50 Tips in 50Minutes

Presented by Betsy Canino, MSN, CRNP

Sherry Simpson, MSN, ANP-BCRichard Schamp, MD

Overview of RAPS Process

Build Risk Adjustment Awareness in Your Team

Get smart- Train, train, train…make sure all your clinicians understand the system

Silent cockpit – Make uninterrupted time for documentation (cone of silence)

Devote resources to getting this right (time = money)

Build into QI program Have a toolbox List of common or overlooked

diagnoses Coding desk references Smartphone or web apps

Involve your Team in Risk Adjustment Processes

Undiscovered jewels – think tank with the team…what are we missingWhat have you coded in the past and what’s missing this timeLow hanging fruit – what are team members already documenting but not codingMake Friends – Who else where you are is working on this…people in finance, a coder?? Have a drink together!!Pep rallies- Keep everyone informed about how you are doing and brag when things go well!

Use Your Data!

•Compare current diagnoses to past diagnoses submitted

•Coding patterns among providers/sites

•Missing encounters/assessments

Model Output ReportPDAC ReportsRAPS Return FilesEMR reports

Chronic Conditions

If you missed it at an annual or semi, see them again and document.Make sure all chronic conditions are addressed and documented and coded at least annually.Once amputated, never returns –don’t miss the obvious.

Chronic Conditions can be Slippery fish

Treatment is evidence of diagnosis

Sherlock Holmes…look for clues that would indicate a diagnosisMedication list Check under the bed – What have consultants documented that might not be capturedIDT assessments (esp SW, RN, Dietician, Rehab)

Don’t Dawdle

As your momma always said-don’t dawdle.You can’t get this all done in the last week…make it a daily practice.Anticipate deadlines and schedule accordingly.

Prepare for Risk Adjustment Sweep

Risk Adjustment Submission deadlines in March and September Internal monitoring process to validate that all RAPS data is submitted Benchmark to submit all eligible RAPS data within 45 days from DOS Consistency eliminates the last minute data submission pressure and helps ensure accurate and complete risk adjustment submission. http://www.npaonline.org/member-resources/payment

Don’t miss the bus: Compliance Datesfor RAPS and EDS files

Ingrain deadlines in your plan at the submitter level and clinician levelDec 31, 2016 – last date to have face-to-face visit for diagnoses that will ultimately impact payment for PY 2017Jan 31, 2017 (CMS Memo on 4/20/16) (vs Feb 3, 2017 CSSC Newsletter Jan 2016) – deadline to submit diagnosis codes for 2015 dates of service Mar 3, 2017 – submission deadline for 2016 service dates to use in the 2017 mid-year model runSep 8, 2017 – submission deadline for 2018 Initial Model Run (7/1/16 through 6/30/17 DOS)

HPMS Memos

When reviewing new HPMS memos Document receipt date, a brief description, requirements,

follow-up timeframes and who will “own” the issue Pay attention to NPA Health Plan Management Conference Call http://www.npaonline.org/member-resources/payment/medicare-part-

d/health-plan-management-call-summaries

Monthly Membership Report Reconciliation

Develop a monthly review process to support the accuracy of the monthly Medicare payment. Ensure all supporting documents are in order at this time to validate any changes requested. This compliance step will assist with signing the Monthly Plan Attestation and the Enrollment Data Validate (EDV) process required by CMS.

Comparing Part D Bid amounts

Validate the fields on the Monthly Membership Report (MMR) related to Part D against the current Part D Bid for accuracy Important compliance step that ensures accurate prospective payment from CMS for all Part D participants.

State and County Codes Important field on the Monthly Membership Report (MMR) Determines which County rate for risk adjustment payment Influenced by address on the SS check, e.g., representative payees Not validating this field could result in significant underpayment Not easy to correct…

Screen New Participants

Review all new participants’ eligibility in the CMS MARx system prior to enrollment

Pre-validating eligibility for Medicare parts A, B & D eliminates enrollment errors.

