MEDICARE RISK ADJUSTMENT A PROSPECTIVE APPROACH TO RISK ADJUSTMENT AND ACCURATE DOCUMENTATION AND CODING

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1 MEDICARE RISK ADJUSTMENT A PROSPECTIVE APPROACH TO RISK ADJUSTMENT AND ACCURATE DOCUMENTATION AND CODING

2 WHAT IS RISK ADJUSTMENT? Risk Adjustment ensures that accurate payments are made to Medicare Advantage (MA) organizations based on the health status of their enrolled beneficiaries. Risk adjustment helps predict the overall disease burden and support additional costs of disease management to provide a high level of quality care. Risk Adjustment provides MA organizations with incentives to enroll and treat less healthy individuals.

3 HOW IS THE HEALTH STATUS OF ENROLLED MEMBERS CAPTURED? Payment is based on assignment of diagnoses to disease groups known as Hierarchical Condition Categories (HCC s). There are 70 HCC categories with over 3,000 ICD-9-CM codes grouped into the different HCC s. Each HCC disease category reflects chronic conditions which are often the most expensive for Medicare to treat such as Diabetes and CHF. Each HCC carries a weighted score relative to the cost of care. This score is used in calculating the risk score of each member. Diagnoses need to be documented and coded to the highest specificity available to reflect the most severe manifestation and cost of care. CMS does not carry over diagnoses from previous years. Diagnoses must be reported at least yearly.

4 THE PROVIDER S ROLE IN RISK ADJUSTMENT The provider is responsible for providing accurate and complete documentation of the patient s health related conditions in the medical record that will stand up to CMS s risk adjustment validation audits. The provider must accurately report the ICD-9- CM diagnoses codes to the highest level of specificity based on documentation in the medical record. An accurate analysis of each patient s health status leads to consistent treatment and a higher quality of care.

5 THE PROSPECTIVE APPROACH TO RISK ADJUSTMENT Purpose To collect and document the most accurate, complete and current diagnosis data of each member s acute and chronic conditions. To improve the quality of diagnosis data submitted to CMS. Provide an opportunity for PCP s to engage members who require active management of chronic illness and encourage preventive measures to improve quality of life.

6 Medicare Members with Chronic Conditions may become Under- Nourished Evidenced-based Geriatric Protocols for Best Practice sets the following benchmark for undernutrition: A BMI<22, or wt loss of >10 lbs in the last 6 months intentional or unintentional or serum albumin <3.5. The caveat for the albumin # is no acute illness, so two values separated by at least six weeks are required. Document and assess the nutritional deficiency in Medicare Members with Chronic Conditions.

7 Medicare Members with Chronic Conditions may develop Malnutrition With chronic diagnosis and/or conditions as the disease process progresses, the members nutrition status can become affected. Examples of a few diagnosis for Chronic diagnosis or conditions are COPD, CKD, CHF, Dementia, Cancer, Cardiomyopathy, and End Stage Renal Disease. The National Collaborating Center for Acute Care Guideline, asserts that an individual is malnourished when he or she displays the following values: A BMI <22 and documented weight loss. Any chronic condition patient with 2 albumins <3.5, BMI<18.5 or unintentional weight loss >10% over the last six months. BMI less than 20 and unintentional wt loss< 5% within the last 6 months. Document and assess nutritional deficiencies in Medicare Members with Chronic Conditions.

8 Group Health Plan s, Physician Education Program Provider s will receive a Medical Condition Documentation Form for each member requested by GHP needing a new evaluation to update their diagnosis data. Schedule an appointment with the member for a face-to-face encounter to update their diagnosis data. Complete the Medical Condition Documentation and the Hedis tool. Progress notes and supporting documentation for the quality tool must be faxed to the plan within 30 days of the visit. The plan will determine if the information provided by the provider is complete for payment to be processed. Only one (1) form per Advantra member per year will be paid per practice. The provider when asked will provide the plan corrected or additional information if it is determined that such information is needed within fifteen (15) calendar from the health plans request. The plan will provide instructions on how to provide the additional information, Progress notes must be legible, signed with provider s credentials, dated, patient s name and second identifier (ex: DOB) on every page, and complete documentation to support diagnoses. Fax the requested medical record documentation per the provided instructions. Please FAX EACH MEMBER S RECORD SEPARATELY.

9 DOCUMENTATION AND CODING GUIDELINES Chronic diseases treated on an ongoing basis may be coded and reported as many times as the patient receives treatment and care for the conditions. Document and code known conditions that describe a patient s status such as lower limb amputations including toes, gastrostomy, ileostomy, tracheostomy colostomy, cystostomy, nephrostomy, and renal dialysis status. Specifically document all conditions that impact the patient s overall health status such as old MI s, pacemakers, hemiplegia, residuals of CVA, MS, Parkinson s Disease, Myasthenia gravis, seizures, RA, AAA, AIDS, or HIV status, etc. Do not code diagnoses documented as probable, suspected, questionable, rule out, or working diagnosis. Rather, code the conditions to the highest degree of certainty for that encounter/visit, such as symptoms, signs, abnormal test results, or other reasons for the visit. Include documentation in the face-to-face office visit note to support the documented diagnoses. Ex: document status of condition, recent lab values, pertinent exam or clinical findings, symptoms, patient education of condition.

