1. Risk Adjustment Coding
How does Risk Adjustment Coding relate to your medical practice and what you can do to help

2. What is it?
Risk adjustment methodology accounts for known and discovered heath data elements and compares levels of wellness among patients. The accurate selection of diagnosis codes plays a vital role in all risk adjustment models.

3. Also known as
Risk Adjustment Coding also called HCC coding : Hierarchical Condition Categories
In 2004 Medicare implemented an HCC model to adjust capitation payments to private health care plans for the health expenditure risk of their enrollees. The Centers for Medicare and Medicaid (CMS) Risk Adjustment Model measures the disease burden that includes over 70 HCC categories, which are correlated to diagnosis codes.
CMS' model is accumulative, meaning that a patient can have more than one HCC category assigned to them. Some categories override other categories and there is a hierarchy of categories.
CMS.gov/Medicare – which, while 127 pages in length, will provide a good history and detailed reasons for why Medicare developed this reporting model for health plans to use.

4. Example of What Hierarchy Looks Like

5. A little more info for you
The following categories reflect a few common chronic conditions found in the Medicare population, that Medicare Advantage Plans look for to be documented in a patient's chart:
Diabetes without complications - HCC 19
Chronic Obstructive Pulmonary Disease - 108
Congestive Heart Failure - 80
Breast Cancer – 10
Ischemic Heart Disease - 92
Angina - 83

6. HCC Coding for Exchange Members
You are probably familiar with Risk Adjustment if your office participates with Medicare Advantage Plans.
Risk Adjustment Coding is in the beginning stages for Commercial plans as the Affordable Care Act has been rolled out is the second full year plans have participated in this project.

7. Commercial Risk Adjustment
Risk Adjustment is required of all qualified health insurance plans sold to individuals and small groups both within and outside of exchanges.
Commercial Risk Adjustment reallocates premium income among plans.
Meaning, there is a funds transfer from lower risk plans to higher risk plans.
Plans that have more risky members will take from other plans.
Health Policy Briefs and CMS

8. In other words…
The overall approach of the Commercial Risk Adjustment builds on Medicare Advantage. However, there are some significant differences.
In the Medicare system, Risk Adjustment in a two-way transaction between each plan and CMS. No plans risk score has an effect on other plans. In the ACA system, plans with risk above the median will receive payments, which are funded by plans below the median. Whether a plan is low or high risk is determined relative to other plans – after the benefit year is complete.
Info obtained from : CMS website and Federal Register

9. Let’s Compare

10. Why is it done?
Health Plans are required to do risk adjustment for Commercial plan members. Plans who do not participate are financially penalized by the Health and Human Services (HHS)
Risk Adjustment is done to deter plans from “cherry picking” members.

11. Plans are participating
2014 dates of service was the first year that a plan was able to participate in the Exchanges Risk Adjustment project. The chart review took place at the end of 2014/early 2015 for the 2014 DOS.
The window for plans to submit diagnosis codes to CMS for consideration of their plans’ “sickness rate” (Risk Score) is short. Plans have until mid-end of April each year. It is always for the previous year.
After that, plans will undergo an audit and then they will be notified where they fell into the averages ranking discussed previously.

12. Medicaid Risk Adjustment
2016 is a planning year for the Medicaid RA line of business. Like the Commercial plans, Medicaid Risk Adjustment has a fairly short submissions window. Plans have until June to have HCCs validated so that they are applied to member risk scores.
Medicaid Risk Adjustment still measures the illness burden of members, but risk scores are applied to capitation rates for future payments.

13. Similar to Medicare Advantage
If you are familiar plans calling your practice for Medicare charts, nothing has changed for the Commercial charts. A plan will be looking for pretty much the same items in charts.
You already know that this is not an “audit” – there is no recoupment of payments that were made to your practice. Plans must validate conditions to prove their members’ health status.

14. Similarities, continued
We ask for your cooperation with the chart collection process. If you don’t have the manpower to supply charts, often times a plan has staff members that can come to you for the collection. Because the chart review is required, your compliance with records request is very important.

15. Continued
Similar to Medicare, the health plan will obtain analytics that are based on claims data history for members. This tells us which member charts we need to obtain for review. We use this method for Commercial, and will do the same for Medicaid.
For example, a claims history will often see Asthma or Diabetes billed, and suddenly those conditions are not reported on new claims. We know the condition probably didn’t go away, so we look to the chart to validate the condition and let CMS know the person is still being treated for the previously documented problem.

16. Coding and Documentation
The insurance carriers rely on correct coding to be done by practices; however they are still required to validate what is submitted.
We will always work with an office who has questions and will give feedback on chart documentation questions.
Good documentation will assist office staff with proper billing.

17. Coding and Documentation
A patient chart should tell a story of that person’s history.
Every encounter should include the reason why the person came to the office. CMS also requires that each medical record is self supporting. The chief complaint should not simply be “follow up”. Follow up of what? WHY did Sally Smith come in to see Dr. Jones last week? Follow up of her longstanding diabetes? There, that’s better!

18. Coding & Documentation Challenges
Because plans rely on the providers to accurately code records, a problem often seen is “upcoding”. Upcoding can undermine risk adjustment if it distorts the actual health to risk profile of a plan.
Upcoding can make it appear that plan members are sicker than they actually are. The availability of diagnosis based information will be important to making risk adjustment accurate. This is why the chart validation is so crucial – both for Medicare members and those enrolled in a Commercial or Medicaid product.