Verify other key indicators, such as, date of birth, presence of other insurance or employer group or union coverage

60-Day Advanced Notice of Medicare Eligibility

CMS requires all participants who become eligible for Medicare while enrolled in your program receive a 60-day advanced notice of Medicare eligibility. Develop a routine review process to meet this requirement and notify participant that their Medicare benefit will be assigned to your plan. This will streamline the enrollment into Medicare for this group of participants.

Maintain Access to CMS systems

Update passwords regularly to all of the CMS systems Improves response time to CMS deadlines Eliminates frustration when you can’t log on. Consider a calendar reminder every 60 days to update passwords Make sure multiple staff have access in case somebody leaves

Ensure Timely Monthly AttestationsUse MARx plan payment schedule to guarantee timely attestationsPublished in the Plan Communication User Guide (PCUG)Monthly payment attestations due 45-days from the date of MMRHave all adjustments documented well before the due dateAdd calendar reminders or include due dates in a master compliance calendar.

https://www.cms.gov/Research-Statistics-Data-and-Systems/CMS-Information-Technology/mapdhelpdesk/Downloads/Updated-Year-2016-Plan-MARx-Monthly-Schedule-Color-.pdf

Part D Policy and Procedure

Nine major Part D audit elementsReview related P&Ps annuallyEnsure that all elements are clearly addressed in P&Ps and up to date with the ever-changing Part D requirements. Document all changes to policy and routinely update existing procedures to ensure compliance with all Part D requirements.

Don’t know what a field means on a CMS report?

Use the Plan Communications User Guide (PCUG) – AppendicesDefines all fields contained in almost all CMS reports. Essential to fully understanding CMS reports and requirements. Updated by CMS periodically with the latest field definitions. https://www.cms.gov/Research-Statistics-Data-and-Systems/CMS-Information-Technology/mapdhelpdesk/Downloads/PCUG-Appendices-v102-August-31-2016.pdf

Buddy codes in Documentation

Always document the relationship between conditions. If a condition is caused by, related to, or secondary to another

diagnosis, this should be documented for clarity’s sake E.g., if cataract is due to Diabetes, show the connection

DiagnosingDiagnose conditions that you are actively treatingTreatment is prima fascia evidence of diagnosisGenerally, if a condition is treated, then a diagnosis exists

Supporting Documentation Make sure that each active diagnosis addressed at a face-to-face

encounter has supporting documentation to allow for coding Show evidence of medical decision-making, such as monitoring,

referral, treatment or assessment. Include date, provider name and signature

Easily MissedAlways evaluate for stage one pressure ulcers, and document appropriately during a face to face visit. These are typically found and treated by nursing staff and sometimes missed in PCP documentation. PCP should evaluate and document every pressure ulcer at least once. These are high risk and impact payment.

Auditing

Auditing medical records and coding is always a good idea. Auditing should be done frequently by internal sources and occasionally by external vendors to assure corporate compliance.

HOS-M Survey

Promote your annual HOS-M survey each year. Have participants bring their HOS-M survey to the PACE Center to complete. Though it must be a self-report, support by PACE staff can lead to more complete return.

Non-clinical Staff in your Risk Adjustment Processes

HCC Police – Get non-clinical staff to double-check completeness.Example: be fastidious in completing (signing and saving) all assessments and progress notes. ICD 10 codes from unsigned notes are not eligible for RAPS.

Every Rx points to a Diagnosis

Be sure to document and code all diagnoses. Some ICD-10 codes may not map to a Part A&B HCC for a Part C premium, but will map to a RxHCC, which helps Part D payments.E.g., Hypertension, GERD.

Document Medical Decision-making

Make sure there is clear medical decision-making notation attached to each diagnoses on an assessment. There can be no coding of a simple problem list.

