Risk Adjustment Factor. April 30, 2015

Transcription

1 Risk Adjustment Factor April 30, 2015

2 Agenda What is RAF? The HCC Model Documentation and Coding for RAF The ICD-10-CM Transition Our Ask 2

3 What is RAF? 3

4 RAF Defined Accurate RAF coding drives 4 key factors of a successful population health program Additional Resources Better Analytics Wholepatient view Encourages regular engagement Provides a payer with additional resources to manage the health of a riskier population More accurate coding leads to improved predictive modeling and stratification of a population Creates individual patient profiles that reflect their overall health instead of episodic issues Encourages regular outreach to patients who aren t visiting the practice but may need follow up Used to assess the clinical complexity of a patient and predict the burden of illness for individuals and populations Acts as a multiplier when calculating CMS payments to a payer Factors into the bidding and payment of MA plans Focuses on identification, management and treatment of chronic conditions. 4

5 Why is RAF Important? Capturing appropriate diagnosis codes through the RAF program drives improved patient care and clinical quality. Enhances physicians understanding of the comparative riskiness of their panel Allows for an accurate account of the population s clinical profile, including conditions treated by specialists, complications and comorbidities Helps identify previously undocumented suspect medical conditions through integration of disparate patient data using clinical algorithms Improves accuracy of patient stratification for clinical programs, referral to care manager and care team Helps providers develop comprehensive and coordinated care plans to manage the whole patient Encourages outreach to patients without regular visits to their primary care physician Patients with chronic conditions cost more to treat and therefore need to be coded accurately The only way to ensure appropriate reimbursement from CMS is through accurate ICD-9-CM coding and physician documentation Fair payment for accurate treatment 5

6 Why Should You Engage? As a physician or care team member, you can Capture the true burden of illness for your patient panel Improve identification for care management programs and quality initiatives Drive high quality care through a comprehensive medical record Build a foundation for the transition from volume to value-based care Ensure integrity and compliance with clinical documentation standards Cultivate a partnership with the health system and plan. 6

7 Physician Led Solutions Traditional RAF approach Health Plan led Physician led Value add of provider-led solutions Advantages of a physician-led solution: Physician ownership and accountability for RAF outcomes: Engaged and incentivized physicians actively building comprehensive patient profiles Fewer diagnostic gaps, reducing the necessity for payer involvement in RAF programs Improved care coordination amongst primary care physicians, their patients, and specialists Engagement of embedded care managers, practice managers, etc.: Ensures that RAF efforts are custom-tailored to the individual practices RAF data output can be modified/structured and fed into down-steam analytics (e.g. risk stratification) 7

8 The HCC Model 8

9 Characteristics of CMS-HCC Model The HCC model contains 79 diagnostic categories, reflective largely of chronic conditions experienced in a Medicare population Risk scores for each diagnosed HCC are added together for each patient, as are additional factors for comorbidities (ex. CHF and COPD) Over 3,000 ICD-9 diagnosis codes are used to compile an accurate risk profile Conditions must be documented and billed at least once per calendar year for inclusion in the risk model The model is also calibrated to account for disease severity, requiring coding specificity (ex. diabetes unspecified vs. diabetes with renal complications) 9

10 Characteristics of the HCC Model It s Additive Document and Code all diagnoses specific to each patient Hierarchies and Disease Interactions Patients diagnosed with multiple HCC s in a single hierarchy will be reimbursed at the highest paying HCC Additional payments are offered when certain diseases coincide When these diseases are present in the same patient, CMS recognizes a higher cost associated with treatment which necessitates an increased payment Examples include: CHF and COPD CHF and Renal Disease 10

11 The HCC Model DM Hierarchy HCC and Risk Score *17 Diabetes with acute complications* Risk score *18 Diabetes with neurological or other specified manifestations Risk score *18 Diabetes with renal or peripheral circulatory manifestations Risk score *18 Diabetes with ophthalmologic manifestations Risk score *19 Diabetes, no complications Risk Score Sample Associated Dx/ICD-9-CM Codes Diabetes with ketoacidosis Code: 250.1x Diabetes with neurological manifestations Code also manifestation, e.g. DM polyneuropathy Codes: 250.6x, (357.2) Diabetes with renal manifestations Code also manifestation, e.g., DM nephropathy Codes: 250.4x, (583.81) Diabetes with ophthalmologic manifestations Code also manifestation, e.g., DM retinopathy Codes: 250.5x, ( ) Diabetes mellitus Code: *Hierarchy 11

