Gail Woytek, RHIA, CCS, CRC Medicare Part C Risk Adjustment Coding Hierarchical Condition Categories NOV29th 2016 Gail Woytek, RHIA, CCS, CRC Rochester Regional Health Information Management Association

objectives Explain how and why Medicare Part C and Risk Advantage Plans were created Define principles of Hierarchical Condition Category (HCC) Coding Describe difference between Medicare Advantage and PACE HCCs Demonstrate coding scenarios with compliant application of codes Present CMS tables for use

Medicare Part C Medicare Part C is Medicare Advantage (MA) model Otherwise known as MA plan Developed to expand options under private insurance plans Differs from traditional fee-for-service models i.e., Medicare Part A (inpatient services) and Medicare Part B (outpatient and physician services) Combines Part A and Part B into one product Company offering health care plan is paid monthly premium per beneficiary rather than fee for each service

History of Risk Adjustment Balanced Budget Act of 1997 mandated implementation of Risk Adjustment (RA) to increase payment accuracy Many refinements in the RA methodology over the years By 2007, payments to MA plans were 100% at CMS-HCC rate Not only are diagnosis codes used for payment methodology, but also other demographics Beneficiary’s age Gender Race Socioeconomic status Place of service codes Patient conditions i.e., ESRD patient or in hospice

What is Risk Adjustment? Patient’s chronic conditions Clinical acuity and diagnostic profile of those enrolled in plans Ensures payment Promotes fair payments to MA plans and rewards efficiency and excellent care Predictive payment methodology

Predictive Modeling Analytical review of previously submitted data to CMS to identify possible future diagnoses that should be used for risk adjustment purposes Health care plans may use analytics to look at this data and determine that a patient may have a condition that had not been documented thoroughly by the physician and not captured Condition could have been incorrectly coded either by someone not qualified, or a diagnosis code could have been selected from a pick list in an EMR

Predictive Modeling, cont. A retrospective review of the medical records of patients that have been targeted as having a suspected condition can be performed by a certified coder The diagnosis can be validated and submitted for payment. Reflects the health of the patient Predict future costs Being able to predict patient’s future needs can help disease management and improve quality of care

Risk Adjustment Models Chronic Illness and Disability Payment System Medicaid (CDPS) Hierarchical Condition Categories Medicare HHS-HCC Commercial Insurance Prescription based model RX HCC Models can be reviewed three basic ways Retrospectively Concurrently Prospectively

Who is being Risk Adjusted? Participants eligible for Medicare Dual eligible special needs patients that are entitled to medical assistance under a Medicaid state plan End Stage Renal Disease patient Program for All Inclusive Care for the Elderly (PACE)

PACE Growing rapidly in United States Programs provide comprehensive medical and social services to those that meet certain eligibility requirements Over 55 years of age Sufficiently frail to be considered for nursing home care yet are community dwelling

PACE, cont. Their risk scores are based on their demographic factors, diagnosis codes and frailty factor Frailty factors are based on the number of limitations in activities of daily living (ADLs) PACE and ESRD patients fall into the same HCCs which differ slightly from the MA HCCs

hccs An HCC is determined by taking a patient’s ICD-diagnoses codes and filters them into Diagnosis Groups, then into Condition Categories where hierarchies or related disease processes are used to determine a HCC numeric code Not all codes fall in to an HCC, typically the codes that determine an HCC are costly to manage; chronic or serious conditions

hccs, cont. Not all codes fall in to an HCC Some codes map to an HCC for MA but not PACE Payments differ between MA HCCs and PACE HCCs HCCs change each year, recent changes were made to accommodate ICD-10, make sure you are familiar the annual changes RX HCCs use dx codes to predict Part D spending

Change Examples In 2014 the MA HCC reimbursement rate had a blended model, with each version paying at a different rate. This year there is only one rate In 2014, MA and PACE plans were paid for peripheral neuropathy, this year only PACE plans will be reimbursed for that diagnosis The HCCs for diabetes underwent a major change for payment year 2015 also. Most of the manifestations do not fall in to a higher level HCC

