There is a YOU in TEAM: Every Department Plays a Role in Successful Risk Adjustment Management

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Coleen Richardson
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1 There is a YOU in TEAM: Every Department Plays a Role in Successful Risk Adjustment Management

2 HCC Risk Adjustment What Is It? A payment methodology that uses demographics and diagnosec informaeon to predict a per parecipant, per month (PM/PM) rate that reflects the poteneal cost of complexity of care and required treatment The intended purpose is to reimburse appropriately for care

3 What Are The Demographics Considered In Risk Adjustment? Age Gender Disability status Medicaid Status InsEtuEonal/Community Status Frailty

4 What Are The Diagnos=cs Considered In Risk Adjustment? The health status of your PACE OrganizaEon s parecipants To be considered for risk adjustment, a condieon must be included in the HCC Model Hierarchical CondiEon Categories

5 How Do You Make CMS Aware Of The Health Status of Your Par=cipants? Ensure that: Demographic informaeon is accurate & current Medical history is on site, reviewed, and addressed at the pre- enrollment history and physical DocumentaEon is thorough, accurate, and code- able Codes are submiyed to CMS and accepted If a diagnosis was not accepted, figure out why backtrack to fix it and resubmit Take advantage of the reports that CMS creates every month

6 Basis Of The CMS HCC Model DiagnosEc Categories should be clinically meaningful They should predict medical expenditures They should have adequate sample sizes in the populaeon Hierarchies should characterize illness levels and accumulate unrelated disease processes Encourage specific coding Not reward coding proliferaeon ProliferaEon should not be penalized CategorizaEon must be consistent

7 CMS Hierarchical Disease Categories Table 11. List of Disease Hierarchies for the Revised CMS- HCC Model (PACE 6/6/11) DISEASE HIERARCHIES Hierarchical Condi=on Category (HCC) If the Disease Group is Listed in this column Then drop the HCC(s) listed in this column Hierarchical Condi=on Category (HCC) LABEL 8 MetastaEc Cancer and Acute Leukemia 9,10,11,12 9 Lung and Other Severe Cancers 10,11,12 10 Lymphoma and Other Cancers 11,12 11 Colorectal, Bladder, and Other Cancers Diabetes with Acute ComplicaEons 18,19 18 Diabetes with Chronic ComplicaEons End- Stage Liver Disease 28,29,80 28 Cirrhosis of Liver Severe Hematological Disorders DemenEa With ComplicaEons Drug/Alcohol Psychosis Schizophrenia Quadriplegia 71,72,103,104, Paraplegia 72,104, Spinal Cord Disorders/Injuries Respirator Dependence/Tracheostomy Status 83,84 83 Respiratory Arrest Acute Myocardial InfarcEon 87,88 87 Unstable Angina and Other Acute Ischemic Heart Disease Cerebral Hemorrhage Hemiplegia/Hemiparesis Atherosclerosis of the ExtremiEes with UlceraEon or Gangrene 107,108,161, Vascular Disease with ComplicaEons CysEc Fibrosis 111, Chronic ObstrucEve Pulmonary Disease AspiraEon and Specified Bacterial Pneumonias Dialysis Status 135,136,137,138,139,140, Acute Renal Failure 136,137,138,139,140, Chronic Kidney Disease, Stage 5 137,138,139,140, Chronic Kidney Disease, Severe (Stage 4) 138,139,140, Chronic Kidney Disease, Moderate (Stage 3) 139,140, Chronic Kidney Disease, Mild or Unspecified (Stages 1-2 or Unspecified) 140, Unspecified Renal Failure Pressure Ulcer of Skin with Necrosis Through to Muscle, Tendon, or Bone 158,159,160, Pressure Ulcer of Skin with Full Thickness Skin Loss 159,160, Pressure Ulcer of Skin with ParEal Thickness Skin Loss 160, Pressure Pre- Ulcer Skin Changes or Unspecified Stage Severe Head Injury 80,167 How Payments are Made with a Disease Hierarchy EXAMPLE: If a beneficiary triggers HCCs 140 (Unspecified Renal Failure) and 141 (NephriEs), then HCC 141 will be dropped. In other words, payment will always be associated with the HCC in column 1, if a HCC in column 3 also occurs during the same colleceon period. Therefore, the organizaeon s payment will be based on HCC 140 rather than HCC 141.