12 The HCC Model Neoplasm Hierarchy HCC and Risk Score HCC 8 Metastatic Cancer and Acute Leukemia Risk score HCC 9 Lung and Other Severe Cancers Risk score Sample Associated Diagnoses Secondary malignant neoplasm of bone and bone marrow Acute lymphoid leukemia remission Malignant neoplasm of liver primary Malignant neoplasm of upper lobe of lung HCC 10 Lymphoma and Other Cancers Risk score Malignant neoplasm of adrenal gland Hodgkin s disease HCC 11 Colorectal, Bladder and Other Cancer Risk score Malignant neoplasm of transverse colon Malignant neoplasm of cervix HCC 12 Breast, Prostate and Other Cancers and Tumors Risk Score Malignant melanoma Malignant neoplasm breast 12

13 Characteristics of the HCC Model Sample HCCs HCC 22 Morbid Obesity New HCCs HCC 124 Exudative Macular Degeneration Sample Associated Diagnoses Body Mass Index of 40 or greater, Adult Exudative macular degeneration HCC 135 Acute Renal Failure HCC 136 Chronic Kidney Disease (Stage 4-5 and ESRD) HCC 157 Pressure Ulcer of Skin with Necrosis Through to Muscle, Tendon or Bone Acute kidney failure Chronic kidney disease stage V End Stage Renal Disease Pressure ulcer stage IV HCC 158 Pressure Ulcer of Skin with Full Thickness Skin Loss Pressure ulcer stage III HCC 159 Chronic Ulcer of Skin, Except Pressure Ulcer of heel 13

14 Documentation and Coding for RAF 14

15 Important Elements of RAF Coding ICD-9-CM is the official diagnosis code set for risk adjustment payment Role of the provider is to capture and document all conditions that are treated, managed, or affect patient care during a face-to-face visit Coded diagnoses must be supported by medical record documentation including, evaluation, assessment and treatment plan Accurate coding and documentation is crucial for accurate risk profile 15

16 Central Tenets of High Quality Documentation Quality documentation captures all conditions that are assessed, treated, managed, and which affect patient care at each visit, or at least once a year Conditions need to be captured during a face to face visit by a Physician, Nurse practitioner or Physician Assistant in an office visit, hospital, or outpatient setting Assess all conditions that coexist at time of encounter Consider disease specificity and comorbidities Accurately code all diagnoses and submit on a claim 16

17 RAF Coding Process Conduct RAF Assessment during a face-to-face encounter Document appropriate conditions in patient s medical record (Treat, Evaluation, Assessment or Monitor - TEAM) Apply the specific ICD-9-CM code(s) to the claim 17

18 2014 Documentation Quality Results Example #1 Condition comorbidities specified Management plan Conditions treated by specialists included Conditions under management included Status of conditions specified Example #2 The physician used suggested verbiage from the worksheet to detail that the condition was managed by a specialist, with a follow-up visit scheduled Each condition is thoroughly assessed in A&P with discussion of status and future management Medication plan and specifics are provided 18

19 Coding Issues 29% of encounters reviewed had Doc./Coding issues Case study: Physician evaluates conditions on the worksheet but neither bills nor documents conditions A Evaluate conditions on worksheet B Bill conditions Despite evaluating 6 chronic conditions from the assessment worksheet, the physician only billed V70.0 (physical exam). C Document conditions None of the checked conditions were evaluated in the A/P section of the medical record. 19

20 Appropriate RAF Coding - Example The example below showcases appropriate coding/billing and documentation. The assessment and plan section treats, evaluates, assesses and monitors (TEAM) the presented conditions HPI Sally comes into the office today with labored breathing and shortness of breath. Pt. has a history of COPD and Congestive Heart Failure. A/P COPD Exacerbation Patient currently taking Spiriva. Will increase dosage and patient will follow-up with pulmonologist. CHF Currently stable. Patient will continue on Lasix ICD-9-CM Code Description HCC Risk Score Obstructive Chronic Bronchitis with Acute Exacerbation Congestive Heart Failure, NOS Total RAF Score

21 Documentation Tips A code cannot be justified in the record if the diagnosis is only listed on the Problem List Auditors cannot connect diagnosis with medications or treatment plans the physician must do this in the documentation Codes billed on a claim should be assessed/treated by the provider in the Assessment and Plan Appropriate Documentation Language Examples Chronic condition X is stable and will continue current management. Chronic condition Y s management requires the following interventions/ changes Chronic condition Z is currently managed by a specialist with a scheduled follow up visit. 21

