RISK ADJUSTMENT DOCUMENTATION AND CODING

Transcription

1 RISK ADJUSTMENT DOCUMENTATION AND CODING Complete coding matters to the health of your practice and patients July 2014

2 OBJECTIVES At the completion of this provider workshop, you will: Know what risk adjustment is and the impact it will have for your practice Understand Hierarchical Condition Categories (HCCs) Be familiar with correct documentation guidelines Understand the impact that incomplete coding can have on your practice 2

3 OVERVIEW Risk adjustment is a tool used to predict health care costs based on the relative risk of enrollees to protect against potential effects of adverse selection. The Affordable Care Act (ACA) includes commercial risk adjustment for small group and Individual plans. Medicare risk adjustment has been in place for Medicare Advantage plans for some time, and is part of our Medicare Program Management. Medicare risk adjustment utilizes Hierarchical Condition Category (HCC) grouping logic in its risk adjustment model. For commercial risk adjustment, the U.S. Department of Health and Human Services (HHS) employs the HCC grouping logic used in the Medicare risk adjustment program, but with HCCs refined and selected to reflect the expected risk adjustment population. 3

4 HIERARCHICAL CONDITION CATEGORIES Disease groups, organized into body systems or similar disease processes, and are referred to as HCCs. The HCCs used for Medicare and commercial risk adjustment are different. The CMS- and HHS-HCC models include both diseases and demographic factors, called coefficients. There are sets of coefficients for: New enrollees Members in the community Members in long-term care institutions Enrollees with end-stage renal disease The models are cumulative; a patient may be assigned to more than one category. Some HCCs will trump other related conditions (only one HCC in a category may be assigned). 4

5 HHS COMMERCIAL RISK ADJUSTMENT Commercial risk adjustment is one of three new risk stabilization programs established by the ACA to be implemented in January The program is intended to encourage health plan competition based on quality improvements and efficiency, mitigating the impact of potential adverse selection and stabilizing premiums. Either the state exchange or HHS will be responsible for operating risk adjustment models. The HHS risk adjustment model redistributes money from insurers with healthier patient populations to those with sicker patient populations. 5

6 COMPARISON OF HHS AND CMS MODELS Attributes Dx Code Capture Acceptable Codes Medicare Advantage Commercial Implications Age, gender, medical conditions Age, gender, medical conditions and financial status for those who qualify for cost-sharing reductions. The model also includes demographic attributes and product information. Medical conditions have to be treated/addressed and documented annually or need to specify that the member no longer has the condition Conditions documented during face-to-face encounter with accepted provider types Commercial risk adjustment requires additional data capture for demographics Chronic conditions not documented annually are not captured in risk scores Same, therefore easier in establishing provider practices Acceptable Encounters Professional, inpatient and outpatient Same, therefore easier in establishing provider practices Historical Conditions Coded and reported conditions transfer with member No member-level data transferred between plans For commercial risk adjustment, all conditions need to be documented annually and when plan changes 6

7 IMPORTANCE OF RISK ADJUSTMENT CODING CMS and HHS require health plans to report complete and accurate diagnostic information on our members. Currently, roughly 90% of the diagnostic information submitted to CMS comes from provider claims data. Health plans must attest that the reported diagnostic information is correct and accurate. Health plans do not review 100% of the claims coding and/or clinical documentation generated by providers. Appropriate diagnosis code reporting and complete clinical documentation at the provider level increases the accuracy of member risk scores. Accurate member risk scores promote consistent contracted provider revenue and competitive member premiums. 7

8 EFFECTS ON PROVIDERS Why will providers be affected? How will providers be affected? Each patient s entire risk profile must be reflected in the medical record and completely coded in claims and encounter data Opportunities to Improve Care Practice Financial Health of Your Practice 8

9 PROVIDER PREPARATION STEPS Review impact and opportunities to improve clinical documentation and complete code capture Standardize processes for complete medical record documentation and coding to minimize disruption to practice flow Utilize tools and resources to identify and remediate incomplete coding Develop internal checkpoints for the most common documentation and coding errors prior to claim or encounter submission 9

10 PROVIDER PRACTICE IMPLICATIONS Step 1: Document each patient s demographic information and clinical information in the medical record. Make sure you use the best practices for documentation accuracy. Step 2: HHS and CMS use claims data and patient demographic information to calculate a patient s risk score. Complete medical record documentation and submission of all appropriate diagnosis codes, using the highest level of specificity, comes as a result of employing best practices for documentation, coding and billing. Step 3: HHS and CMS reviews and validate risk scores through data validation audits If coding is accurate and complete, provider practices are minimally disrupted, allowing greater focus on patient care and other practice aspects. If coding is inaccurate or incomplete, there is a higher likelihood of requests for medical records due to HHS requirements for documentation to support accurate risk score submission by insurers. More medical record requests, by HHS or a Plan, means higher practice disruption and cost. Inaccuracies in coding, once known, do require correction. 10

11 DOCUMENTATION REMINDERS: THE BASICS Each page of a note must include: The patient s name Date of birth or other unique identifier (on the first page) Date of service (including the year) The provider s signature must be legible and include credentials. Legibility issues can be solved with a pre-printed signature/credential block and a handwritten signature above Electronic signatures should include the date and time of authentication, the service provider s name and credentials and include a statement such as Electronically signed by or Authenticated by 11

