1. Coding, Documentation and Attribution: How This Impacts the Deployment of Your Team Members
Linda Gates-Striby CCS-P, ACS-CA
Director, Corporate Compliance
St. Vincent Medical Group
Indianapolis, Indiana
Ty J. Gluckman, MD, FACC, FAHA
Medical Director, Clinical Transformation
Providence Heart and Vascular Institute
Portland, Oregon

2. Disclosures
Linda Gates-Striby, CCS-P, ACS-CA
Nothing to disclose

3. Disclosures
Tyler J. Gluckman, MD, FACC Consultant Fees/Honoraria Boehringer Ingelheim

4. Incident-To Billing
Way of billing outpatient services (most commonly in a physician’s office) by non-physician practitioners (e.g., PAs, NPs)
It was developed by Medicare; such rules may not apply to other payers
Billed under the physician’s NPI if conditions are met
“Incident-to” services must be part of the patient’s normal course of treatment, during which a physician personally performed an initial service and remains actively involved in the treatment (NOT a new problem)
You do not have to be physically present in the treatment room while the service is being provided, but you must be present in the immediate office suite to render assistance if needed

5. Shared/Split Billing
Way of billing Evaluation and Management (E/M) visits that are “shared” or “split” between a physician and a non-physician practitioner (e.g., PAs, NPs)
If documentation requirements are met, the visit can be billed under the physician’s PIN (100% of the fee schedule), as opposed to the PA’s/NP’s PIN (85%)
The PA/NP must be from the same group practice and the same specialty
The physician and PA/NP must both perform and document their face-to-face encounter with the patient
The portion of the E/M service performed and documented by both the physician and PA/NP must be substantive, which includes part or all of the history, exam, or medical decision

6. Shared/Split Billing—What’s Not Adequate
“I have personally seen and examined the patient independently, reviewed the (PA’s/NP’s) history, exam, and medical decision making and agree with the assessment and plan as written” signed by the physician
“Patient seen” signed by the physician
“Seen and examined” signed by the physician
“Seen, examined and agree with above” signed by the physician
“As above” signed by the physician
Signature alone by the physician
Documentation by the PA/NP stating “The patient was seen and examined by myself and Dr. ____________, who agrees with the plan.” signed by the physician

7. If You Have Seen One Form of Attribution . . .
CMS Attribution Basics
Attribution depends on who provides the “Plurality of Primary Care Services”.
Medicare uses a two-step process for determining which patients are tied to a provider and who will constitute the spending-per-beneficiary and claims-based-quality-measure denominators.
Medicare is now aligning the methods used in ACO patient attribution with the VBPM patient attribution – this is intended to create consistency between Medicare’s Value-Based Payment initiatives.
Good News for 2017!
In 2017 CMS is also reviewing APPs in the equation for “Plurality of Services”
Team-based Care

8. Medicare’s 2-Step Approach
Step 1: Beneficiaries are assigned to the primary care provider (whether physician, NP, PA, or CNS) who provided the “plurality of primary care services” to the patient, as measured by allowed charges (i.e., E & M visits).
But what if they were not seeing a PCP?
Step 2
Step 2: Beneficiaries are assigned to the practice whose non-primary care providers (i.e., specialists) provided the “plurality of primary care services” to the patient, as measured by allowed charges – again – E & M visits.
But wait there’s more. “Primary Care Services” may include services that a specialist provides, but which are unrelated to the conditions and events that Medicare is tracking.

9. Specific patient name is available Take the time to do a deeper dive
Who are You Accountable For?
Specific patient name is available
Take the time to do a deeper dive
What about the PCP?
Is there a PCP?
 You don’t have to guess - review your QRUR report- it lists all of the patients
Shows your total patient cost – and from where
Were these episodes ones you controlled?
Are there other provider costs that are hurting your score?
This can be an eye opening experience!
 The data is based on Medicare claims data
If there are providers not in your network – this may be one of the only ways you will see their costs
You may see that the patient has providers they are seeing that you were never aware of
The ACC has provided extensive web sessions on how to use your QRUR reports!
One thing specialists can do is confirm that the patient has a PCP
If they have a PCP, make sure they are seeing them at least once per calendar year
Finding out a patient with COPD, for example, is assigned to you can actually signify a gap in care and no one may be managing that condition.
A quick review may not only avoid attribution errors, but could lead to better patient outcomes

10. Metrics are Patient-Centered
One way to help with appropriate attribution is to ensure that the PCP is conducting and billing for the Medicare Annual Wellness visit
This can help ensure that the patient stays connected to the PCP both clinically and through the attribution process
This also provides an opportunity to ensure that chronic conditions are addressed and hopefully coded and billed once per calendar year (HCC & RAF scoring)
In a P4P world it doesn’t always matter if you are the specialist or the PCP - You need to know what care your patients are receiving. You simply can’t stop with providing the best possible care in your field and sending patients out the door.

