1 ICD-10: Don t Let Risk Adjustments Be An Afterthought Tuesday, October 28, 2014 1:30-2:30PM PST Presented by: Kim Browning, CHRS, PMP, CHC Executive Vice President, Cognisight, LLC Barb Nutting, RHIT, CCS-P Health Information Director, PACE CNY
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?
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
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
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 1433 0.288 412.704 5% 1 52 Dementia Without Complication 1280 0.343 439.040 6% 2 18 Diabetes with Chronic Complications 1263 0.344 434.472 6% 3 85 Congestive Heart Failure 1212 0.361 437.532 6% 4 51 Dementia With Complications 1038 0.616 639.408 8% 5 Top 20 111 Chronic Obstructive Pulmonary Disease 1021 0.388 396.148 5% 6 Major Depressive, Bipolar, and Paranoid 58 Disorders 957 0.318 304.326 4% 7 138 Chronic Kidney Disease, Moderate (Stage 3) 901 0.227 204.527 3% 8 96 Specified Heart Arrhythmias 895 0.276 247.020 3% 9 75 Polyneuropathy 791 0.281 222.271 3% 10 103 Hemiplegia/Hemiparesis 514 0.481 247.234 3% 11 19 Diabetes without Complication 446 0.124 55.304 1% 12 Chronic Kidney Disease, Mild or Unspecified 139 (Stages 1-2 or Unspecified) 419 0.227 95.113 1% 13 135 Acute Renal Failure 389 0.617 240.013 3% 14 79 Seizure Disorders and Convulsions 346 0.252 87.192 1% 15 84 Cardio-Respiratory Failure and Shock 307 0.326 100.082 1% 16 21 Protein-Calorie Malnutrition 304 0.653 198.512 3% 17 23 Other Significant Endocrine and Metabolic Disorders 302 0.240 72.480 1% 18 48 Coagulation Defects and Other Specified Hematological Disorders 296 0.258 76.368 1% 19 100 Ischemic or Unspecified Stroke 285 0.333 94.905 1% 20 HCC HCC Description Membe rs Valu e Total RAF Weight % of Total 138 Chronic Kidney Disease, Moderate (Stage 3) 208 0.227 47.216 4% 1 111 Chronic Obstructive Pulmonary Disease 199 0.388 77.212 7% 2 18 Diabetes with Chronic Complications 176 0.344 60.544 6% 3 85 Congestive Heart Failure 175 0.361 63.175 6% 4 96 Specified Heart Arrhythmias 169 0.276 46.644 4% 5 108 Vascular Disease 164 0.288 47.232 4% 6 52 Dementia Without Complication 162 0.343 55.566 5% 7 51 Dementia With Complications 131 0.616 80.696 7% 8 Chronic Kidney Disease, Mild or Unspecified 139 (Stages 1-2 or Unspecified) 112 0.227 25.424 2% 9 75 Polyneuropathy 106 0.281 29.786 3% 10 22 Morbid Obesity 68 0.342 23.256 2% 11 84 Cardio-Respiratory Failure and Shock 62 0.326 20.212 2% 12 103 Hemiplegia/Hemiparesis 55 0.481 26.455 2% 13 135 Acute Renal Failure 54 0.617 33.318 3% 14 Pressure Ulcer of Skin with Partial Thickness 159 Skin Loss 51 1.071 54.621 5% 15 79 Seizure Disorders and Convulsions 47 0.252 11.844 1% 16 Other Significant Endocrine and Metabolic 23 Disorders 41 0.240 9.840 1% 17 78 Parkinson's and Huntington's Diseases 40 0.555 22.200 2% 18 Atherosclerosis of the Extremities with 106 Ulceration or Gangrene 36 1.313 47.268 4% 19 88 Angina Pectoris 36 0.210 7.560 1% 20 Top 20
