Risk Adjustment Medicare and Commercial

Risk Adjustment Medicare and Commercial Transform your thinking about documentation and coding 900-1169-0715

Introduction In a time of continual regulatory reform and the evolution of payer/provider reimbursement models, are you potentially at risk? Is your practice being disrupted by having to frequently correct coding errors? Does your documentation and coding truly reflect the health status of your patients? Are you receiving accurate compensation based on the risk of your patient population? Today s discussion will focus on the importance of accurate medical documentation and coding, and how this can translate to quality data that promotes the financial health of your practice and the health of your patients.

1. Why does accurate coding matter to your practice and your patients? What is risk adjustment? How does it work? Contents 2. How can it affect your practice? 3. How can you ensure your practice isn t at risk? How can you best prepare your practice? How can Florida Blue help?

Medicare Risk Adjustment (MRA) and Commercial Risk Adjustment (CRA) Programs Risk adjustment is a component of the health care reform designed to improve coverage, preserve consumer choice and improve quality of care for patients. What differentiates MRA? Administered by the Center for Medicare and Medicaid Services (CMS) Risk Adjustment payments are made to Medicare Advantage plans Medicare Advantage plans reimburse physician groups with whom they are in risk-sharing relationships according to contractual agreements What differentiates CRA? Either the state or federal government (Department of Health & Human Services) will be responsible for operating risk-adjustment models Insurers pay in/out based on the risk associated with their individual and small group enrollees As a result, the risk-adjustment model redistributes money from insurers with healthier patient populations to those with sicker patient populations What do MRA and CRA have in common? Tools used to predict health care costs based on the relative actuarial risk of enrollees in risk adjustment-covered plans. Minimizes the incentive for health plans to select enrollees based on their health status. Encourage competition based on quality improvements and efficiency, mitigating the impact of potential adverse selection 1 and stabilizing premiums. Assesses health plans by the amount of risk they are taking on measured in part by the chronic conditions present within their patient populations 1. Adverse selection occurs when a larger proportion of persons with poorer health status enroll in specific plans or insurance options, while a larger proportion of persons with better health status enroll in other plans or insurance options. Plans with a subpopulation with higher-than-average costs are adversely selected. Source: HHS Risk Adjustment Model, May 7, 2012 (Center for Consumer Information and Insurance Oversight, Centers for Medicare and Medicaid Services, Department of Health & Human Services) http://cciio.cms.gov/resources/files/fm-1c-risk-adj-model.pdf

Risk Adjustment Models Age Gender Demographics Diagnosis 2015 CMS Hierarchical Condition Category Model 2015 HHS Hierarchical Condition Category Model 69,828 ICD-10 Codes 69,828 ICD-10 Codes 8,830 Diagnosis Codes 7,685 Diagnosis Codes 79 HCCs 127 HCCs Infants 0-1 Child 1-20 Adult 21-64 5

Risk Score Calculation Step 1: Physicians document each patient s demographic information and disease burden in the medical record. Step 2: Patients risk scores are calculated by summing demographic and disease burden factors, weighted by their estimated marginal contributions to total risk. Using corresponding claims data, CMS and/or HHS calculates risk scores. Step 3: CMS and/or HHS reviews and validates risk score calculations based on claims data submitted from health plans. Key to payment and/or the redistribution of funds is the validation of risk adjustment data submitted by the health plan, which relies on medical record documentation and claims submissions. CMS and HHS employ a multi-step data validation audit process, which is performed at random, to ensure diagnoses are substantiated by medical records. Illustrative Calculation (Baseline: Average price for individual = $1,000): Female, 57 = $500 =.5 risk factor Condition A = $700 =.7 risk factor Risk Score = 0.5 + 0.7 = 1.2 Individual costs 120% of indexed cost, or approximately $1,200 Source: HHS Risk Adjustment Model, May 7, 2012 (Center for Consumer Information and Insurance Oversight, Centers for Medicare and Medicaid Services, Department of Health & Human Services) http://cciio.cms.gov/resources/files/fm-1c-risk-adj-model.pdf

1. Why does accurate coding matter to your practice and your patients? What is commercial risk adjustment (CRA)? Contents How does it work? 2. How can it affect your practice? 3. How can you ensure your practice isn t at risk? How can you best prepare your practice? How can Florida Blue help?