Dx: Ischemic CardiomyopathyRemember when diagnosing and

coding for “Ischemic Cardiomyopathy” in a patient with chronic heart disease to also document CHF if present. Ischemic Cardiomyopathy codes to ischemic heart disease which risk adjusts to Part D only. Heart Failure Codes (i50.--) risk adjust to Part C.

Dx: Calcified AortaDon’t forget to review diagnostic imaging reports for “Calcified Aorta” or aortic atherosclerosis. This represents vascular disease (ICD-10 Code: i70.) This code does risk adjust if you are treating the condition: addressing risk factors for vascular disease – smoking cessation, lipid and BP management, etc.

Dx: Diabetes Mellitus

Uncontrolled Diabetes Mellitus in ICD 9 (250.02) did not risk adjust to HCC 18 Diabetes Mellitus with Complications. Diabetes Mellitus with Hyperglycemia (E11.65) in ICD 10 does. Be sure to document hyperglycemia in your face-to-face visits.

DX: Hepatitis C

Make sure to document all participants with Chronic Hepatitis C. In 2016 there is a Rx-HCC for Hepatitis C. Make sure it’s specified as “chronic”. One word can make the difference for generating revenue from an HCC to help provide needed care.

Dx: Dementia with behavioral disturbance

In ICD 10, a participant documented with dementia and behaviorsthat present risks to himself or others will map to HCC 51 Dementia with Complications. The CMS HCC model rewards specificity in documentation and coding.(Dementia with Depression, Delusions or Delirium no longer do.)

Major Depression inICD-10

Note that Major Depression, unspecified (296.20 in ICD-9) will no longer risk adjust in ICD-10.More specificity is needed, so document if the MDD is mild, moderate or severe. You can also document if in partial or full remission. All of these conditions will risk adjust.

Venous Ulcers

If ulcers are due to chronic venous insufficiency or venous hypertension, be sure to document as “varicose veins of [specify location] with ulcers” or“chronic venous hypertension with ulcer of [specify location]”

Planning Ahead

Best to leave some extra appointment slots in November and December for “catch-up” visits. Some participants miss an assessment or need close follow-up on chronic conditions that maybe were not documented earlier in the year. This is the time to close those care gaps and documentation gaps.

Be Careful with AbbreviationsAvoid the use of abbreviations in medical record documentationUse only standard abbreviations -- Do not create your ownCheck with local hospital for list if your organization doesn’t have an approved standard

Diagnosing Mild Chronic Kidney Disease (CKD)

Remember to document the pathology (nephrosis, microalbuminemia, etc) AND the renal function (estimated GFR).An eGFR > 60 does not make a diagnosis of CKD, without evidence of kidney disease.

DX: Diabetes

When documenting for diabetes, document about:• Type or etiology of diabetes• Body system affected• Complication(s) affecting that body system• Presence of Hyper/hypoglycemia • Document any insulin use

Stroke

“Stroke” or “CVA” is an acute diagnosis and should not be continued post hospital or other acute care. Be careful to document and code for any sequela of the stroke that persist.

Sources for Diagnosis Codes

Remember that diagnostic codes from Labs/Radiology Reports or claims are not eligible for RAPS submission. If a provider uses the diagnostic information and documents a diagnosis in the medical record that affects patient care, then the diagnosis code is

Face to Face

To be eligible for risk adjustment, a diagnosis must be documented in the context of a face-to-face visit.

Beware “Favorite” Specific Codes in EMRFor example, a physician may “favorite” a code in the EHR for diabetes (e.g., E08.21, diabetes mellitus due to underlying condition with diabetic nephropathy) because he or she treats this condition most frequently. However, what if every claim includes this same exact diagnosis? Even with its specificity, the code may not be the best option for every visit, especially if a patient has another manifestation of the diabetes.

Daley says payers could notice reporting patterns in which the diagnosis code is always the same—particularly when the code is highly specific. This may trigger an audit, he adds.

Beware Cloning Notes

Avoid “copy and paste” withoutupdates/edits.Auditors notice!

