CMS HCC RISK ADJUSTMENT ROBERT RESNIK MD MBA

Transcription

1 CMS HCC RISK ADJUSTMENT ROBERT RESNIK MD MBA trianglemedicalgroup.com

2 Definitions Risk Adjustment Factor (RAF) Risk Score HCC- Hierarchical Condition Categories RX HCC

3 Risk Adjustment Factors (RAF) CMS uses risk adjustment to account for differences in beneficiarylevel risk factors that can affect quality outcomes or medical costs, regardless of the care provided. The goal of risk adjustment is to enable more accurate comparisons across networks that treat beneficiaries of varying clinical complexity It removes the differences in health and other risk factors that impact measured outcomes but are not under the TIN s control. The purpose is so that Centers for Medicare and Medicaid Services (CMS) can pay plans for the risk of the beneficiaries they enroll, instead of calculating an average amount for Medicare/ Medicare Advantage beneficiaries.

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7 Demographic RAF for Medicare Enrollees

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9 Table 1. HCCs included in the CMS-HCC risk-adjustment model6 HCC number and brief description of disease/condition HCC82 = Respirator Dependence/Tracheostomy Status HCC1 = HIV/AIDS HCC83 = Respiratory Arrest HCC2 = Septicemia, Sepsis, Systemic Inflammatory Syndrome/Shock HCC84 = Cardio-Respiratory Failure and Shock HCC6 = Opportunistic Infections HCC85 = Congestive Heart Failure HCC8 = Metastatic Cancer and Acute Leukemia HCC86 = Acute Myocardial Infarction HCC9 = Lung and Other Severe Cancers HCC87 = Unstable Angina and Other Acute Ischemic Heart Disease HCC10 = Lymphoma and Other Cancers HCC88 = Angina Pectoris HCC11 = Colorectal, Bladder, and Other Cancers HCC96 = Specified Heart Arrhythmias HCC12 = Breast, Prostate, and Other Cancers and Tumors HCC99 = Cerebral Hemorrhage HCC17 = Diabetes with Acute Complications HCC100 = Ischemic or Unspecified Stroke HCC18 = Diabetes with Chronic Complications HCC103 = Hemiplegia/Hemiparesis HCC19 = Diabetes without Complication HCC104 = Monoplegia, Other Paralytic Syndromes HCC21 = Protein-Calorie Malnutrition HCC106 = Atherosclerosis of the Extremities with Ulceration or HCC22 = Morbid Obesity Gangrene HCC23 = Other Significant Endocrine and Metabolic Disorders HCC107 = Vascular Disease with Complications HCC27 = End-Stage Liver Disease HCC108 = Vascular Disease HCC28 = Cirrhosis of Liver HCC110 = Cystic Fibrosis HCC29 = Chronic Hepatitis HCC111 = Chronic Obstructive Pulmonary Disease HCC33 = Intestinal Obstruction/Perforation HCC112 = Fibrosis of Lung and Other Chronic Lung Disorders HCC34 = Chronic Pancreatitis HCC114 = Aspiration and Specified Bacterial Pneumonias HCC35 = Inflammatory Bowel Disease HCC115 = Pneumococcal Pneumonia, Empyema, Lung Abscess HCC39 = Bone/Joint/Muscle Infections/Necrosis HCC122 = Proliferative Diabetic Retinopathy and Vitreous Hemorrhage HCC40 = Rheumatoid Arthritis and Inflammatory Connective Tissue Disease HCC124 = Exudative Macular Degeneration HCC46 = Severe Hematological Disorders HCC134 = Dialysis Status HCC47 = Disorders of Immunity HCC135 = Acute Renal Failure HCC48 = Coagulation Defects and Other Specified Hematological Disorders HCC136 = Chronic Kidney Disease, Stage 5 HCC54 = Drug/Alcohol Psychosis HCC137 = Chronic Kidney Disease, Severe (Stage 4) HCC55 = Drug/Alcohol Dependence HCC157 = Pressure Ulcer of Skin with Necrosis to Muscle/tendon/Bone HCC57 = Schizophrenia HCC158 = Pressure Ulcer of Skin with Full Thickness Skin Loss HCC58 = Major Depressive, Bipolar, and Paranoid Disorders HCC161 = Chronic Ulcer of Skin, Except Pressure HCC70 = Quadriplegia HCC162 = Severe Skin Burn or Condition HCC71 = Paraplegia HCC166 = Severe Head Injury HCC72 = Spinal Cord Disorders/Injuries HCC167 = Major Head Injury HCC73 = Amyotrophic Lateral Sclerosis and Other Motor Neuron Disease HCC169 = Vertebral Fractures without Spinal Cord Injury HCC74 = Cerebral Palsy HCC170 = Hip Fracture/Dislocation HCC75 = Myasthenia Gravis/Myoneural Disorders, Inflam/Neuropathy HCC173 = Traumatic Amputations and Complications HCC76 = Muscular Dystrophy HCC176 = Complications of Specified Implanted Device or Graft HCC77 = Multiple Sclerosis HCC186 = Major Organ Transplant or Replacement Status HCC78 = Parkinson's and Huntington's Diseases HCC188 = Artificial Openings for Feeding or Elimination HCC79 = Seizure Disorders and Convulsions HCC189 = Amputation Status, Lower Limb/Amputation Complications HCC80 = Coma, Brain Compression/Anoxic Damage

