RISK ADJUSTMENT CODING Hierarchical Condition Categories

AGENDA What is Medicare Park C? What is Risk Adjustment? Who is being Risk Adjusted? How are they being Risk Adjusted? What is an HCC? How does HCC coding differ from inpatient or outpatient coding in a facility? What is a RADV audit?

CALLED MEDICARE ADVANTAGE PLANS MEDICARE PART C CALLED MEDICARE ADVANTAGE PLANS They are similar to private health plans and take the place of “Original Medicare”. These plans must be approved by Medicare and follow Medicare rules. Medicare pays a fixed amount each month to the company offering the MA plan.

What is Risk Adjustment? The process of accommodating chronic conditions to determine the amount of reimbursement to the health plans It is used to determine the clinical acuity of patients, in other words, their diagnostic profile It can be done prospectively, concurrently or retrospectively

Risk Adjustment cont. Risk Adjustment allow CMS to pay insurance plans for the risk of the beneficiaries, allowing Medicare to make appropriate and accurate payments for enrollees with differences in expected costs. RA coding for Medicare Advantage Plans began in 2004, with 100% risk adjusted payment completed in 2004

WHO IS BEING RISK ADJUSTED? Those participants eligible for Medicare Dual eligible special needs patients that are entitled to medical assistance under a Medicaid state plan ESRD patients The patients can be on or off the Health Insurance Exchange or belong to an Accountable Care Organization

WHO? CONT. Members of PACE programs PACE is the acronym for Program for All Inclusive Care of the Elderly Their risk score is based on a participant’s demographic factors and diagnoses codes. A frailty factor is also used to determine the Medicare payment.

How are patients Risk Adjusted? Payment is based on the expected health care costs using diagnoses from the previous year and: Age Sex Medicaid Status Original reason for entitlement Institutionalized Frailty

Prospective Risk Adjustment Involves coding diagnoses from a Health Risk Assessment Tool The HRA can be completed in the home by a provider or by the patient’s PCP The HRA covers HCC and Non HCC diagnoses. The HRA also takes in to account HEDIS review measures An Annual wellness visit is mandatory

CONCURRENT/RETROSPECTIVE REVIEWS Clinical Reviewers on site for a practice under the MA insurance plan or at a PACE site Paper copies faxed or copied and mailed PDFs EMRs either on site or remote access

SO WHAT EXACTLY IS A CMS HCC? Hierarchical Condition Category Essentially a category of ICD-9 codes that fall in to a related disease process or condition. CMS will provide payments for the most severe manifestation of a disease process. Not all codes fall in to an HCC! RX HCCs

THE CMS MODEL TABLE The Risk Adjustment models change each year Payments differ between MA models and PACE models This year there is a blended model for MA plans to determine the risk score

HCC PAYMENT VALUES The lower the HCC number, the higher the acuity and therefore a higher payment is made to the plan PACE AND ERSD use the same payment model Some HCC’s “trump” other HCCs

WHAT TO CODE FOR RA? DO CODE ALL CHRONIC CONDITIONS THAT ARE BEING TREATED! DON’T CODE “HISTORY OF” CODES OF CONDITIONS NOT CURRENTLY BEING TREATED ( OR IN YOUR REVIEW YEAR) CODES THAT DO NOT FALL IN TO AN HCC

ACCEPTABLE DOCUMENTATION FACE TO FACE VISITS THAT ARE: LEGIBLE !!! SIGNED !!! CLEAR, CONSISTENT AND COMPLETE !!! FROM AN ACCEPTABLE PROVIDER TYPE AND FACILITY MDS AND EXTENDERS PT, OT OTHER PROVIDERS AND FACILITIES ON CMS ACCEPTABLE LISTS

CLEAR AND CONCISE ?? “The interpreter speaks her diuretic” Social history: “ He was fishing all day today and caught a few fish” “ She does have some ovaries left” “He does not need any preventative stuff at his age” 87

HCC CODING HCC coding uses Outpatient coding guidelines; cannot use any suspected, probable, possible, rule out, etc. Cannot code directly from a diagnostic test, the provider must verify the diagnosis Must code from the exact narrative documented by the provider and not make assumptions or diagnose Only code to the highest degree of specificity

Benchmark and Target Dx Benchmark data is compiled from the dx codes submitted to CMS for payment from previous years; PCP offices, hospitals, prescriptions filled, DME provided Target dx are those that informatics may determine would be logically present, but not captured and submitted Other conditions that are being monitored, evaluated, assessed and treated (MEAT)

ADDENDS These are similar to physician inquiries where the reviewer sees incomplete documentation regarding a chronic condition that the provider should be reimbursed for treating. Chronic conditions that are monitored, evaluated, assessed or treated need to be documented in the record at least once in the review (payment)year

RADV AUDITS RADV stands for Risk Adjustment Data Validation These are annual audits conducted by CMS to verify a plan’s risk adjustment payments There are two types: National: Several plans are asked to submit a small sample of documentation with no financial impact Targeted: 30 plans, both MA and PACE per review year with financial implications

RADV AUDIT CONT. The goal of these audits are to determine the national payment error rate for MA programs and to assess the quality of the data submitted for payment The audits use enrollee based stratification data; those with the highest risk scores, lowest risk scores and the middle stratum. The data is collected from these three stratums so as to reduce the variability that a random sample would have

QUESTIONS?

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