MA vs. Pace HCCs Patient profile 88 years old Male Senile dementia, COPD, DM II, Right Hemiplegia due to old CVA, CKD III, S/P L AKA Code MA HCC PACE HCC 250.00 19 294.20 112 RX 52 112 RX 438.21 103 496 111 585.3 138 V49.76 189

Payment Values The lower the HCC number the higher the acuity and therefore a higher payment CMS provides payment only for the most severe manifestation of a disease process Not all codes used for HCCs Codes tell the story

“Trump” Codes Examples of codes that trump others from the same “family” or disease groups: Ca of the colon code 153.9 HCC 11 with mets to the brain 198.2 HCC 8. Drop the code for ca of the colon. HCC 8 has the more severe risk Vascular insufficiency of the colon code 557.1 HCC 108 will be trumped by atherosclerosis of the artery of the extremity with gangrene 440.24 HCC 106

Hierarchy Example ICD-9 Code ICD-9 Description MA Model 22 (for 2015 DOS) PACE Model 22 (for 2015 DOS) 1983 Sec Mal Neo Brain/Spine 8 1984 Sec Malig Neo Nerve Nec 1985 Secondary Malig Neo Bone 1539 Malignant Neo Colon Nos 11 1540 Mal Neo Rectosigmoid Jct 1541 Malignant Neopl Rectum 1542 Malig Neopl Anal Canal 1543 Malignant Neo Anus Nos

Hierarchy Example, cont. ICD-9 Code ICD-9 Description MA Model 22 (for 2015 DOS) PACE Model 22 (for 2015 DOS) 5848 Ac Renal Failure Nec 135 5849 Acute Renal Failure Nos 5851 Chro Kidney Dis Stage I   139 5852 Chro Kidney Dis Stage Ii 5853 Chr Kidney Dis Stage Iii 138 5854 Chr Kidney Dis Stage Iv 137 5855 Chron Kidney Dis Stage V 136 5856 End Stage Renal Disease 5859 Chronic Kidney Dis Nos 586 Renal Failure Nos 140

Additive Example Patient has multiple sclerosis, angina, and diabetes Code HCC 340 77 413.9 88 250.00 19

RX HCC ICD-9 Code ICD-9 Description 2015 RX HCC 2400 Simple Goiter 42 : Thyroid Disorders 2409 Goiter Nos 2410 Nontox Uninodular Goiter 2411 Nontox Multinodul Goiter 2419 Nontox Nodul Goiter Nos 24200 Tox Dif Goiter No Crisis 2720 Pure Hypercholesterolem 45 : Disorders of Lipoid Metabolism 2721 Pure Hyperglyceridemia 2722 Mixed Hyperlipidemia 2723 Hyperchylomicronemia 2724 Hyperlipidemia Nec/Nos 2725 Lipoprotein Deficiencies 2728 Lipoid Metabol Dis Nec 2729 Lipoid Metabol Dis Nos

Coding Nuances Not all codes map to an HCC Condition Code HCC Essential Tremor 333.1 None Parkinson’s Disease 332.0 78 Accidental Barbiturate OD E937.0 Suicide by Barbiturates E950.1 58 Ischemic Cardiomyopathy 414.8 Idiopathic Cardiomyopathy 425.4 85 Not all codes map to an HCC

HCC Coding Requirements Face to Face visit Acceptable provider Code only from the narrative of the provider, do not “diagnose” the patient yourself based on diagnostics or drugs prescribed “History of” diagnoses are not coded, confirm by the documentation whether that condition is currently being treated

Hcc coding Requirements, cont. Use “TAMPER” acronym to ascertain if condition is currently being treated Treat Assess Monitor or Medicate Plan Evaluate Refer

HCC CODING Requirements, cont. Some chronic conditions that need to be addressed annually are Amputations of the lower limbs, or toes Paralysis Sickle cell trait Multiple Sclerosis COPD

HCC CODING Requirements, cont. Outpatient coding guidelines are used for the coding of both MA and PACE models Look up every code!! No use of suspected, probable, consistent with, rule out All diagnosis codes must be coded to the highest degree of specificity Do code the diagnoses that are used for the RX HCCs, for example asthma, hyperlipidemia

CMS Documentation Requirements Must be legible Must be signed Approved credentials must be in record Clear, consistent, complete Must have a face to face in the payment year The diagnosis must be substantiated in the documentation