Why and How Will MRA and CRA Affect Physicians? Why will physicians be affected? Risk adjustment relies on physicians to perform accurate medical record documentation and coding practices in order to capture the complete risk profile of each individual patient. How will physicians be affected? Financial Health of Your Practice Opportunities to Improve Care Practice Accurate medical records and diagnosis code capture on claims / encounter data the first time helps reduce the administrative burden of adjusting claims. For physicians involved in risk-sharing arrangements, it also ensures more accurate payments and reflection based on the severity of illness burden. Accurate risk capture improves high-risk patient identification and the ability to reach out / engage patients in disease and care management programs and care prevention initiatives. It also helps in the endeavor to identify practice patterns and reduce variation when clinically appropriate.

Patient Health and Cost of Care: The Connection Between What You Need to Know Capturing risk accurately is important to ensure accurate payment for providers that are in a risk-sharing relationship. Care delivery innovations are transitioning physician payment to a more value-based reimbursement system (e.g., a risk-sharing relationship) in which fee-for-service schedules will likely play a smaller role in how physicians are reimbursed. Under alternative payment models, or risk-based payment systems (e.g., pay for performance, global budgets), accurate payment depends on correctly capturing the risk of patients in medical record documentation and in coding. Example from the AMA: The cost of treating a patient with diabetes ranges from $28 to $5,111, with the average being $556. If physicians treat lower-risk diabetic patients and receive the average payment, they would mostly likely be overcompensated. By comparison, physicians who treat higher-risk diabetic patients would be left largely uncompensated for treating those patients if they receive the average amount. Risk adjustment is a method to fix this issue. Based on the severity of the patient s condition (or the risk they represent) payment will accurately reflect the risk represented. Medical record documentation and accurate coding are critical to appropriately assess risk and ensure proper payment.. Source: American Medical Association, Evaluating and Negotiating Emerging Payment Options, 2012

Care Practice and Patient Health: Intervention Strategies Prospective risk analytics based on medical coding help decide which intervention strategy will work best on a patient-by-patient basis. Messaging and Outreach Medical Record Review Medication Management Patient Visit Support Source: Innovalon Webinar, 3/27/2013, The Value of Bridging the Gap Between Retrospective, Prospective Risk Adjustment, and Clinical and Quality Outcomes

Florida Blue Healthcare Quality Programs Comprehensive Quality & Risk Program Health Risk Assessments HEDIS and STARS Focuses on Medicare Advantage HMO and PPO members who have with clinical, care and/or quality gaps which need to be closed. Each identified member will have an associated Comprehensive Quality & Risk Health Assessment Form available to the assigned or attributed physician. Comprehensive Quality & Risk Health Assessment Form will be displayed in Availity. Members who haven t seen a primary care physician during a 12 month period or are home bound qualify for a health risk assessment. Health risk assessments are performed by a nurse practitioner, physician s assistant, or physician. A summary of the results are given to the member. The member s physician will receive results as well. Improves health outcomes for our members. Improves member experience and how they feel about the quality of care they receive from both Florida Blue and their providers. Enhances provider engagement with our members. Ensures diagnoses and quality measures documented in medical records are captured for submission to CMS, performance reporting and prospective initiatives 11

Comprehensive Quality & Risk Health Assessment Form Comprehensive Approach Targeted Medicare Advantage HMO/PPO members who have care and/or quality gaps Collecting and documenting patient conditions and satisfying care and quality measures Facilitates review and management by the physician Pre-populated member information, indication of chronic conditions, outstanding care and/or quality measures Form accessed from the physician s activity dashboard on Availity.com Easy to navigate and initiative web-based form Physician completes, signs, dates and submits the form electronically Benefits Email notification from Availity indicating any updates to the panel roster Reports for prioritized outreach to patients needing a comprehensive annual wellness visit Process consistency Efficient management of the member s health assessment Eases the completion process and improves the quality of information collected Maintain document integrity and security Reduces costly paper handling and manual routing 12

