1. Understanding Risk Scoring
Medicare uses diagnosis within their Hierarchical Condition Categories (HCC) to determine the financial risk of a patient.
About 11,000 ICD10 diagnosis correlate statistically with increased medical costs
Most HCC codes are related to chronic conditions
Weighted based on the severity of the condition
Depression vs Major Depression
Renal Insufficiency vs Chronic Renal Failure
More specific codes are usually more heavily weighted
Weights are additive

2. Documentation Requirements
Must assess any condition listed on a claim
Must have a treatment plan or “continue …”
Do not use “rule/out” or “suspected”
Do not use adjectives e.g., “might be”, “could be”, “consistent with”, “suggestive of”, “suspect”, or NOS
Don’t use “History of …” Specify that condition is present or active.
Document and Code all conditions
at least once annually

3. Additional Risk Scoring Information
Annually assess each chronic condition and code appropriately
Submit up to 12 ICD-10 codes per claim (check with your billling vendor/clearing house)
Correctly sequence the codes
Purpose of visit #1 Z00.01 or chief complaint
Followed by highest complexity/intensity dx
ICD-10 codes can be added to Annual Wellness Visit and any other visits, as long as assessed and documented
Specialists coding
Depression coding

4. Specificity Coding Examples
Arrhythmia vs PAT
Hepatitis C vs Chronic Hepatitis C
Old CVA & weakness vs CVA & paresis
DM & proteinuria vs DM & nephropathy
Renal Insufficiency vs CKD
Asthma vs Chronic Obstructive Asthma
Bronchitis vs Chronic Bronchitis
Neuropathy vs Peripheral/Idiopathic Neuropathy

5. Coding Opportunities: Malnutrition
Weight loss > 5% in 1 month
Weight loss > 7.5% in 3 months
Weight loss > 10% in 6 months
Weight loss > 20% in 12 months
Protein calorie malnutrition = RAF
Cachectic and/or malnourished appearing in documentation

6. Coding Opportunities: Dependence
Alcohol
Sedative
Opioid
Status: continuous, episodic, in remission, unspecified
DSM IV criteria for Dependency: 3 of 7 criteria
Inability to cut down or control use
Larger amount of longer period
Withdrawal if attempt to wean off
Tolerance to the drug
Interruptions in work / home / legal problems

7. Management of Risk Levels: Low Risk
Wellness
Involves a majority of patients attributed to your practice. Keeping them healthy is the best strategy.
Annual wellness exams
Promote healthy lifestyles: diet, exercise, stress management, social supports, spiritual fulfillment
Appropriate screenings & immunizations

8. Management of Risk Levels: Rising Risk
Disease focused practice protocols and interventions
Diabetes, HTN, COPD, Asthma, Back Pain, etc.
Frequency of visits
Evidence-based care guidelines / treatments
Bringing patients to goal
Specialist co-management
Payer disease management programs

9. Management of Risk Levels: High Risk
High Risk Patient List
Frequent visits/touches (calls)
Customized patient care plans – shared with patient and caregivers
Complex Care Coordinators
Health Plan Case Managers
POLST forms and Advanced Directives

10. High Risk Member Activity Report
Patient Name (Last,First)
DOB
Carrrier
Diagnosis Description
High Risk Issue(s) - based on ACO reports, office chart reviews or other sources of information
Each provider to review plan for his/her patient and initial
Last PCP office visit
Next office visit
Updates on patient's plan of care, interventions being used, care coordination, or next phone call to patient
AETNA
Hypertension (high blood pressure)
Moderate Clinical & Financial Impact
UNIVERSAL ULCERATIVE (CHRONIC) COLITIS
Chronic Lower Back Pain
Standard High Clinical & Financial Impact

11. Remember What Works: Frequent Interactions Use your Patient Registry
Office Access & Patient Communications
Annual Wellness Visits
Use your Patient Registry
Find patients with gaps in quality care
Written Patient Care Plans
For high risk patients and high frequency ER utilizers
Shared with the patients
An office-based Clinical Coordinator empowered to implement population management interventions (ER f/u, Care Transitions)