8 This Is What A Disease Category Looks Like Table&11.&&List&of&Disease&Hierarchies&for&the&Revised&CMS:HCC&Model&(PACE&6/6/11) DISEASE&HIERARCHIES Hierarchical&Condition&Category&(HCC) If&the&Disease&Group&is&Listed&in&this&column Then&&drop&the&HCC(s)&listed&in&this&column 134 Dialysis*Status 135,136,137,138,139,140, Acute*Renal*Failure 136,137,138,139,140, Chronic*Kidney*Disease,*Stage*5 137,138,139,140, Chronic*Kidney*Disease,*Severe*(Stage*4) 138,139,140, Chronic*Kidney*Disease,*Moderate*(Stage*3) 139,140, Chronic*Kidney*Disease,*Mild*or*Unspecified*(Stages*1I2*or*Unspecified) 140, Unspecified*Renal*Failure 141

9 Basic Rules Risk- based eneees MUST submit all exiseng parecipant diagnoses that affect risk adjustment annually These diagnoses MUST be code- able according to Official Coding Guidelines Diagnoses submiyed for risk adjustment MUST be documented in the medical record of the paeent annually

10 HCC Basics For PACE CY2015/PY2016 3,125 diagnoses for ICD- 9 8,939 for ICD HCC categories Risk factor is ayached to each HCC Each qualifying HCC only counts once annually Risk Rate is based on cumulaeve HCCs per individual (and the parecular demographics) DocumentaEon must support each HCC annually according to coding guidelines and CMS rules.

11 Do You Need A Coder? Absolutely, but the coder can only code what the documentaeon supports and only what they have the background and experience to code If you leave all the coding and the understanding of CMS rules up to your coder, the unintended impact of that decision is that you are leaving your cash flow and revenue decisions up to your coder They didn t ask for that responsibility, and you probably didn t intend it

12 Or Should You Just Train Your Care Providers To The HCCs? Good documentaeon (and coding) is all inclusive and not just HCC related Coders are trained to code what physicians specifically write and most good, experienced coders are trained to code for billing purposes (CPT and DRG) ICD coding is different DocumenEng completely and and coding completely for the HCCs is important for payment Coding everything is important for reporeng DocumenEng everything is esseneal for quality care

13 What Can A Coder Do? A coder can only code what is wriyen by a provider. A coder cannot diagnose, interpret, translate, or intuit. Coder needs to stay current and educated re: constantly changing codes and rules and guidelines

14 What Can Providers Do? Problem list keep it updated and correct Repeat all diagnoses that have not resolved annually, sign and date everything Communicate/Clarify specialty diagnoses at IDT meeengs If a chronic disease exists, document it specifically annually may seem redundant, but it s required Review, sign and update your pre- admission physicals AGAIN, on admission and AT LEAST annually thereaper Seems silly, but when you review a lab sign and date it, document what the informaeon is telling you in a note, or link lab back to original encounter note

15 When Documen=ng, Words Ma^er In PACE, unconfirmed or inconclusive diagnoses should not be submiyed for risk adjustment PACE is considered an outpaeent serng Possible Probable Suspected Likely QuesEonable Appears to be Rule Out Working Diagnosis of Consistent with CompaEble with Comparable with Suspicion of

16 What s A RAPS Cluster? Basics: HICN Provider Type From Date Thru Date Diagnosis Code A RAPS file can contain as liyle as one cluster

17 Understanding The CMS Calendar Everyone Coding staff, Clinical staff, Finance staff, and IT staff, needs to have a basic understanding of how the submission and reimbursement calendar works. It s complicated Basically, the earlier you get your data submiyed relaeve to the cutoff dates for risk score calculaeons, the earlier you will receive your risk adjusted premium payments.

18 Understanding The CMS Calendar PMPM rate is by calendar date One year s cumulaeve diagnoses create the next year s risk rate/ risk score Risk Score is adjusted twice per year January and July January 1 is an interim rate PMPM (2016) Based on 12 months of diagnoses submiyed Submissions with service dates between July 1, June 30, 2015 (submiyed by the September 2014 deadline) July 1 is an actual rate PMPM (2016) Based on 12 months of diagnoses submiyed Submissions with service dates between January 1 December 31, 2015 (submiyed by the March 2016 deadline)

19 RATES And Dates 2015 Members 2015 Rate is determined by diagnoses confirmed in medical record during 2014 calendar year and accepted for reimbursement by CMS New Medicare Enrollees have flat rate for 18 months so a new member in January 2015 will not have a change in risk score unel July 1, 2016 New PO Par2cipant rates Will NOT be impacted by your PACE organizaeon prior to January 2016; all 2015 payments are based on prior plan submission Recurring Members Diagnoses confirmed by 2014 medical record New Enrollees Flat Rate 1/1/2015 7/1/2016 NO IMPACT New ParEcipants Adjusted Rate from Prior Plan NO IMPACT unel Jan 2016

20 Risk Score Run Dates of Service Deadline for Submission of RAPS 2015 IniEal (January) 7/ /30/2014 Friday, 09/12/ Final 1/1/ /31/2013 Saturday, 1/31/ Mid Year (July) 1/1/ /31/2014 Friday, 3/6/ IniEal (January) 7/1/2014 6/30/2015 Friday, 9/11/ Final 1/1/ /31/2014 Monday, 2/1/ Mid Year (July) 1/1/ /31/2015 Friday, 3/4/ IniEal (January) 7/1/2015 6/30/2016 Friday, 9/9/ Final 1/1/ /31/2015 Tuesday, 1/31/ Mid Year (July) 1/1/ /31/2016 Friday, 3/3/2017