Chronic “Status” Conditions

Ostomy: Z93.- Gastrostomy, ileostomy, urostomy, tracheostomy, cystostomy

HIV status: Z21 Asymptomatic HIV status

Amputation: Z89.- Lower extremities (AKA, BKA, foot and toe)

Dialysis status: Dialysis, fitting adjustment catheter, presence of dialysis catheter

Transplant status: major organs (heart, lung, marrow, stem cell, pancreas, etc)

Non-commital Language Cannot be Coded

When possible, avoid using qualifying language to describe diagnoses. Instead, describe what is being treated.

Always Document to Highest Degree of Specificity

Documentation should accurately reflect the health status of the participant. E.g., if participant has iron deficiency anemia, document as such, instead of simply designating as “anemia”. The HCC model rewards specificityCMS is moving away from paying for non-specific codes

Specificity Matters

Per ICD-10-CM official coding guidelines, active diagnosis codes must be coded to the highest level of specificity.

ICD 10 DiabetesCodes are Combination Codes

E11.2- DM2 w/Renal ComplicationsE11.3- DM2 w/Ophthalmic ComplicationsE11.4- DM2 w/Neurologic ComplicationsE11.5- DM2 w/Circulatory ComplicationsE11.6- DM2 w/Other Spec’d Complicationse.g. Arthropathy, Skin Ulcers, & oral complications

One Code captures both Diabetes & the Complication. However both must be documented. If appropriate, the complicated DM code will map to both “Complicated DM HCC” & “Manifestation HCC”.

Dx: Vascular Dementia

Item No. Description Value1 Abrupt onset 22 Stepwise deterioration 13 Fluctuating course 24 Nocturnal confusion 15 Preservation of personality 16 Depression 17 Somatic complaints 18 Emotional incontinence 19 History of hypertension 1

10 History of stroke 211 Associated atherosclerosis 112 Focal neurological symptoms 213 Focal neurological signs 2

Use the HachinskiScale to Screen for vascular dementia. A cut-off score ≤ 4 for DAT and ≥ 7 for VaD

Sensitivity of 89% and a specificity of 89% (Moroney 1997)

Dx: Chronic Respiratory Failure

TWO types – Hypercapnic or Hypoxemic.If requiring continuous O2 (hypoxemic) then alsodocument Chronic Resp Failure (518.83)• Oxygen dependence (>15 hrs/day)• Document Hypoxemia at rest (not only with exercise or sleep)• Usually CHF or COPD as etiologyICD10 Respiratory failure (NEC) (J96.xx) • Acute and Chronic Resp Failure map to the same HCC• Can designate Hypoxia (J96.11) vs Hypercapnia (J96.12)

UnacceptableSignature/ Authentication

• “Signed but not read”• “Dictated but not signed/ read”, etc.• Signed by someone other than the treating

provider (nurse, transcriptionist, etc.) on provider’s behalf

• Signature stamps were phased out effective 12/31/2008. (EMR systems that affix an image that looks like a signature stamp are approved)

Acceptable Signature/ Authentication

• Handwritten signature or initials OK if printed name and credentials are on progress note

• Legible handwritten signature with credentials • CMS does not recognize Practice Name as rendering provider • Dr. is a title, not a credential • Electronic signature/ authentication (e.g. “authenticated by”,

“completed by”, “finalized by”, “validated by”, “attested by”, “sealedby”, etc.)

DX: Malnutrition

Use the Mini-Nutritional Assessment (MNA) to screen for malnutrition.Takes less than 5 minutes to completeWell validated.

Hematologic Malignancies

Leukemia and Multiple Myeloma can be coded if disease is present, is in remission, or is in relapse.

C90.00 Myeloma not having achieved remissionC90.01 Myeloma in remissionC90.02 Myeloma in relapse

*All three codes map to HCC 9

Use this Z-code when believe it has been cured:

Z85.79: Personal History of other malignant neoplasms of lymphoid, hematopoietic and related tissues.