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12 Disease Hierarchies Can only get credit for one diagnosis within each HCC category HCC 18 Diabetes with Chronic Complicationd Diabetes with neuropathy HCC 18 E11.40 Diabetes with retinopathy HCC 18 E11.39 Diabetes with nephropathy HCC 18 E11.29 All Code to HCC 18 which is DM with Chronic Complications All have same risk score value within HCC18 Only get credit for one but should always document as many chronic complications as possible 12

13 Disease Hierarchies within Condition Categories HCC s are grouped into Condition Categories Diabetes HCCs Diabetes with Acute Complications-HCC17 Diabetes with Chronic Complications-HCC18 Diabetes without Complications-HCC19 HCC 17 over rides HCC 18 and HCC 19 while HCC 18 over rides HCC 19 HCC If the Disease Group is Listed in this Column Then drop the Disease Group listed in this column 17 Diabetes with Acute Complications 18, Diabetes with Chronic Complications 19 13

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15 RAF REIMBURSEMENT FOR MA PLANS PROPER ICD-10 Coding generates RAF Score RAF SCORE DETERMINES REIMBURSEMENT FOR MA PLAN PROPER DOCUMENTATION IS NEEDED TO MAINTAIN THE REIMBURSEMENT

16 PATIENT RAF Score AVERAGE MEDICARE PATIENT s RAF IS 1.0 National Average 1.0 approx = $9100 CMS reimburses 1% HIGHER for every 0.01 RAF increase Normalization Factor Applied to keep the average FFS risk score at 1.0 For PY 2017, CMS-HCC Normalization Factor is.998 MA Coding Pattern Adjusted Score Applied to adjust for the difference in coding patterns between MA and FFS For PY 2017, adjustment is 5.66%

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18 RAF Values CHANGE Through the Years HIV 2012 RAF RAF RAF.312 DM w/o complications 2011 RAF RAF RAF.104 DM with complications 2011 RAF RAF RAF.318