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 61 2.425 147.925 2% 1 82 Respirator Dependence/Tracheostomy Status 17 1.732 29.444 0% 2 Atherosclerosis of the Extremities with Ulceration 106 or Gangrene 98 1.313 128.674 2% 3 46 Severe Hematological Disorders 29 1.078 31.262 0% 4 70 Quadriplegia 43 1.075 46.225 1% 5 158 Pressure Ulcer of Skin with Full Thickness Skin Loss 103 1.071 110.313 1% 6 159 Pressure Ulcer of Skin with Partial Thickness Skin Loss 180 1.071 192.780 2% 7 160 Pressure Pre-Ulcer Skin Changes or Unspecified Stage 105 1.071 112.455 1% 8 157 Pressure Ulcer of Skin with Necrosis Through to Muscle, Tendon, or Bone 29 1.071 31.059 0% 9 186 Major Organ Transplant or Replacement Status 3 1.032 3.096 0% 10 Amyotrophic Lateral Sclerosis and Other Motor 73 Neuron Disease 2 1.016 2.032 0% 11 9 Lung and Other Severe Cancers 58 1.006 58.348 1% 12 27 End-Stage Liver Disease 34 1.003 34.102 0% 13 71 Paraplegia 24 0.868 20.832 0% 14 Amputation Status, Lower Limb/Amputation 189 Complications 84 0.804 67.536 1% 15 83 Respiratory Arrest 5 0.769 3.845 0% 16 10 Lymphoma and Other Cancers 38 0.695 26.410 0% 17 114 Aspiration and Specified Bacterial Pneumonias 143 0.691 98.813 1% 18 21 Protein-Calorie Malnutrition 304 0.653 198.512 3% 19 8 Metastatic Cancer and Acute Leukemia 3 2.425 7.275 1% 1 Atherosclerosis of the Extremities with 106 Ulceration or Gangrene 36 1.313 47.268 4% 2 46 Severe Hematological Disorders 4 1.078 4.312 0% 3 70 Quadriplegia 1 1.075 1.075 0% 4 157 Pressure Ulcer of Skin with Necrosis Through to Muscle, Tendon, or Bone 3 1.071 3.213 0% 5 158 Pressure Ulcer of Skin with Full Thickness Skin Loss 28 1.071 29.988 3% 6 159 Pressure Ulcer of Skin with Partial Thickness Skin Loss 51 1.071 54.621 5% 7 160 Pressure Pre-Ulcer Skin Changes or Unspecified Stage 11 1.071 11.781 1% 8 73 Amyotrophic Lateral Sclerosis and Other Motor Neuron Disease 1 1.016 1.016 0% 9 9 Lung and Other Severe Cancers 8 1.006 8.048 1% 10 27 End-Stage Liver Disease 1 1.003 1.003 0% 11 71 Paraplegia 2 0.868 1.736 0% 12 Amputation Status, Lower 189 Limb/Amputation Complications 12 0.804 9.648 1% 13 83 Respiratory Arrest 1 0.769 0.769 0% 14 10 Lymphoma and Other Cancers 7 0.695 4.865 0% 15 Aspiration and Specified Bacterial 114 Pneumonias 15 0.691 10.365 1% 16 21 Protein-Calorie Malnutrition 20 0.653 13.060 1% 17 134 Dialysis Status 4 0.617 2.468 0% 18 135 Acute Renal Failure 54 0.617 33.318 3% 19 51 Dementia With Complications 131 0.616 80.696 7% 20
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 1038 0.616 639.408 8% 1 52 Dementia Without Complication 1280 0.343 439.040 6% 2 85 Congestive Heart Failure 1212 0.361 437.532 6% 3 18 Diabetes with Chronic Complications 1263 0.344 434.472 6% 4 108 Vascular Disease 1433 0.288 412.704 5% 5 Top 20 111 Chronic Obstructive Pulmonary Disease 1021 0.388 396.148 5% 6 Major Depressive, Bipolar, and Paranoid 58 Disorders 957 0.318 304.326 4% 7 103 Hemiplegia/Hemiparesis 514 0.481 247.234 3% 8 96 Specified Heart Arrhythmias 895 0.276 247.020 3% 9 135 Acute Renal Failure 389 0.617 240.013 3% 10 75 Polyneuropathy 791 0.281 222.271 3% 11 138 Chronic Kidney Disease, Moderate (Stage 3) 901 0.227 204.527 3% 12 21 Protein-Calorie Malnutrition 304 0.653 198.512 3% 13 Pressure Ulcer of Skin with Partial Thickness 159 Skin Loss 180 1.071 192.780 2% 14 8 Metastatic Cancer and Acute Leukemia 61 2.425 