Acceptable Providers

Acceptable Facilities Covered Facilities Hospitals Short-term (General/Specialty) Long-term Rehabilitation Children’s Psychiatric Medical Assistance Facilities/Critical Access Hospitals Community Mental Health Centers 1 Federally Qualified Health Centers 2/Religious Non-Medical Health Care Institutions Formerly Christian Science Sanatoria Rural Health Clinics

Non-Acceptable Facilities Non-Covered Facilities Free-standing Ambulatory Surgical Centers (ASCs) Home Health Care Free-standing Renal Dialysis Facilities

Coding Challenges A very common diagnosis you will see in provider’s record is cancer. Unless the patient is undergoing chemotherapy, radiation therapy or hormonal therapy, it cannot be coded. Just a note in the record stating the patient is being followed by an oncologist does not imply a current cancer diagnosis Compression fractures must be current to be captured, many MDs continue to document despite the fracture occurring in the past. There must be some sort of treatment, such as pain management

Challenges, CONT. Artificial openings. Morbid obesity and malnutrition.

Challenges, CONT. A pcp may not always document a peripheral vascular disease or peripheral neuropathy, but a podiatrist note will have the elements of documentation that you can use to capture the code The same goes for some ophthalmology diagnosis codes. Be sure to review all consultant notes to code any significant diagnosis

Challenges, CONT. If a condition is contradicted in different parts of the record do not code it Some serious conditions due fall in to HCCs such as hip fractures that occurred in that payment year Be very careful with amputations, most that you will encounter in HCC coding will be past surgical, not traumatic

More coding challenges! Don’t make assumptions regarding drug prescriptions. If a patient is on Lamictal, do not assume they have a seizure disorder, this drug is also used for bipolar disorder. If a patient is on warfarin, do not assume it is for a vascular condition, it could be for a fib, mirtazapine for depression or an appetite stimulant This is true particularly for RX HCCs, there should be a correlation between the drug that may be on the medication list, aspirin may not necessarily be taken for CAD

Physician Queries If you see documentation in a medical record that indicates a condition is being treated or addressed in some way, but the provider has not specifically written that diagnosis in his assessment, it is appropriate to query that provider in a non leading way to clarify his documentation. This allows for not only accurately identifying the patient’s medical profile, but also results in correct reimbursement the provider

Example The code of 250.00 has been submitted on a patient, but prescriptions being filled for Plavix have been filled. That patient may have vascular manifestations of diabetes that the provider did not document properly or the record was not coded to the highest degree of specificity The patient has a PMH of CVA , but no codes for any residual effect. That medical record can be reviewed for a possible hemiplegia as a result of the CVA

RADV AUDITS CMS Risk Adjustment Data Validation (RADV) Audits Purpose is to verify a plan’s risk adjustment payments, assess the quality of the data submitted, and determine the national payment error rate Both MA plans and PACE programs are targeted annually to submit samples of their documentation May be financial implications dependent on findings

Risk-Free Risk Adjustment Coding Use official ICD-CM outpatient coding guidelines Look up every diagnosis code Do not make assumptions re, do not diagnose the patient yourself Use all parts of the patient face to face visit; the CC, HPI, PMH, PSH, ROS, PE, Assessment and Treatment Plan, consultant notes, etc to substantiate your code Code to highest level of specificity Ensure the note/record meets CMS requirements

Chronic conditions that should be addressed once per year Sickle cell trait COPD AAA if seen in PMH with size and no surg hx Diabetes Multiple Sclerosis Organ transplants (not kidney) including stem cell HIV

Tricky diagnoses Dementia: what type? Behavioral disturbance? Depression: 311 (RX) 296.20? Diabetes with manifestations: Due to? With? Morbid obesity: BMI? Stage? Malnutrition/ cachexia? Skin ulcers: Venous? Pressure? Stage?

references http://www.cms.gov/medicarehealth https://www.com.gov/medicare/medicareadvantage/plan:payment/downloads/ radvchecklist.pdf http://www.cms.gov/medicare/medicare-advantage/planpayment/paymentvalidation.html

Thank you Q&A