based Modifier B. Medicare Advantage Plans C. Meaningful Use D. Workers Compensation Plans

4 Question 2 Which two MIPS categories are Risk Adjusted: A. Cost and Quality B. Improvement Activities and Advancing Care Information C. Quality and Advancing Care Information D. Cost and Improvement Activities

5 Question 3 Which of the following are NOT factored into a patient s HCC score: A. Age B. Gender C. Income Level D. Diagnosis History E. Medicare/Medicaid Eligibility Status

6 Question 4 Patient A s HCC score of 1.2 and Patient B s HCC score of 0.8, which of the following is true: A. Patient B has a higher expected cost B. Patient A has a higher expected cost C. They both have the same expected cost D. Not enough information to determine expected cost

7 Coding is Becoming More Important Volume Value Reimbursement Reimbursement Risk Adjusted MIPS Categories HCC Scores Population Health Management Patient Portal Data Source: White Plume Technologies 2016

8 New Programs Designed to Shift Risk Triple Aim = Better Care, Lower Costs and Improved Patient Experience CMS Patients Providers Higher premiums Higher deductibles Quality Measures Cost Risk Adjustment

9 It Sounds So Simple CMS We are going to start measuring and paying for quality Providers but my patients are sicker than yours CMS ok, prove it! Source: White Plume Technologies 2016

10 HCC Score Hierarchical Condition Categories created in 2004 Original purpose for capitated Medicare Advantage plans HCC is used to measure patient acuity Risk based adjustment Current Uses: Medicare Advantage Risk Adjustment Hospital Value Based Purchasing Risk Adjusted Transfer Payments for ACA Exchange Plans Commercial Payers Risk Adjusted plans

11 HCC Score Demographics + Diagnoses = HCC Score Demographics Age Gender Eligibility Status (Medicare, Medicaid and Disability) Diagnosis Codes from the past 12 months HCC Score x Average Medicare Cost per beneficiary = Projected Medicare Cost Higher HCC Score = Sicker Patient = Higher Projected Medicare Expenditure

12 Risk Adjusted Coding Example No Conditions Coded 76 Year Old Female Medicaid Eligible Some Conditions Coded All Conditions Coded DM without complications X X DM with complications X X Vascular Disease X X CHF X X Disease Interaction (DM + CHF) X X Total HCC Avg Cost per Medicare Beneficiary x $9, Total MA Projected Cost $5, x $9, $6, x $9, $16,380.52

13 Quality Payment Program Final Rule 10/14/16 MACRA: Out with the old.and in with the new Goodbye SGR cut of 21% Meaningful Use PQRS Value Based Modifier MIPS APM Hello

14 Impact of MIPS on Physician Practices MIPS CATEGORY WEIGHTS 15% 30% 30% 60% 45% 30% 30% Cost Quality Improvement Activities 15% 15% 15% 15% Advancing Care Information 25% 25% 25% 25%

15 MIPS Payment Adjustments Performance Threshold Negative Adjustment Positive Adjustment 0 MIPS Score MIPS Score compared to peers Performance Threshold to be determined by CMS Adjustment to FFS in 2019 Larger adjustments for extreme scores Total adjustments are revenue neutral for CMS Source: White Plume Technologies 2016

16 Pick Your Pace in MIPS If you don t send in any 2017 data, then you receive a negative 4% payment adjustment. If you submit a minimum amount of data, avoid a downward payment adjustment. If you submit 90 days of 2017 data to Medicare, you may earn a neutral or small positive payment adjustment. If you submit a full year of 2017 data to Medicare, you may earn a moderate positive payment adjustment. Source:

17 What are payers using diagnosis codes for? CPT and Dx Code Claim FFS (30 days) Provider centric coding for 35 years Physicians paid on productivity and CPT codes Diagnosis code required for medical necessity ICD-9 and ICD-10 Denials predicted to increase % because of ICD-10 Denials have not increased, because of ICD-10 grace period on unspecified codes Source: White Plume Technologies 2016

18 Coding is Becoming More Important Volume Value Reimbursement Reimbursement Risk Adjusted MIPS Categories HCC Scores Population Health Management Patient Portal Data Source: White Plume Technologies 2016

19 HCC Coding Example What your patients actually look like What Medicare (and commercial payers) think your patient looks like Source: White Plume Technologies 2016

20 HCC Coding Example What your patients actually look like What you code What Medicare (and commercial payers) think your patient looks like Source: White Plume Technologies 2016

21 HCC Coding Example What your patients actually look like What you code matters Current Year.Fee for Service, payers begin to deny for unspecified codes Next Year HCC Score for patient population Two Years..MIPS Resource use and Quality Measures, risk based adjustment on patient acuity What Medicare (and commercial payers) think your patient looks like Source: White Plume Technologies 2016

22 HCC Coding Example Total Knee Arthroplasty Total Knee Arthroplasty Total Knee Arthroplasty Unspecified OA, unspecified knee 1. Primary OA, left knee 2. Morbid obesity 1. Primary OA, left knee 2. Morbid obesity 3. Type 2 diabetes with polyneuropathy FFS FFS Q4 HCC Adj Cost -$4,009 -$705 +$2,624 Source: White Plume Technologies 2016