147.925 2% 15 Septicemia, Sepsis, Systemic Inflammatory 2 Response Syndrome/Shock 276 0.520 143.520 2% 16 78 Parkinson's and Huntington's Diseases 244 0.555 135.420 2% 17 106 Atherosclerosis of the Extremities with Ulceration or Gangrene 98 1.313 128.674 2% 18 160 Pressure Pre-Ulcer Skin Changes or Unspecified Stage 105 1.071 112.455 1% 19 158 Pressure Ulcer of Skin with Full Thickness Skin Loss 103 1.071 110.313 1% 20 HCC HCC Description Membe rs Valu e Total RAF % of Total 51 Dementia With Complications 131 0.616 80.696 7% 1 111 Chronic Obstructive Pulmonary Disease 199 0.388 77.212 7% 2 85 Congestive Heart Failure 175 0.361 63.175 6% 3 18 Diabetes with Chronic Complications 176 0.344 60.544 6% 4 52 Dementia Without Complication 162 0.343 55.566 5% 5 159 Pressure Ulcer of Skin with Partial Thickness Skin Loss 51 1.071 54.621 5% 6 106 Atherosclerosis of the Extremities with Ulceration or Gangrene 36 1.313 47.268 4% 7 108 Vascular Disease 164 0.288 47.232 4% 8 138 Chronic Kidney Disease, Moderate (Stage 3) 208 0.227 47.216 4% 9 96 Specified Heart Arrhythmias 169 0.276 46.644 4% 10 135 Acute Renal Failure 54 0.617 33.318 3% 11 Pressure Ulcer of Skin with Full Thickness 158 Skin Loss 28 1.071 29.988 3% 12 75 Polyneuropathy 106 0.281 29.786 3% 13 103 Hemiplegia/Hemiparesis 55 0.481 26.455 2% 14 Chronic Kidney Disease, Mild or Unspecified 139 (Stages 1-2 or Unspecified) 112 0.227 25.424 2% 15 22 Morbid Obesity 68 0.342 23.256 2% 16 78 Parkinson's and Huntington's Diseases 40 0.555 22.200 2% 17 84 Cardio-Respiratory Failure and Shock 62 0.326 20.212 2% 18 2 40 Septicemia, Sepsis, Systemic Inflammatory Response Syndrome/Shock 34 0.520 17.680 2% 19 Rheumatoid Arthritis and Inflammatory Connective Tissue Disease 36 0.376 13.536 1% 20 Top 20
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.
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
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 131 0.616 80.696 1 1 1 111 Chronic Obstructive Pulmonary Disease 199 0.388 77.212 1 0 1 85 Congestive Heart Failure 175 0.361 63.175 1 0 1 18 Diabetes with Chronic Complications 176 0.344 60.544 1 0 1 52 Dementia Without Complication 162 0.343 55.566 1 0 1 159 Pressure Ulcer of Skin with Partial Thickness Skin Loss 51 1.071 54.621 1 1 1 106 Atherosclerosis of the Extremities with Ulceration or Gangrene 36 1.313 47.268 1 1 1 108 Vascular Disease 164 0.288 47.232 1 0 1 138 Chronic Kidney Disease, Moderate (Stage 3) 208 0.227 47.216 1 0 1 96 Specified Heart Arrhythmias 169 0.276 46.644 1 0 1 135 Acute Renal Failure 54 0.617 33.318 1 1 1 158 Pressure Ulcer of Skin with Full Thickness Skin Loss 28 1.071 29.988 1 1 0 75 Polyneuropathy 106 0.281 29.786 1 0 1 103 Hemiplegia/Hemiparesis 55 0.481 26.455 1 0 1 139 Chronic Kidney Disease, Mild or Unspecified (Stages 1-2 or Unspecified) 112 0.227 25.424 1 0 1 22 Morbid Obesity 68 0.342 23.256 1 0 1 78 Parkinson's and Huntington's Diseases 40 0.555 22.200 1 0 1 84 Cardio-Respiratory Failure and Shock 62 0.326 20.212 1 0 1
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
What PACE CNY Is Already Doing To Prep For ICD-10 12 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.