21 What Reports Should Be Viewed EVERY MONTH?

22 Repor=ng Naming Conven=ons Mailbox IdenEficaEon RSP#9999.RSP.FERAS_RESP_ RPT#9999.RPT.RAPS_RETURN_FLAT RPT#9999.RPT.RAPS_ERRORRPT_ RPT#9999.RPT.RAPS_SUMMARY_ RPT#9999.RPT.RAPS_DUPDX_RPT_ RPT#9999.RPT.RAPS_MONTHLY_ RPT#9999.RPT.RAPS_CUMULATIVE_ RPT#9999.RAPS_ERRFREQ_MNTH_ RPT#9999.RAPS_ERRFREQ_QTR_ Report Name FERAS Response Report RAPS Return File RAPS TransacEon Error Report RAPS TransacEon Summary Report RAPS Duplicate Diagnosis Cluster Report RAPS Monthly Plan AcEvity Report RAPS CumulaEve Plan AcEvity Report RAPS Monthly Error Frequency Report RAPS Quarterly Error Frequency Report

23 FERAS: Front End Risk Adjustment System FERAS Response Report Indicates if a file is accepted or rejected IdenEfies the reason for rejeceon SFTP users receive this report the same business day of submission Direct Connect or Gentran users receive this report the next business day aper submission

24 RAPS Return File Contains the enere submiyed transaceon Generated in response to RAPS file submission IdenEfies errors specific to line item transaceons A flat file layout for easy download into Excel

25 RAPS Transac=on Error Report Communicates errors found in CCC records during processing Displays only 300, 400, and 500 level error codes Report Layout

26 RAPS Error Resolu=on Steps Determine the error level of the code to idenefy nature of the problem Look up the error code Determine course of aceon Resolve all errors in a Emely manner

27 RAPS Duplicate Diagnoses Cluster Report IdenEfies diagnosis clusters with 502 error message (duplicate) These clusters were accepted into the system, but were not stored in the RAPS database Report Layout

28 RAPS Monthly Plan Ac=vity Report Provides monthly summary of the status of submission by SubmiYer ID and Plan Number

29 RAPS Cumula=ve Plan Ac=vity Report Provides cumulaeve summary of the status of submissions by submiyer IS and Plan Number Available in data file format and flat format One available each month if RAPS have been submiyed in month prior

30 RAPS Error Frequency Report 2 Reports- Monthly & Quarterly Provide summary of all errors associated with files submiyed in test or produceon within a month or a quarter

31 Model Output Report (MOR) The Part C MOR is provided in the data file format and the report format. There will be one such report for each plan for each month. The filename will contain the string HCCMODD.

32 Monthly Membership Report (MMR) The Part C MMR is provided in a data file format and a report format. There is one such report for each plan for each month. The filename will contain the string MONMEMD.

33 But Why Does This Ma^er To Me? I Just Want To Provide Good Health Care! There is a disconnect between how clinicians document to provide good care, how coders are trained, and what CMS expects non- clinicians (coders) to pull from a chart to submit for reimbursement Your PACE organizaeon needs to be appropriately reimbursed for the risk it is taking on in order to conenue to provide that good health care

34 Over Time Ongoing efforts of every department in your program will maintain the right level of reimbursement, ensuring that you are receiving appropriate payment in a Emely manner for the risk that you are taking.

35 Develop a TEAM- Based Risk Adjustment Strategy Risk Adjustment should be an integrated approach between Coding Staff Clinical Staff Finance/AdministraEve Staff

36 Ques=ons?

37 Resources hyp:// informaeon regarding risk adjustment, announcements, documents, special reports, coding, encounter data. hyp:// informaeon regarding ICD- 10 coding, updates, etc hyp:// gateway to Medicare Advantage and PrescripEon Drug Programs. InformaEon regarding risk adjustment, encounter data, data submission & reporeng. Links to CMS instruceons, training materials NaEonal Technical Assistance Risk Adjustment 101 ParEcipant Guide This is a 36 page overview/primer of the risk adjustment process.

38 Presenter Contact Info Eileen Black, RN, Client Services Manager - PACE, DxID eblack@dx- ID.com Cyndi Young, RN, Senior Director of Clinical OperaEons for PACE Programs, Ascension Health Senior Care cyoung@alexianbrothers.net

39 Thank you!

79 HCCs CMS-HCC Risk Adjustment Model. ICD-10-CM to CMS-HCC Crosswalk. Over 9,500 ICD-10-CM codes map to one or more.

79 HCCs CMS-HCC Risk Adjustment Model. ICD-10-CM to CMS-HCC Crosswalk. Over 9,500 ICD-10-CM codes map to one or more. 2017 CMS-HCC Risk Adjustment Model Over 9,500 ICD-10-CM codes map to one or more 79 HCCs ICD-10-CM to CMS-HCC Crosswalk CMS-HCC Model On April 4, 2016, the Centers for Medicare & Medicaid Services (CMS)