19. Examples of upcoding Some examples of upcoding are as follows :
A provider who has billed a claim with the diagnosis of diabetes mellitus, when the chart documentation supports glucose intolerance.
Another example would be a person who presents with shortness of breath, but their claim comes in with a diagnosis code of asthma.
In the above cases, the claim would produce an HCC, but the chart note does not support the coding

20. Coding and Documentation
It is very important for chart notes to make sense within itself. For example, your office coder will have a difficult time capturing the patient’s correct diagnosis codes when the chart contradicts itself (shown in example on the next page)
The physician should make sure the note is accurate – this will reduce the need for staff to ask for clarification, thus the billing can get out the door quicker.

21. Here, the physician states there are no skin complaints
However, here they are indicating the person has skin cancer.

22. Coding and Documentation
The documentation must be legible – and every visit must be signed by the person who examined the patient. The provider is also required to use their credentials when they sign off on a note.
Your documentation must support billed services.
Reasons for ancillary testing need to be clear. Even though you can’t bill a rule-out, they are acceptable statements in a medical record.
For example, “we’re sending Sally Smith for a chest x-ray to rule out pneumonia”

23. Legibility and Credentials are Critical!

25. One more signature example

26. Coding and Documentation
NCQA, CMS, and other resources, which are provided in a handout today, will assist practices with the current documentation requirements.
As noted a couple times previously, one of the most important things your provider can do for your medical records is make sure every note is able to stand alone. Stand-alone means the note is self supporting in that the person being treated is clearly identified, the reason the person is being seen is stated, and what course of action will take place.
Information borrowed from : CMS site, & NCQA.org

27. Resources Official Coding Guidelines on CDC website Coding Clinic
AHIMA
AAPC
AMA
AHA (American Hospital Association)

28. Specificity
A risk adjustment coder will look for the highest level of specificity we can find. This helps to paint a clear picture for CMS of what a person’s medical condition is.
For example, it is important to document the stage of a person who has Chronic Kidney Disease.

29. Specificity, continued
Another example is when a patient has several conditions that may or may not be related to each other… for instance : Sally Smith had a CVA. She now has hemiplegia or hemiparesis. A physician should make the link (IF it is appropriate to do so) by saying “Ms. Smith has hemiplegia due to the CVA.
This tells the plan there is a late effect of the CVA, and it lends to specificity ICD10 gives us.

30. And the code is….
Please note, this is unspecified site. There are more specific codes to indicate if the hemiplegia is affecting the right or left side and whether or not it’s dominant side or not

31. Plans get Audited
Health Plans undergo random audits by CMS and HHS. Currently 10% of Medicare Advantage plans are called for an audit each year. However, they are looking to increase the number of plans they audit.
This is part of the reason the plans do risk adjustment. If plans are able to validate conditions in a record, when they are called on for the audit, they are confident they will pull through it.

32. Plans get Audited, continued
On the Commercial/ACA population, health plans will be audited every year.
Depending on plan population size, there will be up to 200 members selected in the audit sample. The members in the audit are not selected by the plan, they are selected by CMS.
The audit begins July 1st for the members that were just submitted for risk adjustment scores (remember that April deadline).

33. Plans get Audited, continued
Health plans are ultimately responsible for what is billed on a claim, that is another reason we look to validate conditions in medical records. When a health plan is audited, CMS tells the plan which member charts are being chosen for validation purposes. When a claim comes in telling the plan, for example, a person has an active cancer when they do not, the plan can not validate the condition and the plan gets penalized for the submission.
Lets Look at a few examples

34. In this example, it would be tough for the health plan to argue that this person has cancer.
The CC for this visit states ‘prostate cancer’. Perhaps it should be worded to be follow up of history of cancer.
This gentleman has no prostate
This record clearly indicates the diagnosis code should be a personal history represents a current cancer, which in this case, is not the case. This claim should bill out using ICD9 code V10.46 (personal history of prostate cancer)

35. Here, we are told when this person was diagnosed, and that she had a mastectomy
This note indicates to us we should code this as personal history. However, this was billed – which is an active cancer ICD9 code

36. Last Cancer Example
This note should be billed to your payer as V10.3 – personal history of breast cancer

37. What you document is crucial
In this final chart note example, this is a chart that I was looking at while trying to respond to an audit. CMS was asking the plan to validate Congestive Heart Failure,
When reviewing claims history, this diagnosis code was billed just once, leaving the plan slim opportunity to validate. It is possible for the condition to be documented elsewhere, but just not on a claim.

38. This encounter was billed with 428
This encounter was billed with – as you can see it is not documented in this record. Is it lumped in to Number 9?
What are the “other issues” ?

39. Plans get audited, continued
Sometimes a health plan will reach out to a provider office with feedback. This stems from the chart reviews and is meant to be helpful to your practice. Sometimes our seasoned physicians are “stuck” in documentation guidelines of the past and need a gentle reminder that things have changed. Likewise, there are always new doctors graduating medical school and they often have questions.

40. Here to help
Remember, your health plans are here to help your practice. If you are audited, we want you to pass.
Your local health plans offer trainings at their offices on a periodic basis. They have teams working on creating sessions geared towards the transition to ICD10.