23 MIPS Reminder Remember MIPS compares your cost and quality scores to those of your peers

24 Most Frequently Used HCC Codes Rank ICD-10 Code Description HCC Weight 1 E11.9 Type 2 diabetes mellitus without complications E11.65 Type 2 diabetes mellitus with hyperglycemia J44.9 Chronic obstructive pulmonary disease, unspecified H35.32 Exudative age-related macular degeneration I48.91 Unspecified atrial fibrillation I48.0 Paroxysmal atrial fibrillation E66.01 Morbid (severe) obesity due to excess calories I48.2 Chronic atrial fibrillation I50.9 Heart failure, unspecified C61 Malignant neoplasm of prostate Source: White Plume Technologies 2016

25 HCC by Specialty Specialty Average HCC per Dx Oncology Nephrology Cardiology Internal Medicine Family Practice Ophthalmology Orthopaedics Pediatrics OBGYN Source: White Plume Technologies 2016

26 HCC by Practice Specialty Average = Source: White Plume Technologies 2016 Practice Average HCC per Dx Practice Average HCC per Dx Practice Practice Practice Practice Practice Practice Practice Practice Practice Practice Practice Practice Practice Practice Practice Practice Practice Practice Practice Practice Practice Practice Practice Practice Practice Practice Practice Practice Practice Practice

27 HCC by Provider Practice Average = Source: White Plume Technologies 2016 Practice Average HCC per Dx Practice Average HCC per Dx Provider Provider Provider Provider Provider Provider Provider Provider Provider Provider Provider Provider Provider Provider Provider Provider Provider Provider Provider Provider Provider Provider Provider Provider Provider Provider Provider Provider Provider Provider

28 Provider Specific and Comorbidity Regression Analysis Provider Practice Rank HCC per Diagnosis Provider 1 Top 25% Practice Average 50% Provider 2 Bottom 25% Are Provider 1 s patients nearly twice as sick as Provider 2 s patients? No! The difference is in how they code! Provider HCC per Diagnosis Primary Diagnosis % of Encounters with HCC comorbidities Provider I10 - Hypertension 32% Practice Average I10 - Hypertension 29% Source: White Plume Technologies 2016 Provider I10 - Hypertension 5%

29 Provider Specific and Comorbidity Regression Analysis HCC Rank Comorbid HCC Diagnosis with Primary Diagnosis of Hypertension Value 1 E Type 2 diabetes mellitus without complications I Paroxysmal atrial fibrillation I Peripheral vascular disease, unspecified I Unspecified atrial fibrillation J Chronic obstructive pulmonary disease, unspecified I Other secondary pulmonary hypertension I Cardiomyopathy, unspecified I Supraventricular tachycardia E Morbid (severe) obesity due to excess calories I Cerebral infarction, unspecified Source: White Plume Technologies 2016

30 HCC Coding Example Source: White Plume Technologies 2016

31 HCC Coding Example Source: White Plume Technologies 2016

32 Coding is Becoming More Important Volume Value Reimbursement Reimbursement Risk Adjusted MIPS Categories HCC Scores Population Health Management Patient Portal Data Source: White Plume Technologies 2016

33 Takeaways Diagnosis coding is going to be more important in the future More specific diagnosis codes required Comorbidities capture for accurate risk adjustment Patient acuity will impact target Quality and Cost scores Quality and Cost measured against peers Leverage existing tools to: Make this easy and painless for your physicians Provide billing and coding team tools to review and correct missing data Source: White Plume Technologies 2016

34 Question 1 HCC codes were originally used for Risk Adjustment in which program: A. Value Based Modifier B. Medicare Advantage Plans C. Meaningful Use D. Workers Compensation Plans

35 Answer 1 HCC codes were originally used for Risk Adjustment in which program: A. Value Based Modifier B. Medicare Advantage Plans C. Meaningful Use D. Workers Compensation Plans

36 Question 2 Which two MIPS categories are Risk Adjusted: A. Cost and Quality B. Improvement Activities and Advancing Care Information C. Quality and Advancing Care Information D. Cost and Improvement Activities

37 Answer 2 Which two MIPS categories are Risk Adjusted: A. Cost and Quality B. Improvement Activities and Advancing Care Information C. Quality and Advancing Care Information D. Cost and Improvement Activities

38 Question 3 Which of the following are NOT factored into a patient s HCC score: A. Age B. Gender C. Income Level D. Diagnosis History E. Medicare/Medicaid Eligibility Status

39 Question 3 Which of the following are NOT factored into a patient s HCC score: A. Age B. Gender C. Income Level D. Diagnosis History E. Medicare/Medicaid Eligibility Status

40 Question 4 Patient A s HCC score of 1.2 and Patient B s HCC score of 0.8, which of the following is true: A. Patient B has a higher expected cost B. Patient A has a higher expected cost C. They both have the same expected cost D. Not enough information to determine expected cost

41 Question 4 Patient A s HCC score of 1.2 and Patient B s HCC score of 0.8, which of the following is true: A. Patient B has a higher expected cost B. Patient A has a higher expected cost C. They both have the same expected cost D. Not enough information to determine expected cost

42 Contact Information Matthew Menendez Vice President White Plume Technologies, LLC x Text Matthew to for updates, blog posts, webinars and more!