Medical Records Review and Audit Retrospective and value-based provider audits are performed to review provider s coding practices and proactively identify both deficiencies and opportunities where Florida Blue can provide effective feedback and education to the provider group. The goal of these audits is to validate that all risk conditions applicable to the member are captured within the progress notes along with assessment and treatment options for each. This review & audit process ensures compliance with CMS and HHS Risk Adjustment Data Validation requirements by verifying diagnosis codes previously submitted to CMS and/or HHS via claims data. If diagnosis codes previously submitted are not supported in the medical record, the required corrections must be submitted to CMS and/or HHS accordingly. 13

Common Errors to Avoid Demographic Requirements Missing and/or illegible physician/practitioner signature and/or credential Cloning Electronic Medical Records Missing record Other: Incorrect beneficiary Name on record and other documents do not match Date of service outside of data collection period Invalid provider type (e.g., skilled nursing facility, freestanding ambulatory surgical centers, laboratories, pharmacy, etc.)

Documentation Observations & Coding Opportunities Demographic Requirements Providers' progress notes did not meet the authentication criteria for demographic information per CMS guidelines which include; Provider signature/credentials, legibility, date of service and/or members' name. 1 2 15

Accurate Medical Record Documentation and Code Capture Medical coding of patient encounters is only as good as the underlying medical record documentation. Best Practices in Medical Record Documentation Documentation needs to be sufficient to support and substantiate coding for claims or encounter data Diagnoses cannot be inferred from physician orders, nursing notes, or lab or diagnostic test results; diagnoses need to be in the medical record Chronic conditions need to be reported every calendar year including key condition statuses (e.g., leg amputation and/or transplant status must be reported each year) Each diagnosis needs to conform to ICD-10 coding guidelines Include condition specificity where required to explain severity of illness, stage or progression (e.g., staging of chronic kidney disease) Treatment and reason for level of care need to be clearly documented; chronic conditions that potentially affect the treatment choices considered should be documented Best Practices in Medical Coding Accuracy Specificity Thoroughness Consistency

Documentation for Accurate Coding Do not document History of any disease that currently exists. The statement History of in diagnosis coding terms means that the patient no longer has that condition. However, History of is acceptable when documenting status conditions such as an amputation. Documentation must indicate how physicians are monitoring, evaluating, assessing and treating chronic conditions. Each diagnosis must have an assessment and plan using sample language: Acceptable Documentation M-monitoring, E-evaluating, A-assessing/addressing, T-treatment Examples of documentation within progress note: Hypertensive CKD 3, stable well controlled Continue meds COPD, stable on Advair Monitor/Evaluate Stable Improved Deteriorating Assess COPD HTN Rheumatoid arthritis Treatment Continue to monitor D/C med Refer to orthopedic surgery for consult Past Medical History Problems List Active Problems 17

Documentation Observations & Coding Opportunities No M.E.A.T. Patient's systemic chronic conditions are noted within the "Past Medical History," "Chronic Problems" and/or Assessment section; but, a treatment plan was not documented for all of the chronic conditions to validate management, evaluation, assessment or treatment (MEAT) for the specific date of service. 1 Polymyalgia rheumatica listed in the Medical problems list 3 2 Submitted condition of Polymyalgia Rheumatica (M35.3) was never directly addressed in note. Therefore condition becomes a listing only diagnosis of a chronic condition without MEAT to clinical support. 18

Documentation Observations & Coding Opportunities Missed Opportunities Missed opportunity for co-existing conditions: comparison reviews between Florida Blue Claims System and the medical records reviewed, showed sites were not submitting all the co-existing conditions that were assessed, managed, and documented in the progress notes by the primary care physician; which could result in potential missed risk diagnoses. Added Malnutrition-263.9, condition is supported (E46) BMI-14.1, weight 93 lbs. Noted under "Physical Exam" constitutional: cachectic. (R64) Condition was assessed by the provider but not submitted in the claim. 19