22 Patient Centered Primary Care (PCMH) Model and RAF PCMH is a care model that includes a comprehensive, team based, coordinated approach to patient care. The Primary Care Team is wholly accountable for a patient s physical and mental health care needs and coordinates patient care across the broader health care system. The Primary Care Physician evaluates the management of patient chronic conditions and documents the associated treatment plans. In the CMS-HCC model: Can a Primary Care Physician bill a diagnosis code that he is not treating? Yes, it is the responsibility of the Primary Care Physician to capture all conditions and monitor the treatment of those conditions. 22

23 Documentation Tips Linking Conditions Coders can only code what is documented by the provider Diagnoses relationships cannot be assumed or inferred Related conditions must be linked together in the medical record If two or more conditions are related, the provider must use the appropriate verbiage in the MR so that the correct code(s) can be assigned Diabetic Linking Examples Diabetes with Retinopathy Retinopathy due to Diabetes Diabetic Retinopathy 23

24 Appropriate RAF Coding Properly Linking Conditions A/P Patient with chronic kidney disease stage IV due to type 2 DM that has been well-controlled by insulin. The patient also receives dialysis on a regular basis at the outpatient clinic. The dialysis has been currently going well. Patient also had below-knee amputation last year. No noticeable infection present. ICD-9-CM Code Description HCC Risk Score Diabetes with renal manifestations, Type II or unspecified type, not stated as uncontrolled Chronic kidney disease stage IV, requiring chronic dialysis V45.11 Renal dialysis status V49.75 Below Knee Amputation, Status Total RAF Score The Aim: Ensuring a comprehensive patient profile is documented and billed annually 24

25 Non-Specific Language Using symbols such as +,, or will not infer a diagnosis Abnormal lab values do not equate to a diagnosis Provider must use definitive language to bill a condition blood pressure indicates an elevated blood pressure reading, not hypertension GFR < 15 on its own should not be coded as Renal Failure. Renal Failure must be documented in the note in order to code it Probable CKD cannot be billed as CKD. Do not use question of or rule out 25

26 HCC Coding Example A/P Patient is here today for chest congestion. Chest x-ray and cultures reveal Pneumonia. She has sugar and hx of Heart Problems with current edema. Chest is wheezy with rales. Plan to increase fluids, monitor glucose readings, and antibiotics. How can we make this note better? ICD-9-CM Code Description HCC Risk Score 486 Pneumonia, Unspecified Abnormal blood sugar Cardiovascular disease, unspecified 0.0 Total RAF Score 0.0 The documentation above does NOT support submitting these diagnoses. 26

27 HCC Coding Example A/P Patient is here today for chest congestion. Chest x-ray and cultures reveal pneumococcal pneumonia. She has diabetes controlled by diet and Metformin. Chest is wheezy with rales. Plan to increase fluids, monitor glucose readings bid at home, and oral antibiotics. Patient has Chronic Systolic CHF with present edema. Will continue Lasix. Patient is to call for glucose readings over 200 and return for a follow-up appointment in one week. ICD-9-CM Code Description HCC Risk Score 481 Pneumococcal Pneumonia Diabetes mellitus, Type II or unspecified type, not stated as uncontrolled Chronic Systolic Heart Failure Total RAF Score Takeaway Being as specific as possible will boost risk score in some cases. 27

28 Can t Miss Chronic Conditions Morbid Obesity (BMI >= 40) Major Depressive Disorder CHF COPD Diabetes with and without manifestation(s) CKD I - V & ESRD Atrial Fibrillation Malnutrition PVD 28

29 ICD-10-CM Transition 29

30 ICD-10-CM is Coming..Finally We Think.. 4/7/2015 CMS 2016 Announcement CMS cannot accept or process ICD-9 codes for risk adjustment for services with dates of service beginning October 1, Additionally All entities covered by HIPAA must use ICD-10 for dates of service starting October 1, 2015, which includes health care providers and payers who do not deal with Medicare claims but are covered entities under HIPAA Full transition to 2014 HCC Model ICD-10-CM Preliminary list on CMS website 30

31 ICD-10-CM Transition ICD-9-CM vs. ICD-10-CM ICD-10-CM requires greater coding accuracy and specificity ICD-9-CM currently has 13,000 codes, ICD-10-CM has nearly 70,000 ICD-9-CM consists of 3-5 numerical digits, ICD-10-CM is alphanumeric and will consist of 3-7 digits ICD-10-CM allows for condition laterality, which is limited in ICD-9-CM CPT/E&M/HCPCS codes will remain unchanged 31