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?
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 20 138 Chronic Kidney Disease, Moderate (Stage 3) 208 0.227 1 111 Chronic Obstructive Pulmonary Disease 199 0.388 2 18 Diabetes with Chronic Complications 176 0.344 3 85 Congestive Heart Failure 175 0.361 4 96 Specified Heart Arrhythmias 169 0.276 5 108 Vascular Disease 164 0.288 6 52 Dementia Without Complication 162 0.343 7 51 Dementia With Complications 131 0.616 8 139 Chronic Kidney Disease, Mild or Unspecified (Stages 1-2 or Unspecified) 112 0.227 9 75 Polyneuropathy 106 0.281 10 22 Morbid Obesity 68 0.342 11 84 Cardio-Respiratory Failure and Shock 62 0.326 12 103 Hemiplegia/Hemiparesis 55 0.481 13 135 Acute Renal Failure 54 0.617 14 159 Pressure Ulcer of Skin with Partial Thickness Skin Loss 51 1.071 15 79 Seizure Disorders and Convulsions 47 0.252 16 23 Other Significant Endocrine and Metabolic Disorders 41 0.240 17 78 Parkinson's and Huntington's Diseases 40 0.555 18 106 Atherosclerosis of the Extremities with Ulceration or Gangrene 36 1.313 19 88 Angina Pectoris 36 0.210 20
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 3 2.425 1 106 Atherosclerosis of the Extremities with Ulceration or Gangrene 36 1.313 2 46 Severe Hematological Disorders 4 1.078 3 70 Quadriplegia 1 1.075 4 157 Pressure Ulcer of Skin with Necrosis Through to Muscle, Tendon, or Bone 3 1.071 5 158 Pressure Ulcer of Skin with Full Thickness Skin Loss 28 1.071 6 159 Pressure Ulcer of Skin with Partial Thickness Skin Loss 51 1.071 7 160 Pressure Pre-Ulcer Skin Changes or Unspecified Stage 11 1.071 8 73 Amyotrophic Lateral Sclerosis and Other Motor Neuron Disease 1 1.016 9 9 Lung and Other Severe Cancers 8 1.006 10 27 End-Stage Liver Disease 1 1.003 11 71 Paraplegia 2 0.868 12 189 Amputation Status, Lower Limb/Amputation Complications 12 0.804 13 83 Respiratory Arrest 1 0.769 14 10 Lymphoma and Other Cancers 7 0.695 15 114 Aspiration and Specified Bacterial Pneumonias 15 0.691 16 21 Protein-Calorie Malnutrition 20 0.653 17 134 Dialysis Status 4 0.617 18 135 Acute Renal Failure 54 0.617 19 51 Dementia With Complications 131 0.616 20
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
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 0.240 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 0.617 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
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- 438.21, (HCC 100), weight.437 Hemiparesis due to old spinal cord injury, stable. ICD-9 code 342.90 + 907.2 (HCC 100),.437 If it wasn t documented it wasn t done. 18
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Query Reason Statistics 20 30 25 20 15 10 5 0
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 http://www.cms.gov/medicare/health- Plans/MedicareAdvtgSpecRateStats/Announcements-and- Documents.html 21
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: http://www.cms.gov/research-statistics-data-and- Systems/CMS-Information- Technology/mapdhelpdesk/Plan_Communications_User_Guide. html Screenshots on next 2 pages
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
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
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
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!
Questions 27 Kim Browning, CHRS, PMP, CHC Executive Vice President, Cognisight, LLC Kbrowning@cognisight.com Barb Nutting, RHIT, CCS-P Health Information Director, PACE CNY Bnutting@lorettosystem.org Thank you!