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MEDICARE RISK ADJUSTMENT HCC CARDIOLOGY
Presented by Susan Wyatt CPC, CPC-I, CPMA Director of Risk Adjustment Audit and Education Do not reproduce or redistribute without written permission. 9/18/2018
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What is Medicare Risk Adjustment? (MRA)
Before 2003 After 2003 Payment to Health Plan (Managed Care) Payment to Health Plan (CMS HCC Managed Care) Not influenced by Health Status Based on Demographics “Capitated” Flat rate/member/year Risk Adjusted for Health Status Based partially on Demographics MRA payment methodology was mandated by the Balanced Budget Act of 1997 9/18/2018 Do not reproduce or redistribute without written permission. 9/18/2018
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What is an HCC? (Hierarchical Condition Category)
14,400 ICD-9 Diagnosis Codes All Codes in the ICD-9 3,000 Reimbursable ICD-9 Codes Map to 1 of 79 Categories Each Code aka an “HCC” 79 Categories of Codes Clinically Related Conditions Additive and Hierarchical Chronic and Acute Conditions Do not reproduce or redistribute without written permission. 9/18/2018
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Why is MRA Important? RAF Score
Specific diagnostic documentation and coding of conditions is necessary for accurate reimbursement Disease Interactions HCC Categories Demographics RAF Score Documentation HCC DX Codes Documentation is the Core RAF Score reflects disease burden of the patient Current Year Reporting Predicts Revenue for Upcoming Year Do not reproduce or redistribute without written permission. 9/18/2018
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Documentation Guidelines
Encounter must be a face-to-face visit Legible Signature and Provider Credentials Patient Name; DOB; DOS on every page (backside too!) Manage, Evaluate, Assess, Treat – MEAT! All Chronic Conditions must be documented at least once every year! Document Acute Conditions when applicable! Think about diagnostic documentation as a form of nomenclature! Thorough documentation promotes Continuity of Care! We cannot code from a problem list or from past medical history! Do not reproduce or redistribute without written permission. 9/18/2018
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CARDIOLOGY CHF (compensated or decompensated) 428.0
HCC 85 .368 CHF (compensated or decompensated) Heart Failure Systolic and/or Diastolic Acute and/or Chronic Cardiomyopathy Metabolic Cardiomyopathy Cardiomyopathy in Other Diseases Secondary Cardiomyopathy 85 & 55 Alcoholic Cardiomyopathy Also – Alcohol Dependent or Alcohol Dependence in Remission Do not reproduce or redistribute without written permission. 9/18/2018
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CARDIOLOGY Unstable Angina 411.1 Angina 413.9
HCC 87 & 88 .258 & .141 Unstable Angina Angina Acute Coronary Occlusion w/o MI Acute Ischemic Heart Disease 96 .295 Atrial Fibrillation Atrial Flutter Paroxysmal Tachycardia NOS (Atrial (PAT) or Ventricular also) Complete or 3rd degree block SSS/-Chronic Sinus Bradycardia/Tachy-Brady Syndrome (If patient has a pacemaker for the SSS or Complete or 3rd degree block then you only code the pacemaker V You cannot code or ) Do not reproduce or redistribute without written permission. 9/18/2018
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CARDIOLOGY Acute MI Initial NOS 410.91 NSTEMI Initial 410.71
HCC 86 .275 Acute MI Initial NOS NSTEMI Initial STEMI Initial Can be coded as acute MI up to 8 wks after initial MI if documentation supports the 8 week time frame. Example: “PT had MI 6 weeks ago” 87 .258 Acute MI Subsequent (admitted back to hospital) Acute MI Unspecified Old MI ( Exists in old model only but still counts for 67%) 412 Chordae Tendinae Rupture Papillary Muscle Rupture Do not reproduce or redistribute without written permission. 9/18/2018
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CARDIOLOGY Ventricular Fibrillation 427.41 Ventricular Flutter 427.42
HCC 84 .329 Cardiogenic Shock Postop Cardiogenic Shock Cardiac Arrest Ventricular Fibrillation Ventricular Flutter 186 .891 Heart Transplant V42.1 Complication of Heart Transplant Do not reproduce or redistribute without written permission. 9/18/2018
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CARDIOLOGY Hypertensive CKD Stages 5 or ESRD 403.91
HCC 136 .224 Hypertensive CKD Stages 5 or ESRD (This is an assumed relationship) Assign code for CKD as well X 85 .368 Hypertensive Heart Ds w/Heart Failure (This is not an assumed relationship-it must be stated) Assign code for Heart Failure as well X Hypertensive Heart Ds & CKD Stg 5 or ESRD Assign code for Heart Failure and CKD as well X X Do not reproduce or redistribute without written permission. 9/18/2018
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CARDIOLOGY Endomyocardial Fibrosis 425.0
HCC 85 .368 Rheumatic Heart Failure Acute Cor Pulmonale Primary Pulmonary Hypertension Pulmonary Hypertension Chronic Pulmonary Heart Disease (Cor Pulmonale) Endomyocardial Fibrosis Hypertrophic Obstructive Cardiomyopathy Myocarditis NOS Myocardial Degeneration Do not reproduce or redistribute without written permission. 9/18/2018
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HCC in the old model only
CARDIOLOGY HCC 176 .566 Reaction to cardiac device, implant or graft HCC in old model only 67% Malfunction cardiac device, implant or graft NOS Malfunction of cardiac pacemaker Malfunction of cardiac prosthetic heart valve HCC in the old model only Malfunction of coronary bypass graft Mechanical complication automatic implantable defibrillator Do not reproduce or redistribute without written permission. 9/18/2018
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HISTORY OF Coders interpretation of “H/O” Providers meaning of “H/O”
Coders use ICD9 interpretation of history which is resolved, gone and typically not coming back. Clinicians use H/O typically meaning the patient’s history, not that the condition is history. Do not reproduce or redistribute without written permission. 9/18/2018
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CARDIOLOGY NON-HCC CONDITIONS
CAD & Sinus Bradycardia 427.89 Ischemic Cardiomyopathy 414.8 Ischemic Heart Disease 414.9 Cardiac Dysrhythmia 427.9 Tachycardia 785.0 Acute Myocarditis 422.90 Do not reproduce or redistribute without written permission. 9/18/2018
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CARDIOLOGY NON-HCC CONDITONS
Pericarditis 423.9 Cardiomegaly 429.3 ASCVD 429.2 Takotsubo Syndrome 429.83 BBB 426.5X Aortic/Mitral Valve Disorders 424.X Cardiac Tamponade 423.3 Do not reproduce or redistribute without written permission. 9/18/2018
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CARDIOLOGY- NON HCC (It is a Part D)
Hypertension, Unspecified 401.9 Hypertension, Benign 401.1 Hypertension, Malignant 401.0 Do not reproduce or redistribute without written permission. 9/18/2018
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Susan Wyatt CPC, CPCI, CPMA
CONTACT INFORMATION Susan Wyatt CPC, CPCI, CPMA 12900 Park Plaza Dr. Cerritos, Ca Fax Do not reproduce or redistribute without written permission. 9/18/2018
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