11. Hierarchical Condition Category (HCC) Codes
HCC codes underlie the methodology CMS uses to determine capitated payments for Medicare Advantage (MA) or other Medicare programs.
The codes allow payments to be risk-adjusted based on patient complexity
The methodology uses a 12-month diagnostic coding history to predict future utilization and risk and creates a risk adjustment factor (RAF) score reflecting the patient’s complexity.
30% of beneficiaries are now in MA, tripling in size over the last 10 years.
Prepares providers for a future with increased risk-based contracts.
Useful for calibrating panel size, productivity, and access.

12. What Do We Mean by Risk Adjustment Factor (RAF)
Used to access the clinical complexity of a patient and predict the burden of illness for individuals and populations
Acts as a multiplier when calculating CMS payments in a year
Factors into bidding and payment of MA plans
Focuses on identification, management, and treatment of chronic conditions
Provides a payer with additional resources to manage the health of a riskier population
Additional Resources
More accurate coding leads to improved practice modeling and stratification of a population
Better Analytics
Encourages regular outreach to patients who aren’t coming to the practice but may need follow-up
Encourages Regular Management

13. Characteristics of CMS HCC Model
79 HCCs For multiple chronic conditions
Disease interactions
Used to adjust payment plans
Characteristics of CMS HCC Model
Considers enrollee’s general age/health/demographics
Uses diagnostic sources
Prospective In nature
Allows for planning of resources
Maps to over 3,000 ICD-10 codes. Claims-based

14. Importance of Accurate Coding of Severity of Illness
Don’t Miss Chronic Conditions
DM & complications
Heart failure
COPD
Atrial fibrillation
Morbid obesity
HTN with complications (HTN alone does not have a RAF score)
Major depression
Peripheral vascular disease
Malnutrition
Use ICD-10 appropriately (i.e., with the greatest specificity as possible)
Accurately capture the conditions that are treated, managed, or impact care
Coded conditions must be documented: MEAT--Manage, Evaluate, Assessment, Treatment plan
Accurate coding and documentation is critical to risk scoring and our future

15. Sample Patient - Mickey M
Sample Encounter and the Cumulative Impact
Sample Patient - Mickey M
HPI
Mickey comes in for a follow up of his HF. He also has DM and CRF, stage IV.
A/P
Chronic systolic HF – Currently stable, to continue current dose of furosemide
Type II DM with stage IV CKD – Stable, scheduled to see nephrologist in 2 weeks
This patient has 3 HCC categories, all three codes risk adjust and would represent an cumulative “scoring”. This patient’s RAF score would be .960
If the anticipated monthly cost was $850 this now adds $850 x .960 = $816/month
Financial Metrics
All 3 conditions result in an extra $816 per month
+ $9,792
Reporting HF only would provide an extra $312 per month
+$3,744
HCC/RAF Scoring

16. Mickey M—What if he also had a skin ulcer?
What Does Coding Correctly Mean?
Mickey M—What if he also had a skin ulcer?
HCC
Condition
RAF
Score
HCC 157
Pressure ulcer of skin with necrosis through to muscle tendon or bone
2.551
HCC 158
Pressure ulcer of skin with full thickness skin loss
1.371
HCC 161
Chronic ulcer of skin except pressure
0.549
HCC 162
Severe skin burn or condition
0.422
A patient with HCC 157 will be spending $2,168 more each month (2.551 X $850)
A patient with HCC 158 will spend $1,165 more per month (1.371 X $850)
A patient with HCC 161 will spend only $466 more per month (0.549 X $850)
A patient with HCC 162 will spend only $358 more per month (0.422 X $850)

17. What Do Your Providers Understand?
How many codes can you submit on a claim?
Do your providers understand the importance of accurately representing the patient’s multiple conditions and their severity?
2017 claims data will be used in the implementation
ICD-10 Revenue Risks

18. Comorbidity/Complication (CC) and Major CC (MCC) Codes
CC/MCC codes play an important role in hospital reimbursement through assignment of the correct MS-Diagnosis Related Group (MS-DRG) code

19. Comorbidity/Complication (CC) and Major CC (MCC) Codes
CC/MCC codes play an important role through risk adjustment of quality measures, including length of stay, readmission rate, and risk of death
AMI Episode Payment Bundle
Patients who receive medical therapy but no revascularization (MS-DRGs ) and includes discharges for Percutaneous Coronary Intervention (PCI) (MS-DRGs )
CMS will adjust payment based on the DRG and composite quality score*
*Defined by the 30-day, all cause, risk-standardized mortality post AMI (40%), excess days in acute care [emergency department visits, observation stays, and hospital readmissions] per 100 discharges (40%), and the HCAHPS score for all patients (20%)

20. CMS Risk Adjustment for AMI 30-Day Mortality Measure
Hierarchical Logistic Regression Model
Coefficients:
Age
Comorbid disease
Indicators of patient frailty
Source:
Inpatient data
Outpatient data
Physician Medicare administrative claims data
12 month look back + index admission

21. Documentation Drill Down Example—Renal Failure (CC 131)
The presence of a code from a CMS-identified CC will incrementally increase the risk of the expected outcome

22. Accurate Severity of Illness = Accurate Expected Outcome

23. Questions