10 USE OF HISTORY OF Do not document chronic conditions that still exist as history of. History of means the disease no longer exists. Use the term "history of only for diseases that have resolved. In chronic conditions such as CHF, use terms such as compensated or controlled to reflect their status. Do not code conditions that were previously treated and no longer exist. However, history codes may be used as secondary codes if the condition has an impact on current care or influences treatment.

11 USE OF HISTORY OF Cancer diagnosis is considered an active disease until the patient has completed receiving active treatment which includes surgery, chemotherapy, radiation, and shows no sign of the disease. Those patients with no sign of the disease (ex: under post treatment surveillance with no evidence of recurrence) should be documented and coded as history of malignancy. Patients receiving hormone therapy for cancer can be coded as having active disease. Document and code any metastases as metastatic disease and not as a new primary malignancy. Document and code the primary as well as the metastatic sites. Late effects of stroke document and code all late effects of CVA. A CVA is an acute event and should be documented and coded as history of CVA after the initial episode.

12 BE SPECIFIC Document and code conditions to the highest specificity known. Specify diagnosis as acute or chronic Renal insufficiency, Hepatitis C Specify stage of CKD Document type of Diabetes, controlled or uncontrolled and any manifestations. Document causal relationship such as diabetic neuropathy or neuropathy 2 to diabetes. Identify, document and code secondary diagnosis for manifestation. Specify type of neuropathy such as peripheral Specify organism responsible for pneumonia

13 DOCUMENT, DOCUMENT, DOCUMENT Selection of an ICD-9-CM diagnosis code is based on documentation in the patient s medical record. REMEMBER IF IT ISN T DOCUMENTED, IT DOESN T EXIST!

14 HEDIS Overview The most widely used set of health care performance measures in the United States. HEDIS includes 75 measures across 8 domains of care. HEDIS measures account for 33% of the overall NCQA Accreditation scores.

15 HEDIS Overview The Affordable Care Act awards quality bonuses to the Medicare Advantage plans that earn 4 or more stars in a 5-star quality rating system. HEDIS scores drive the Star rating assigned to Medicare Plans. Plans that do not achieve a 4 star rating by 2015 will be hard to pressed to remain viable in the MA marketplace.

16 Group Health Plan s Medicare HCC Team GOALS: Work closely with our providers to offer guidance on proper documentation and coding to improve compliance with CMS data validation. Improve risk adjustment initiatives to reflect an accurate picture of the overall disease burden of our member population. Enhance the Star quality rating system within the health plan.

17 CONTACT INFORMATION o For further information you may contact the HCC Medicare Team o Karen Weinzirl o

18 Validated Physician Documentation Patient : Jane Doe DOB: 12/21/1945 DOS: 11/2/2010 Patient here due to dizziness after starting new digoxin.125 mg. Patient has a history of A-fib and is currently experiencing A-fib with a heart 128. She has Chronic Renal Failure secondary to diabetes She has a history of COPD, breast cancer in 1982 and an Old MI. BP 90/60, TEMP 98.3, HR 128 Respirations 22. Pt is alert and orientated. Lungs clear, Heart rate rapid and irregular Abdomen soft and round with bowel sounds in all four quadrants. All pulses present, No JVD or pedal edema. Will have to admit patient to hospital for observation. Diagnosis: A-fib Diabetes type 2 with renal manifestations continue to monitor Blood Sugars Chronic Kidney Disease Stage three stable COPD Lungs are clear John XTZ D,O Electronically signed John XTZ D.O on 11/2/2010 at 9:16 a.m. Validated: Includes patient name date of birth, date of service, physician signature with credentials, and documentation to substantiate documented diagnosis.

19 Not Validated Physician Documentation Patient : Jane Doe DOB: 12/21/1945 DOS: 1/2/2010 Patient came due to cold like symptoms. Patient has a history of Old MI, Diabetes, COPD, CHF and Renal Failure, BP 130/60, TEMP 102.1, HR 103 Respirations 26. Pt is alert and orientated. Looks fine Will have the patient take over the counter Tylenol for her temp, will have her take over the counter medicine for cough and cold like symptoms. Will have the patient return if she had not improved in 48 hours. Diagnosis: Cold Diabetes CHF COPD Renal Failure OLD MI John XTZ D,O Not electronically signed as MD left Signed by Susie Nurse RN Not Validated: Just listing CHF, Diabetes, COPD and Renal Failure as diagnosis does not meet CMS guidelines. A nurse can t sign for an MD for any reason under CMS guidelines.

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