Documentation and Coding Cancer Current Cancer Document any treatment such as chemotherapy, radiation or adjunct therapy Receiving treatment for symptoms Patient elects not to have treatment Code the malignant neoplasm including the affected site History of Cancer Report personal history of malignant neoplasm If a patient s presenting problem, signs or symptoms may be related to the cancer history or if the cancer history impacts the plan of care, report the history code Documentation Type of CA ICD-9 CM ICD-10 CM Risk Factor 84 yr woman s/p mastectomy for breast cancer, on Tamoxifen History of Dukes A colon cancer, no recurrence, no current treatment Current 174.9 C50.919 0.154 History V10.05 Z85.038 0.000 Prostate CA on Lupron Current 185 C61 0.154 Personal history of malignant neoplasm, kidney History V10.52 Z85.528 0.000 20

Cancer Cancer diagnoses that are under current treatment (i.e. adjuvant therapy) are not being captured or submitted as active conditions; A primary malignancy that has been previously treated or excised/eradicated from its site, but continues to receive treatment directed to that site is still considered an active condition. C78.5 Secondary malignant neoplasm of large intestine and rectum, supported. 21

Documentation and Coding Causal Relationship Demonstrating a causal relationship A cause-and-effect relationship between chronic conditions and associated manifestations should be explicitly stated in the medical documentation. A causal relationship is specified by the words due to. Example: Patient is seen for Diabetes Mellitus Type 2, with advanced Diabetes and renal manifestations caused by Diabetes, i.e., Diabetic Nephropathy In order to show a causal relationship, the physician should note labs and urine test results and document: Diabetic Nephropathy or Nephropathy due to Diabetes Mellitus If provider documents the following, then the highest specificity code will be captured: o Diabetic Nephropathy (E11.21) o CKD Stage 3 due to Diabetes (E11.22 and N18.3) If a causal relationship is not clearly indicated in the progress notes, the conditions will be coded separately and the highest specificity code will be missed. 22

Documentation Observations & Coding Opportunities Missed Opportunities Missed opportunity for co-existing conditions: comparison reviews between Florida Blue Claims System and the medical records reviewed, showed sites were not submitting all the co-existing conditions that were assessed, managed, and documented in the progress notes by the primary care physician; which could result in potential missed risk diagnoses. Added Diabetes w/renal manifestations (E11.22 and N18.20) and Diabetic polyneuropathy, (E11.42) which were assessed by the provider and have a treatment plan; but, were not submitted in the claim.. (CKD II N18.2 -was submitted). Missed opportunity Long term current use of Insulin Z79.4 23

Documentation Exercise Linking Diagnoses Scenario Answer Patient presents with: Severely diminished renal function GFR = 14 Macroalbuminuria (albumin >300) HTN Diabetes Based on above in order to capture diagnoses of CKD, HTN and Diabetes to the highest level of specificity, how should the above be documented in the medical record? Correct answer: A, B and C Based on documentation, provider noted chronic kidney disease stage 5 and linked it to the diabetes. Coder can select the highest level of specificity code as per documentation: HTN with CKD5 (I12.0 and N18.5) CKD5 (N18.5) Diabetes with CKD5 (E11.22 and N18.5) A. Hypertension B. Stage 5 Chronic Kidney Disease C. Diabetes Type II with Renal Manifestations Example given shows complete documentation to support Hypertensive Chronic Kidney Disease and Diabetes with Renal Manifestations. 24

How Can Physicians Best Prepare for the Risk- Adjusted Environment? Standardized processes for accurate medical record documentation and coding across clinicians and non-clinicians to minimize disruption to practice flow Review of practice impact and continued opportunities to improve clinical documentation and accurate code capture Develop internal repetitive checkpoints for most common documentation and coding errors prior to claim / encounter submission Utilize tools / resources Florida Blue can provide support to your practice to identify and remediate incomplete or inaccurate coding

Connect with Florida Blue For information about risk adjustment, visit Florida Blue Risk Adjustment Process webpage. Interested in learning about documentation and coding best practices? We offer live webinars and education courses. Visit Availity Learning Center at Availity.com to find a calendar of upcoming webinar sessions and education materials or email us at RiskAdjustmentTraining@floridablue.com 26