12 CODING AND DOCUMENTATION ICD-9 diagnosis coding rules can be counterintuitive to clinical practice. The pneumonic MEAT is used frequently in risk adjustment coding to represent the criteria for capturing a diagnosis code on a particular date of service. For a diagnosis to be coded on a given date of service, the documentation must clearly state that the specific diagnosis was either Monitored, Evaluated, Assessed or Treated during the face-to-face encounter on that day. Risk adjustment diagnoses must be captured from the notes of an approved provider type. MD, DO, PA, ARNP, Clinical Psychologist, PT, OT, Audiologist, DPM, etc. 12

13 CODING AND DOCUMENTATION Clinical documentation from inpatient hospital, outpatient hospital and face-to-face office visits is acceptable for coding and reporting under risk adjustment. Examples of unacceptable documentation sources for risk adjustment coding/reporting include: Super bills Referral forms Encounter forms Patient-only reported conditions Non face-to-face encounter notes The stand alone patient problem list 13

14 CODING AND DOCUMENTATION All relevant diagnosis codes should be reported at least once per year for each patient (preferably every six months). On January 1 each year, the patient s diagnosis information is reset in preparation for a new year of diagnosis encounter data. We are able to receive a maximum of 12 diagnosis codes on an outpatient claim. Confirm how many diagnosis codes per claim are allowed in your system and ensure all applicable diagnosis codes are submitted for each patient during the calendar year. 14

15 CODING AND DOCUMENTATION Annual evaluation, documentation and submission of all relevant diagnoses and corresponding diagnosis codes is paramount for: Data validation audits Promoting quality patient care Accurate patient risk score calculation Ensuring appropriate screening tests are received Ongoing assessment of the patient s chronic conditions 15

16 COMMON ERRORS The historical status of a diagnosis is unclear. The electronic health record was not authenticated. Legible provider signature and credentials are not included. Discrepancies exist between the medical record and the reported ICD-9 codes (Monitor Evaluate Assess or Treat). Chronic or coexisting conditions are not documented or are left out of the clinical documentation for an office visit. The record contains nonstandard abbreviations or up and down arrows to indicate diagnoses. 16

17 COMMON ERRORS The use of quantifying language in the outpatient setting, (e.g. Consistent with, probable, possible.) Patient status conditions are not evaluated and/or documented at least once a year. A cause and effect relationship between diabetes and diabetic manifestation codes is not sufficiently documented and/or coded. The highest degree of ICD-9 diagnosis code specificity was not assigned (4th and 5th digits of ICD-9 codes are not utilized) Regence. 17

18 OPPORTUNITIES FOR CLARIFICATION Do not document and report this if you really mean the patient has Depression 311 Major depression 296.XX Bronchitis 490 Chronic bronchitis Asthma Chronic obstructive asthma Vertebral fracture Pathological fracture of vertebrae CVA with weakness 436 & History of CVA with residual dominant side hemiplegia Patient is very obese Patient is morbidly obese Poorly controlled diabetes Uncontrolled diabetes

19 MEDICARE RISK ADJUSTMENT CASE EXAMPLE Patient: Sally Jones DOB: 12/1/38 DOS: 10/11/12 Patient is a 72 year old female with UTI like symptoms. Patient c/o fatigue, low energy and poor appetite. Patient is status post MI 18 months ago. Patient appears frail and with mild malnutrition. Has lost 23 pounds in the last 4 months. Patient has been complaining of pain with urination, weakness, and has had dry, itchy skin for the past several months. U/A done today shows WBCs, leukocyte esterase, and microalbuminuria. Serum creatinine is 1.5. PMH: Type II diabetes, chronic kidney disease secondary to diabetes, history of BKA skin intact at stump, no erythema. History of MI. Previous UTI 4 months ago with a serum creatinine of 1.6. Lab results at that time revealed stage 2 CKD. A/P: Diabetes-Metformin 500 mg b.i.d. Bactrim for UTI. Malnutrition- Ensure b.i.d. and nutrition consult. RTC in 6 weeks. Referral made to Dr. Smith (Nephrologist) for CKD. Note Electronically Signed by John Anderson, MD 10/11/

20 MEDICARE RISK ADJUSTMENT CASE EXAMPLE Coding Example 1: Typically submitted ICD-9-CM codes for the office visit ICD-9-CM Code Condition HCC DM w/o complication type II 19 (HCC-C) Urinary tract infection Does not risk adjust Coding Example 2: Opportunities for additional risk adjustment code reporting Diabetes w/ renal manif. type II 18 (HCC-C) Stage II CKD 125 (HCC-D) Malnutrition of mild degree 21 (HCC-C) Urinary tract infection Does not risk adjust 412 Prior MI 89 (HCC-D) V49.75 Amputation, below knee 189 (HCC-C) 20

21 BEST PRACTICES Medical coding of patient encounters is only as good as the underlying medical record documentation. Accuracy Specificity Best practices in medical coding Thoroughness Consistency 21

22 MAKING SURE YOU ARE ON THE BALL Engage coders and office staff Engage clinicians to perform accurate capture of primary conditions, as well as presenting co-morbidities, particularly in more complex cases. to ensure the use of coding best practices. Consider taking classes or using concise reference cards. Accurate risk scores Adopt technologies such as electronic health records or other software to improve efficiency and accuracy. 22

23 RESOURCES Thank you for completing our online workshop. We encourage your feedback or questions by . The following resources are available on our provider website, asuris.com: The Risk adjustment section of the Administrative Manual includes key requirements for providers Adequacy of medical record keeping, located under Site review standards, is an important part of our Quality Program Risk Adjustment program information and best practices are listed under Products and Programs, including the Risk adjustment coding and documentation tips (PDF) brochure 23