19 Hierarchical Condition Categories (HCC) List HCC1 HIV/AIDS HCC55 Drug/Alcohol Dependence HCC106 Atherosclerosis of the Extremities with HCC2 Septicemia, Sepsis, Systemic HCC57 Schizophrenia HCC107 Vascular Disease with Complications HCC6 Opportunistic Infections HCC58 Major Depressive, Bipolar, and 0, HCC108 Vascular Disease HCC8 Metastatic Cancer and Acute Leukemia HCC70 Quadriplegia HCC110 Cystic Fibrosis HCC9 Lung and Other Severe Cancers HCC71 Paraplegia HCC111 Chronic Obstructive Pulmonary Disease HCC10 Lymphoma and Other Cancers HCC72 Spinal Cord Disorders/Injuries HCC112 Fibrosis of Lung and Other Chronic Lung HCC11 Colorectal, Bladder, and Other HCC73 Amyotrophic Lateral Sclerosis and HCC114 Aspiration and Specified Bacterial HCC12 Breast, Prostate, and Other Cancers HCC74 Cerebral Palsy HCC 115 PneumocoHCCal Pneumonia, Empyema, HCC17 Diabetes with Acute Complications HCC75 Myasthenia Gravis/Myoneural HCC 122 Proliferattve Diabetic Retinopathy and HCC18 Diabetes with Chronic Complications HCC76 Muscular Dystrophy HCC124 Exudative Macular Degeneration HCC19 Diabetes without Compllcatlon HCC77 Multiple Sclerosis HCC134 Dialysis Status HCC21 Protein-Calorie Malnutrition HCC78 Parkinson's and Huntington's Diseases HCC135 Acute Renal Failure HCC22 Morbid Obesity HCC79 Seizure Disorders and Convulsiuns HCC136 Chronic Kidney Disease, Stage HCC23 other Significant Endocrine and HCC80 Coma, Brain Compression/Anoxic HCC 137 Chronic Kidney Disease, Severe (Stage 4) HCC27 End Stage Liver Disease HCC82 Respirator HCC157 Pressure Uker of Skin with Necrosis HCC28 Cirrhosis of liver HCC83 Respiratory Arrest HCC158 Pressure Ulcer of Skin with Full Thickness HCC29 Chronic Hepatitis HCC84 Cardio-Respiratory Failure and Shock HCC161 Chronic Ulcer of Skin, Except Pressure HCC33 Intestinal Obstruction/Perforation HCC SS Congestive Heart Failure HCC 162 Severe Skin Burn or Condition HCC 34 Chronic Pancreatltis 0.286,276 HCC86 Acute Myocardial Infarction HCC 166 Severe Head Injury HCC 35 Inflammatory Bowel Disease HCC87 Unstable Angina and Other /1::ute HCC 167 Major Head Injury HCC39 Bone/Joint/Muscle lnfections/necrosis HCC88 Angina Pectoris HCC169 Vertebral Fractures without Spinal Cord HCC40 Rheumatoid Arthritis and Inflammatory HCC96 Specified Heart Arrhythmias HCC170 Hip Fracture/Dislocation HCC46 Severe Hemotologic Disease HCC99 Cerebral Hemorrhage HCC173 Traumatic Amputations and Complications HCC47 Disorders of Immunity HCC100 lschemic or Unspecified Stroke HCC 176 Complications of Specified Implanted HCC48 Coagulation Defects HCC103 Hemiplegia/Herniparesis HCC 186 Major Organ Transplant or Replacement

20 Change HCC1 HIV/AIDS HCC2 Septicemia, Sepsis, Systemic HCC6 Opportunistic Infections HCC8 Metastatic Cancer and Acute Leukemia HCC9 Lung and Other Severe Cancers HCC10 Lymphoma and Other Cancers HCC11 Colorectal, Bladder, and Other HCC12 Breast, Prostate, and Other Cancers HCC17 Diabetes with Acute Complications HCC18 Diabetes with Chronic Complications HCC19 Diabetes without Complication HCC21 Protein-Calorie Malnutrition HCC22 Morbid Obesity HCC23 other Significant Endocrine and HCC27 End Stage Liver Disease HCC28 Cirrhosis of liver HCC29 Chronic Hepatitis HCC33 Intestinal Obstruction/Perforation HCC 34 Chronic Pancreatltis HCC 35 Inflammatory Bowel Disease HCC39 Bone/Joint/Muscle lnfections/necrosis HCC40 Rheumatoid Arthritis and Inflammatory HCC46 Severe Hemotologic Disease HCC47 Disorders of Immunity HCC48 Coagulation Defects

21 Major Contributors to risk score trend Diabetes up 20% HCC18 DM with complication up HCC19 DM down Major Depressive/Bipolar HCC 58 +9% Metastatic Cancer/Acute Leukemias HCC8 +8% Rheumatoid Arthritis HCC 40 +7% Morbid Obesity HCC22 +6% Vascular Disease HCC %

22 HCC DOCUMENTATION VALID HCC DOCUMENTATION REQUIRES (3) POINTS Diagnosis - Face 2 Face Visit Status or Condition Stable condition, worsening, labs or tests ordered, medications adjusted Plan of Action COPD, Stable, continue current medications

23 A diagnosis will not pass a CMS AUDIT without the M.E.A.T

24 Documentation for Every Diagnosis must have the M.E.A.T. Monitor signs, symptoms, disease progression, disease regression Evaluate test results, medication effectiveness, response to treatment Assess/Address ordering tests, discussion, review records, counseling Treat medications, therapies, other modalities

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26 Why is documentation important? B19.20 Hepatitis C, unspecified (No HCC) B17.10 Hepatitis C, acute (No HCC) B18.2 Hepatitis C, chronic (HCC-29)

27 Non-Definitive Condtions DO NOT CODE non-definitive conditions Probable Possible Questionable Rule out Code the condition to the highest degree of specificity Signs/Symptoms Abnormal test results Other reason for the visit

28 IF IT IS NOT DOCUMENTED IN THE MEDICAL RECORD...THEN IT DID NOT HAPPEN (Beware of EMR s that automaticall add previous ICD10 codes to superbills)

29 Summary of Documentation MUST EVALUATE EACH DIAGNOSIS ON PROGRESS NOTE MUST BE FACE TO FACE CAN NOT REFER TO PROBLEM LIST AS DOCUMENTATION Use: 1. DM with Neuropathy Stable, meds adjusted, 2. CHF- compensated, continue meds, 3. COPD PFT ordered, refer to pulmonary 4. HTN- uncontrolled, add medication 5. Hyperlipidemia stable on meds. Check labs and increase exercise DIAGNOSIS listed on the progress note without an evaluation or assessment is considered a problem list and does not provide correct documentation

30 Capture the Chronic Conditions! The slate is wiped clean on January 1 EVERY YEAR Amputations grow back! COPD patients have healthy lungs! Diabetes patients have superb pancreases! All kidneys function flawlessly! Colostomy patients have a perfect colon! Get the picture? IF YOU DON T DOCUMENT AND CODE THE CONDITION, YOU LOSE! 30

31 EACH YEAR RISK MEDICAL CONDITIONS (RAF) START AT ZERO NEED TO INCLUDE FACE TO FACE ENCOUNTER PERMANANT CONDITIONS EACH YEAR HIV without symptom Limb amputations Transplant status Hemi or Quadriplegia Ostomies Amputations

32 MUST Create a clear relationship to the diagnosis ACCEPTABLE LINKING VERBIAGE due to because of related to NOT ACCEPTABLE The word with does not establish a cause and effect relationship except in the case of diabetes

33 Disease Interactions Some diseases interact with each other, causing an increase in care management and a corresponding additional risk factor. As an example: Congestive Heart Failure combined with Diabetes When these two diagnoses are reported on the same patient, an additional risk factor is recorded Ratebook Risk Factors CHF HCC Diabetes, chronic complications HCC Disease Interaction of CHF and Diabetes

34 Disease Interaction Interaction RAF Immune Disorders with Cancer CHF with Diabetes CHF with COPD 0.19 CHF with Renal Failure 0.27 Cardiorespiratory Failure with COPD CHF with Heart Arrhythmias 0.105

35 RXHCC vs Medical Condition HCC Male Patient 72 years old with active documented and treated: Hypothryoidism HTN High Cholesterol Dementia Migraines Asthma GERD Carotid Stenosis

36 Hypothyroid Hypertension Hypercholesterol Dementia Migraine Asthma GERD Carotid Stenosis

37 ICD-10 that only RAF for MEDICATION PART D (RX HCC) Hypothyroid/Hyperthyroid/Goiter Panic Disorder/Phobia/ADD Hypercholesterol General Anxiety Dementia/ Alzheimers Migraine Glaucoma Ischemic Cardiomyopathy Carotid Stenosis Cerebrovascular Disease/TIA Asthma GERD/Barrett s Osteoporosis Coronary disease due to plaque (I25.83)

38 Prescription RX RAF Scores Medicare Part D For Medicare Advantage not MSSP

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40 DIABETIC COMPLICATIONS Complications of diabetes are the most frequently omitted conditions in physician medical records. >75% of seniors have diabetic complications If only diabetes or diabetes mellitus (DM) is written in a progress note in the medical record, the correct code is uncomplicated diabetes. E11.9 (RAF 0.104)

41 MUST Document Status of Diabetes Poorly controlled or poor control is vague terminology and does not necessarily indicate uncontrolled blood glucose levels. Uncontrolled DM is coded only when the physician specifically documents the status. E11.9 Type II DM controlled E10.9 Type I DM controlled

42 Quality Documentation in Diabetes Diabetes Type of diabetes: Type I or Type II Is there a manifestation/complication? Identify the system(s) with the manifestations >75% of diabetics have systemic complications Name the manifestation in the system and state manifestation is DUE TO DIABETES Controlled or uncontrolled

43 Manifestations Every patient with diabetes should be evaluated for the many manifestations, co-morbidities of the disease, and complications with the progress notes and tests showing that this evaluation was done DIAGNOSIS ICD-10 HCC WEIGHT Without complications E DM W/Kidney Comp. E DM W/Ophthalmic Comp. DM W/Neurologic Comp. DM W/Circulatory Comp. E11.3X.318 E11.4X.318 E11.5X.318 DM w/oral Comp. E11.6X.318 DM W/CKD E

44 Coding Scenario Type II Diabetic is seen for a severe full thickness chronic left heel pressure ulcer. The patient s history clarifies that ulcer is secondary to Diabetic Peripheral Neuropathy. HbA1C is 9.2%. Physical shows very weak pedal pulses and purple cold toes with poor capillary refill.

45 WHAT WOULD YOU DOCUMENT IN THE ASSESSMENT? DM W/PVD Diabetic Neuropathy Pressure Ulcer

46 Chronic Kidney Disease Stage Severity GFR Value STAGE 1 GFR 90 ml/min with kidney damage (microalbuminuria 1+ protenuria) STAGE 2 Mild GFR ml/min with kidney damage (microalbuminuria 1+ protenuria) ICD -10 HCC Wt N18. 1 N STAGE 3 Moderate GFR ml/min N18. 3 STAGE 4 Severe GFR ml/min N18. 4 STAGE 5 Kidney Failure GFR < 15 ml/min N18. 5 ESRD Code with renal dialysis status Z99.2 Requiring chronic dialysis or transplant N18. 6 CKD Unspecified CKD Unspec. N

47 CARDIOLOGY Be specific: When documenting and coding a significant cardiac diagnosis: Avoid less specific terms, e.g., coronary artery disease (CAD) or atherosclerotic heart disease (ASHD) (NO RAF) But if patient has Angina treated or untreated with pharmacological treatment or interventional cardiology. If angina resolves with PTCA or CABG and NO pharmacologic Rx prescribed DO NOT CODE ANGINA

48 CODING OF MI ACUTE Vs. OLD Acute MI I22.9 for only 4 weeks after diagnosis is made So every visit within 4 weeks the correct code is I22.9 If a patient is seen 4 weeks after an acute MI, and has no continued anginal symptoms, the correct code is I25.2 (recent MI, old MI, or history of MI) RULE- ACUTE becomes OLD after 4 weeks

49 ANGINA RULE- code for cardiac angina if treating. If asymptomatic due to pharmacological treatment, may still continue to code. DIAGNOSIS ICD-10 HCC WEIGHT Angina Pectoris I Chronic Ischemic Heart Disease I25.9 0

50 CHF and other Chronic Cardiovascular Conditions Chronic cardiovascular conditions: Document and code ongoing chronic conditions such as atrial fibrillation or arrhythmias whether they are symptomatic or asymptomatic because of the need for pharmacological treatment and/or interventional cardiology. Congestive heart failure is always chronic after diagnosis. After it is diagnosed, CHF is a chronic condition and should be documented, coded, and treated as such.

51 CHF DIAGNOSIS ICD-10 HCC WEIGHTS Congestive Heart Failure Inability of heart to deliver adequate blood flow to the body, cardinal symptoms include SOB, edema, or CP, diagnosed by clinical findings and +PVC on CXR. Echo may reveal low EF and/or diastolic dysfunction. Acute on chronic systolic heart failure Sudden worsening in cardiac output in a patient with chronic CHF diagnosed clinically and/or by echo. Diastolic Heart Failure unspecified Nonspecific CHF related to impaired blood return diagnosed by echo. I I I Left Heart Failure I Pulmonary Hypertension As found on echocardiogram in dyspneic patient due to known etiology. i.e. COPD, Obstructive Sleep Apnea, Obesity Hypoventilation Syndrome I

52 ARRHYTHMIAS RULE- Once an Arrhythmia, always an Arrhythmia unless permanently corrected without ongoing pharmacological or mechanistic intervention

53 ARRHYTHMIAS DIAGNOSIS ICD-10 HCC WEIGHT Atrial Fibrillation I Atrial Flutter I Sick Sinus Syndrome I Atrioventricular Block, Complete Paroxysmal Supravent Tach (PSVT) Paroxysmal Ventricular Tachycardia I I I Ventricular Fibrillation I

54 VASCULAR DIAGNOSIS ICD-10 HCC WEIGHT Abdominal Aortic Aneurysm -AAA Consider screening males over 65 years of age and patients with risk factors i.e. HTN, smoker, hyperlipidemia I Aortic Ectasia I Aortic Atherosclerosis As found on CXR, CT Atherosclerosis, Extremities Plaque is atherosclerosis Peripheral Vascular Disease Clinical Dx in patient with decreased palpable pedal pulses, thin, hairless, lower legs, cool purple toes I I I

55 RISK ADJUSTMENT Conditions that DON T risk adj Hypertension benign Coronary atherosclerosis, unspecified type of vessel Atherosclerosis Chest Pain Dysrhythmia Conditions that DO risk adj Hypertensive heart disease- Malignant with heart failure Angina pectoris unspecified Atherosclerosis, extremities Angina Atrial fibrillation

56 PULMONARY DIAGNOSIS ICD-10 HCC WEIGHT Obstructive Chronic Bronchitis Chronic cough or mucus production for at least 3 months out of the year in 2 successive years diagnosed clinically and PFT with obstructive pattern (low FEV, high TLC) Emphysema Damage to alveoli frequently diagnosed by smoking history, wheezing, CXR findings and obstructive or decreased perfusion capacity PFT Chronic Obstructive Asthma Chronic asthma characterized by SOB, cough, wheezing, and response to bronchodilators diagnosed clinically or PFT revealed obstructive pattern (FEV1/FVC <80%) reversible with bronchodilators COPD NEC, NOS/CHR Airway Obstruction Chronic obstructive lung disease often diagnosed with smoking history, wheezing, CXR or PFT showing obstructive pattern (FEV1/FVC<80%) J J J J Simple Chronic Bronchitis J

57 MAJOR DEPRESSION Episodic mood disorders (F32.X) are mental diseases that include mood disturbances such as major depression. Physicians are encouraged to carefully document the characteristics of the mood disturbance (e.g. mania, depression, single or recurrent episode) and use specific mental disorder terminology in the final diagnosis. If the physician does not document specific descriptor terms such as major or recurrent, the code F32.9 is used which has NO HCC weight.

58 Other Depressive Episodes Major Depressive disorder, single episode unspecified

59 MAJOR DEPRESSION DIAGNOSIS ICD-10 HCC WEIGHT Major Depressive Disorder, Single Episode One episode of major depression (must have depressed mood and/or loss of interest plus 4 out of the following: change in appetite, sleep disturbance, behavior change, decrease in energy, guilt, inability to concentrate, suicidal ideation) Major Depressive Disorder, Recurrent Episode Recurrent episodes of major depression Major Depressive Disorder, In remission F F F Bipolar F Schizophrenia F

60 PSYCHIATRY DIAGNOSIS ICD-10 HCC WEIGHT Alcohol Dependence/Alcoholism Once an alcoholic, always an alcoholic, even if sober for years. Code annually. Drug Dependence Consider opioid or benzodiazepine dependence in patients who have maladaptive pattern of substance use and without the medication would have signs or symptoms of physical or psychological withdrawal and would seek refills. i.e. patients with chronic pain syndromes on morphine ER, oxycontin, fentanyl patches. F F11.x Opioid Dependence F Benzodiazepine dependence F

61 PSYCHIATRY Long term opioid treatment Z NO RAF Opioid dependence F11.20 RAF A maladaptive pattern of substance use, leading to clinical impairment or distress as manifested by 3 of the following: Tolerance Withdrawal symptoms Increased usage over a longer period than intended Desire or unsuccessful effort to cut down on use Excess time spent in activities to obtain the substance Continued use despite doctor advice or patient knowledge of physical or psychological problem related to the substance use

62 MALNUTRITION ICD-10 Codes E44.x - Malnutrition is often underreported Conditions often seen in the senior patient that limit nutrient ingestion and absorption: Cancer Pancreatitis Alcohol abuse and/or dependence Liver Disease, Alcoholic hepatitis, cirrhosis Obesity CHF, COPD ESRD Celiac Disease Cystic fibrosis Depression / Dementia

63 MALNUTRITION DIAGNOSIS ICD-10 HCC WEIGHT Unspecified malnutrition Wt loss of 5% in 3 months or 10% in 6 months, or BMI <17.9 and low albumin Mild malnutrition BMI Albumin <3.5 Moderate malnutrition BMI <16.0 Albumin <3.5 E E E

64 MORBID OBESITY DIAGNOSIS ICD-10 HCC WEIGHT Morbid Obesity BMI > 40 E Morbid Obesity w/comorbid Conditions BMI>35 (Be sure to link to co morbid Condition) Arthritis, Sleep Apnea, HTN, Hyperlipidemia, Diabetes E

65 Coding of Strokes Strokes are an acute event, and should only be coded when the patient is having the stroke in front of you. Please code as history of stroke, and be sure to code the late effects if applicable.

66 NEUROLOGY DIAGNOSIS ICD-10 HCC WEIGHT Late EF-Hemiplegia Side NOS Nonspecific persistent hemiparesis from CVA diagnosed clinically (paralysis of one side of the body) Late EF Other paralytic syndrome Non specific persistent weakness as a result of a CVA diagnosed clinically Late EF Monoplegia Lower limb Persistent weakness involving one lower limb as a result of CVA diagnosed clinically I I I Late EF Monoplegia Upper limb I

67 NEUROLOGY DIAGNOSIS ICD-10 HCC WEIGHT Seizures/Epilepsy Be sure to document and code annually Parkinsons Consider Parkinsons in patients with resting tremor of head, hands, arms, and possible muscle rigidity, slowness of movement, or postural instability G G

68 ONCOLOGY Under ICD-10 guidelines, malignancies are only coded until the patient has completed definitive treatment: Definitive treatment means surgery, chemotherapy and/or radiation therapy aimed at eradicating the malignancy Patients who do not receive definitive treatment for the their malignancy continue to be coded for the malignancy diagnosis Breast and Prostate CA patients on adjuvant therapy (tamoxifen, lupron) are coded as if they have active disease DOCUMENTATION PITFALLS: ONCOLOGY SURVEILLANCE Patient who have completed therapy can only be coded with a personal history of cancer diagnosis code, even if they are undergoing surveillance for re-occurrence of the malignancy

69 ONCOLOGY Breast and Prostate CA patients on adjuvant therapy (tamoxifen, lupron) are coded as if they have active disease DOCUMENTATION PITFALLS: ONCOLOGY SURVEILLANCE Patient who have completed therapy can only be coded with a personal history of cancer diagnosis code, even if they are undergoing surveillance for re-occurrence of the malignancy

70 ONCOLOGY DOCUMENTATION PITFALLS Metastatic disease has a separate section in the ICD-10, and a separate CMS-HCC payment group. Metastatic disease is HCC Category 8 HCC 8 over rides all other Cancer HCC s including 9, 10, 11 and 12 This is an instance where lack of specificity in documentation leads to a lower payment rate. It is important to indicate when metastatic disease is present, as a secondary malignant neoplasm. Often, metastases are not clearly identified, leading to the coding of multiple primary malignancy sites.

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74 High Level Example of a CMS Payment to a Plan No Diagnoses Reported Some Diagnoses Reported All Diagnoses Reported 68 year old male year old male year old male.300 Dual eligible.192 Dual eligible.192 Dual eligible.192 Type 2 DM, not coded Type 2 DM, no complications.097 Type 2 DM with other skin ulcer.346 Congestive Heart Failure, not coded Congestive Heart Failure, not coded Congestive Heart Failure, coded.355 Disease interaction (DM+CHF).205 Risk Adjustment Factor PMPM base payment $814 PMPM base payment $814 PMPM base payment $814 PMPM for this patient $401 PMPM for this patient $479 PMPM for this patient $1,138 Annual payment $4,806 Annual payment $5,753 Annual payment $13,656 74

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78 Can only get credit for one HCC 18 no matter how many you enter DM with retinopathy, neuropathy, PVD, nephropathy all are HCC 18 Notice ICD-10 Letter does not matter As using 3 coded beginning with I an all RAF

79 GAIN with HCC 106 Gangrene Loose.229 HCC 108 Atherosclerosis Aorta Loose.779 HCC 189 BKA Overall Gain.405 RAF

80 Removed Gangrene Loose Gain Chronic Ulcer HCC Gain Atherosclerosis of Aorta HCC Gain BKA HCC Overall gain.20 RAF

81 Add back Bipolar as only 10 Diagnosis on chart HCC Add Gangrene HCC Gangrene overrides Chronic Ulcer HCC Atherosclerosis of Aorta BKA Overall Gain +.129

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83 CMS Risk Adjustment Data Validation Audits What are CMS Risk Adjustment Data Validation (RADV) Audits? Applicable to Medicare Advantage Plans CMS annual audits that ensure the integrity and accuracy of risk-adjusted payment An audit that verifies diagnosis codes submitted by MA plans are appropriately supported by medical record documentation 83 MA plans may be selected for RADV Audits annually, and if

84 CMS RADV Audits Why should providers care about these? It is the provider s documentation that is being audited, It is the diagnosis codes that have been submitted that are audited, and. Providers are required to assist MA plans when chosen for a RADV audit The more complete the medical records, the less issues The better the documentation, the better the outcome 84

85 IF YOU FORGET TO ADD THE M.E.A.T. THIS COULD BE CONSIDERED DECEIT WHICH MEANS CMS COULD TURN UP THE HEAT