32 ICD-9 vs. ICD-10 Coding Structure ICD-9 CM Example: ICD-10-CM Example: 32 32

33 ICD-10 Coding Structure Example Chronic gout due to renal impairment, left shoulder, without tophus (tophi)

34 Appropriate RAF Coding ICD-10 HPI Jon comes into the office today for a check-up on his Diabetes. Pt. has a history of CKD and Congestive Heart Failure. A/P Type II DM with Stage IV CKD Patient currently stable and will follow up with nephrologist. Chronic Systolic CHF Currently stable. Patient will continue on Lasix ICD-9-CM Code E11.22 Description Type 2 diabetes mellitus with diabetic chronic kidney disease HCC Risk Score N18.4 Chronic Kidney disease, stage IV I50.22 Chronic systolic (congestive) Heart Failure Total RAF Score

35 ICD-10-CM Transition Bizarre ICD-10-CM codes: R46.1-Bizarre personal appearance Z73.1-Type A behavior pattern Z Sibling Rivalry Z63.1-Problems with the in-laws X52-Prolonged stay in weightless environment W56.22xA-Struck by orca, initial encounter W61.62-Struck by a duck, sequela V95.42xA-Forced landing of spacecraft injuring occupant, initial encounter S308.67A-Insect bite (non-venomous) of anus, initial encounter V97.33xD-Sucked into jet engine 35

36 Brief RAF Quiz 36

37 Question Which of the following conditions could be coded from the example below? Answer: A/P 1)Congestive Heart Failure Stable: Patient will continue on IV Lasix with scheduled Cardiologist follow-up next month 2)Hx of COPD 3)DM II: Currently stable and managed on insulin 4)HTN 5)Probable CKD: Scheduled to see nephrologist next week A. COPD and CHF B. CHF, DM II C. CHF and DM II, Hypertension D. CHF, COPD, DM II, and high blood pressure 37

38 Answer Which of the following conditions could be coded from the example below? Answer: A/P 1)Congestive Heart Failure Stable: Patient will continue on IV Lasix with scheduled Cardiologist follow-up next month 2)Hx of COPD 3)DM II: Currently stable and managed on insulin 4)HTN 5)Probable CKD: Scheduled to see nephrologist next week A. COPD and CHF B. CHF, DM II C. CHF and DM II, Hypertension D. CHF, COPD, DM II, and high blood pressure 38

39 Question What conditions can be captured from the example below? A/P 1)ESRD Stable today. Patient currently receives dialysis MWF. Scheduled to follow up with his nephrologist next week. 2)Type II Diabetes Stable on insulin. Answer: A (Diabetes with renal manifestations), (ESRD) B (Diabetes, type II or unspecified), (ESRD), (V45.11) Dialysis status C (Diabetes with renal manifestations), (Diabetes, type II or unspecified) D (Diabetes with renal manifestations), (ESRD), (V45.11) Dialysis status 39

40 Answer What conditions can be captured from the example below? A/P 1)ESRD Stable today. Patient currently receives dialysis MWF. Scheduled to follow up with his nephrologist next week. 2)Type II Diabetes Stable on insulin. Answer: A (Diabetes with renal manifestations), (ESRD) B (Diabetes, type II or unspecified), (ESRD), (V45.11) Dialysis status C (Diabetes with renal manifestations), (Diabetes, type II or unspecified) D (Diabetes with renal manifestations), (ESRD), (V45.11) Dialysis status 40

41 Our Ask 41

42 Ask of Practices and Physicians A Practices Take ownership of making RAF successful and help to integrate with other quality initiatives Provide feedback on what works and suggest how other aspects could be improved B Physicians C Staff Continue excellent care for Premier MA patients Assist with scheduling and early identification Utilize HCC coding guide : document, and code Premier Medicare patients health conditions each calendar year Incorporate appropriate conditions into patients problem list and validate annually Ensure accountability and facilitate smooth office processes Help prepare worksheets, validate completion of progress note and coding, submit worksheet 42

43 The Bottom Line It s good for the health of your community Max reimbursement means the payer has resources to put toward population health technology, clinical programs like PATH, and people/processes that help us identify, reach, and impact the health of patients with varying degrees of need. It s good for physicians While revenues initially flow to the payer, physicians should share in the benefit and receive up to $100 per completed RAF form per patient. The RAF process should help capture a complete 360 view of the patient to support informed medical decision-making. It s good for our patients Patients should be assessed, treated, and cared for based on their complete health profile, not just relevant conditions of the day. It s good for your practice The RAF program provides education, processes, and tools for capturing the health status of all the health plan patients which will help practices manage the population. It s good for the system, and the plan CMS will pay more to care for patients with significant health conditions. If we accurately score the health profile of our patients, we can earn what s available from CMS for treating these patients. Improved accuracy = max reimbursement. 43

44 Thank you for attending today s session. Questions? Whitney Smith, MBA, RHIA wsmith@evolenthealth.com Phone: