10/2/2017

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50 Tips in 50 MinutesPresented by

Lori Pigeon CRNP Asst. Med Director for Quality, Harbor Health PACE

George “Mike” Brett MD CMO: Capstone Performance Systems

David A. Wilner MD Sr. Med Consultant: Capstone Performance Systems

Objectives

Attendees will be able to take home a few practical tips or at least an awareness of needs for future attention. Examples:

• Describe CMS requirements for medical record documentation

• Define best workflow processes for consultant notes (and more)

• Discern patterns from PDAC reports to focus attention on internal processes

• Learn a few tips in proper documentation.

• Determine situations that need attention in their Monthly Membership Reports

What this Presentation is

IS NOT

❖ Highly organized lecture

❖ Comprehensive

❖ Exactly “50”

❖ Introductory

IS

❖ Collection of practical wisdom

❖ Based on experience

❖ Thought-stimulating (raise questions for you to work on later)

Hold questions until end.

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Keepin’ It Engaging

Audience participation through LIVE survey questions in the presentation to keep us awake!

Get out your phones or tablets so you can vote:

1. Text CPSTN to 37607 to join presentation

OR

1. Log into www.pollev.com/cpstn

2. Answer questions when they come on screen

3. Answers are anonymous

4. Only 40 votes/questions – get your answer in quickly!

PACE Medicare Payment is a Premium (not a reimbursement). Your program is “At Risk”

❖ Every Medicare participant has a Risk Score

❖ Raw Risk Score = Sum of demographicrisk factors and diagnosis risk factors

❖ ~10,000 ICD-10 codes in 87 Hierarchical Condition Categories (HCCs)

❖ Risk Score adjusted for normalizationand coding intensity (net ~10%)

❖ A Frailty Factor is added for non-ESRD and non-LTI – average value ~0.138 (0.043 – 0.261)

❖ Average adjusted risk score in PACE is ~2.53

❖ Premium payment = Adjusted Risk

Score X County Rate

❖ Average 2017 PACE County Rate =

$923 ($734 - $1438)

❖ Average premium ~2.53 X $923 =

~$2,336/mo

❖ The model is prospective

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Overview of RAPS Data Process

The more of your

staff that

understand the

details of this

process the better!

Assign staff to Work Your RAPS Error Reports

❖ FERAS errors at file-level

❖RAPS errors at record-level, e.g.,❖ 450 – invalid code for the

date❖ 408 /409 – DOS &

enrollment mismatch❖ 500 – HICN changed

❖Make SURE someone is working the errors on each report – look for systemic problems

CSSC Operations - RAPS-FERAS Error Code Listing-Effective August 14, 2016

So there’s a lot that happens AFTERthe Face-to-Face encounter.

But Wait…

What must happen BEFORE

the Face-to-Face encounter?

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Build Risk Adjustment Awareness and Competency in Your Team

Train all staff involved in the process:

❖ Support staff (clinic administrator, MAs, scheduler)

❖ Clinical providers (doctors, NPs, PAs)

❖ Finance department

❖ Interdisciplinary team

Involve your Team in Risk Adjustment Processes

❖ Undiscovered jewels – think tank with the team…what are we missing

❖ What have you coded in the past and what’s missing this time

❖ Low hanging fruit – what are team members already documenting but not coding

❖ Make Friends – Who else 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!

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

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60-Day Advance Notice of Medicare Eligibility

❖ CMS requires all participants who become

eligible for Medicare while enrolled in your

program receive a 60-day advance 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.

Monthly Membership Report Reconciliation

❖ Develop a process to support the accuracy of

the monthly Medicare payment (MMR)

❖ If it’s not right, ensure all supporting documents

are in order to validate any changes requested

❖ This compliance step will assist with signing

the Monthly Plan Attestation and the

Enrollment Data Validation (EDV) process

required by CMS.

❖ Is Everyone in your program who is eligible for

Medicare on the MMR Report? How do you

know? Who’s checking??

Handle Your Claims Correctly

❖ All External Claims Data must have Medical Record Documentation on file

❖ Preferably prior to submission

❖ Important to Submit Claims Data in a Timely Manner

❖Make Sure to Submit into RAPS as well As EDRS!

❖ In your EMR, make sure all “Provider Types” (1,2,10,20) are submitted into RAPS and do audit sample data each month to assure accuracy

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Use Your Data!

❖ Compare current diagnoses to past diagnoses (HCCs) submitted

❖ Model Output Report

❖ PDAC Reports

❖ RAPS Return Files

❖ EMR reports

❖ Error reports

Use Your Data!

❖ Compare your HCC prevalence against PACE averages

❖ Model Output Report

❖ PDAC Reports

❖ RAPS Return Files

❖ EMR reports

Use Your Data! ❖ RAPS Return Files

❖ Audit against what should have been submitted

❖ Combine together to create a history of diagnoses

❖ EMR Reports❖ Verify all encounters were coded

❖ Verify all diagnosis codes submitted

❖ Find patients with incomplete or wrong diagnoses

❖ Error Reports

❖ Model Output Report

❖ PDAC Reports

❖ RAPS Return Files

❖ EMR reports

❖ Error reports

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Chart Prep-Thinking Ahead

❖ 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.

❖Don’t miss the obvious.

❖Remember: not every clinic visit needs to be 15-20 minutes!

Chronic Conditions can be Slippery fish

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: Z99.2 Dialysis, fitting adjustment catheter, presence of dialysis catheter

❖ Transplant status: Z94.- major organs (heart, lung, marrow, stem cell, pancreas, etc)

Silent Cockpit

❖ Protect time for clinical staff

to complete documentation

❖ Remove distractions and

interruptions

❖ Run interference for your

providers!

Documenting an initial assessment or an annual

/semi-annual visit takes TIME!

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Develop Your Tool Box❖ List of often overlooked diagnoses

❖ Quick reference guide to common diagnoses with supporting evidence

❖ Coding desk references

❖ Smartphone apps such as PACE Dx ICD-10

❖ Websites such as PACEdoc.com

❖ DX/HCC crosswalk

Face to Face

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

❖At this time, telehealthencounters are NOT considered face-to-face.

Treatment = Diagnosis❖Diagnose all conditions that you are

actively treating, even if the condition

is quiescent or stable

❖A Condition Exists if you’re treating itNot Every Treatment is a Pharmaceutical

Behavioral Health interventions.

Care Plan notations

❖Treatment is prima fascia evidence

of a Diagnosis

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Scrub to find all the conditions being treated

Sherlock Holmes…look for clues that

would indicate a diagnosis

❖Medication list

❖Check under the bed – What have

consultants documented that

might not be captured

❖ IDT assessments (esp SW, RN,

Dietician, Rehab)

Every Prescription Points to a Diagnosis

❖ Be sure to document and code all diagnoses.❖ Don’t think that you “know” everything that

maps to an HCC

❖ 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. HT, Hyperlipidemia, GERD, Hypothyroidism, Glaucoma, Osteoporosis

Part D Payments are (partially)

Risk- Adjusted TOO!

Always Document to Highest Degree of Specificity

❖ Documentation should accurately reflect 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 specificity

❖ CMS is moving away from paying for non-specific codes. Ex: F32.9

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Specificity Matters

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

Major Depression inICD-10

Specificity Matters #2Who would’ve known?

Major Depression, unspecified (296.20 in ICD-9)

no longer risk adjusts in ICD-10(F32.9 in ICD-10).

There was a huge change from ICD 9 to ICD 10 in documenting (Major) Depression

First Diagnosis should be based on the DSM 5 criteria Screening tests (PHQ-9) “screen” for the diagnosis. The provider makes the diagnosis

Major Depression (single episode or recurrent) was appropriate in ICD 9.

Need More specificity in ICD 10Mild, Moderate, Severe, partial remission, full remission

Otherwise Major Depression maps to F32.9 which does NOT risk adjust

Specificity Matters #2 DEPRESSION

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Speaking of Specificity…..Fractures need Specificity too!Is the fracture a Traumatic Fracture (ICD 10 “S” Chapter)

Caused by accidents, falls, or force

Is the fracture a Pathologic Fracture (ICD 10 “M” Chapter)

“Pathologic” includes malignancy and fragility (Osteoporotic) fracturesIf Osteoporotic, must specify if “age related” or “drug-induced.”

Document Site

Which bone?

Proximal, Middle, Distal?

Displaced versus Nondisplaced?

Right versus Left?

Initial Encounter (“A”) Versus Subsequent Encounter (“D”) in 7th position of ICD 10 code

❖ Example: Stable Angina. If patient on

meds, then angina may be controlled

without symptoms – still should be

diagnosed and coded. Tip: get a list of

patients on Anti-Angina Meds

❖ Example: Stage B Heart Failure.

May never had been hospitalized, but

has anatomic changes, treated medically

without symptoms. Meets criteria for

diagnosis and can be coded.

Uncover Quiescent Conditions!

• LVH with or without diastolic dysfunction• Wall motion abnormality due to old MI• Reduced systolic function (LVEF <50%)• Valvular Disease

Peripheral Arterial Disease is the most prevalent HCC seen in PACE!

Who is at Risk?• Age 70 (14.5% and 23.2% over age 80!)

• Age 50-69 with DM or smoking history

• Age 40-49 with DM and one other risk factor: smoking, Hyperlipidemia, HTN, Homocysteinemia, Metabolic Syndrome

• With known coronary or cerebrovascular atherosclerosis

Case Finding:

Physical ExaminationABI (arterial brachial

index)Other devices?

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Dx: Vascular Disease

❖ A lot of vascular disease is quiescent – look for evidence of peripheral artery disease and manage it well.

❖ Example: review diagnostic imaging reports for “Calcified Aorta” or aortic atherosclerosis. (ICD-10 = i70.)

❖ Vascular diagnoses are valid and risk adjust if supported by documentation of treatment, such as addressing risk factors for vascular disease – smoking cessation, lipid and BP management, etc.

AsthmaAsthma ICD 10 Codes are J45.-- Codes.

“Mild Intermittent Asthma:” “Mild, Mod., Severe Persistent Asthma”

These do NOT risk adjust (HCC 111 “COPD”)

Does your participant have evidence of Air Trapping in between Acute Exacerbations?

If so, COPD Exists

“Asthma with COPD”“Chronic Asthmatic (Obstructive ) Bronchitis”“Chronic Obstructive Asthma”

J44.9 HCC 111

Dx: Chronic Respiratory Failure

❖ TWO types – Hypercapnic or Hypoxemic.

❖ If Hypoxemic, requiring continuous O2 then also document

Chronic Respiratory Failure • Oxygen ordered continuously (>15 hrs/day)

• Document Hypoxemia at rest (not only with exercise or sleep)

• Usually CHF or COPD as etiology

❖ Respiratory failure (J96.--) • Designate Hypoxia (J96.11) vs Hypercapnia (J96.12)

TIP: get a list of your patients ordered continuous Oxygen

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Is Your Dementia Participant Exhibiting Behaviors?

❖ In ICD-10, a participant documented with dementia and behaviors that present risks to himself or others will map to HCC 51 Dementia with Complications (higher payment than uncomplicated dementia HCC 52)

❖ Dementia with Depression, Delusions or Delirium no longer considered “complicated”

❖ The CMS HCC model rewards specificity in documentation and coding.

Dx: Vascular Dementia

Item Description Value1 Abrupt onset 2

2 Stepwise deterioration 1

3 Fluctuating course 2

4 Nocturnal confusion 1

5 Preservation of personality 1

6 Depression 1

7 Somatic complaints 1

8 Emotional incontinence 1

9 History of hypertension 1

10 History of stroke 2

11 Associated atherosclerosis 1

12 Focal neurological symptoms 2

13 Focal neurological signs 2

❖ Common in PACE, under-

diagnosed

❖ TIP: use the Hachinski

Scale to assess for

vascular dementia.

❖ Cut-off score ≥ 7 for VaD

Sensitivity of 89% and Specificity of 89% (Moroney 1997)

Stroke

❖ “Stroke” or “CVA” is an acute

diagnosis and should not be

continued post-hospital or other

acute care.Common source of inadvertent “Upcoding.”

❖Be careful to document and

code for any sequela of the

stroke that persist.

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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

Dx: Diabetes Mellitus

❖ Uncontrolled Diabetes Mellitus in ICD-9 did not

risk adjust to HCC 18 Diabetes Mellitus with

Complications.

❖ Diabetes Mellitus with Hyperglycemia (E11.65) in

ICD-10 does map to complicated Diabetes.

Document hyperglycemia in your face-to-face

visits.

❖ Same for DM with Hypoglycemia

ICD 10 DiabetesCodes are

Combination Codes

E11.2- DM2 w/Renal Complications

E11.3- DM2 w/Ophthalmic Complications

E11.4- DM2 w/Neurologic Complications

E11.5- DM2 w/Circulatory Complications

E11.6- DM2 w/Other Spec’d Complicationse.g. Arthropathy, Skin Ulcers, & oral complications

❖ One Code captures both Diabetes & the

Complication. However both conditions

must be documented.

❖ If appropriate, the complicated DM code

will map to both “Complicated DM HCC” &

“Manifestation HCC”.

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Buddy codes in Documentation

❖Clinically it is always appropriate to 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

❖Now, if the condition is listed under the term “With” in the alphabetic index, a coder is directed to automatically link the two conditions together!A Coder won’t link only if provider specifically says the second condition is NOT related to the primary condition.

Now every cataract in a diabetic patient is to be coded as a Diabetic Cataract unless provider specifically states otherwise.

Don’t Over-Diagnose Mild Chronic Kidney Disease (CKD)

❖ Document the pathology (nephrosis,

microalbuminemia, etc) AND the renal function

(estimated GFR).

❖ eGFR < 60 is sufficient to diagnose CKD

❖ An eGFR > 60 does not make a diagnosis of

CKD without evidence of kidney disease.

DX: Hepatitis C

❖ Document all participants with Chronic Hepatitis C. As applicable,

specify as “chronic”. One word can make the difference for generating

revenue from an HCC to help provide needed care.

❖ In 2016 there is a Rx-HCC for Chronic Hepatitis C – helps to pay for

the expensive treatment

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Dx: 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]”❖ This specificity maps to HCC 107

❖ THEN describe, document the Ulcer itself! Maps to HCC 161

❖ Micro-ulcers count as ulcers

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 remission

C90.01 Myeloma in remission

C90.02 Myeloma in relapse

*All three codes map to HCC 9

When you believe it has been cured, use

this code: Z85.79: Personal History of other

malignant neoplasms of lymphoid, hematopoietic and related

tissues.

DX: Malnutrition

❖Much more common that we think, esp. post-hospital (20-40%)

❖Use the Mini-Nutritional Assessment (MNA) to screen for malnutrition.

❖Takes less than 5 minutes to complete

❖Well validated.

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Dx: Easily Missed Pressure Ulcers

❖ Always 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.

Sources for Diagnosis Codes

❖ Diagnosis codes from Lab/Radiology claims are not eligible for RAPS submission.

❖ But the reports are still valuable to identify diagnoses!

❖ If a provider uses the diagnostic information and documents a diagnosis in the medical record that affects patient care, then the diagnosis code is eligible.

❖ Add diagnoses from Specialist Consults, labs, etc to active problem list as applicable, then document the condition and treatment at next assessment.

Document medical decision-making and /or impact on patient care

❖ Show evidence of medical decision-making, such as monitoring, referral, treatment or assessment (MEAT)

❖ This can be as simple as:❖ “Stable”

❖ “Continue current treatment”

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Supporting Documentation

❖ The encounter should support medical necessity

❖ Include date, provider name and signature

❖ CMS auditors expect to see standard documentation elements in an encounter: ❖ Subjective❖ Objective❖ Assessment❖ Plan

Beware Cloning Notes

❖Avoid “copy and paste” withoutupdates/edits.

❖Auditors notice!

Beware “Favorite” Codes in EMR

❖ For example, provider “favorites” a code in the EMR for diabetes (e.g., E11.21,

DM2 with diabetic nephropathy) because she sees this condition frequently.

❖ What if every claim/encounter for diabetes includes this same specific diagnosis?

This may trigger an audit.

❖ Be specific, but also be accurate.

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Be Careful with Abbreviations

❖ Avoid the use of abbreviations in medical record documentation

❖ Use only standard abbreviations -- Do not create your own

❖ Check with local hospital for list if your organization doesn’t have an approved standard

Non-commital Language Cannot be Coded

When possible, avoid using qualifying language to describe

diagnoses. Instead, describe what is being treated.

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.

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Don’t Dawdle #2

Providers: SIGN AND CLOSE YOUR NOTES

An Unsigned/Unclosed Note Cannot be Submitted.

No Signed Note No Submission No HCC No Risk Score No Revenue

Best Practice: All notes should be signed and closed within 72 hours

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 like M.D. or D.N.P.

❖ Electronic signature/ authentication (e.g. “authenticated by”, “completedby”, “finalized by”, “validated by”, “attested by”, “sealed by”, etc.)

UnacceptableSignature/ Authentication❖ “Signed but not read”

❖ “Dictated but not signed/ read”, etc.

❖ Signed by someone other than the treating

provider 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

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Auditing ❖ Auditing medical records and validating your coding is always a good idea.

❖ Auditing should be done frequently by internal sources and occasionally by external vendors to assure corporate compliance.

❖ If you don’t audit and redact incorrect codes, you’re telling CMS your coding is 100% perfect. Hmm….Really?

Documenting “Wounds”

Wounds can be “Surgical” or “Traumatic”e.g. Open colectomy surgical wounde.g. “skin tear” traumatic wound

However, most Chronic Wounds are really Skin Ulcerse.g. venous stasis, ischemic, diabetic, pressure, infected, associated with malignancy

All ulcers map to HCC’s. ICD 10 codes for wounds do not.

Prepare for Risk Adjustment Sweep

❖ Risk Adjustment Submission deadlines are 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

❖ Regulations demand quarterly data submission into RAPS

❖ Most TPA’s are submitting monthly. You should too!!

❖ Consistency eliminates the last minute data submission pressure and helps

ensure accurate and complete risk adjustment submission.

http://www.npaonline.org/member-resources/payment

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

Ingrain deadlines in your plan at the clinician level and back office level ❖ Dec 31, 2017 – last date to have face-to-face visit for diagnoses that will

ultimately impact payment for PY 2018❖ Jan 31, 2018 - deadline to submit diagnosis codes for 2016 dates of service ❖ Mar 2, 2018 – submission deadline for 2017 service dates to use in the 2018 Mid-

Year model run❖ Sep 7, 2019 – submission deadline for 2019 Initial Model Run (7/1/17 through

6/30/18 DOS)

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.

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

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

❖ Use the Plan Communications User Guide (PCUG) –Appendices

❖ Defines 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 – use current version!

❖ https://www.cms.gov/Research-Statistics-Data-and-Systems/CMS-Information-Technology/mapdhelpdesk/Downloads/PCUG-Appendices-v102-August-31-2016.pdf

Ensure Timely Monthly Attestations

❖ Use MARx plan payment schedule to guarantee timely attestations

❖ Monthly payment attestations due 45-days from the date of MMR

❖ Have all adjustments documented well before the due date

❖ Add calendar reminders 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

HOS-M Survey affects your Frailty Factor value

❖ 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 returns

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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…

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

Situation

In August of 2016, the Mid-Year Reconciliation revealed a significant take back from CMS.

The above resulted in an analysis of the current billing system.

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Goal

To increase HCC/risk score from 2.1 to 2.45 by July of 2017 for ESP PACE participants.

Measure

Utilize Risk Score Trend run chart.

Gap Analysis of Current Billing

Lack of education for MD/NP on their influence on coding

No auditing process for compliance

Process was too complicated

Chart hygiene: understanding where/how documentation (free texting)

Missed opportunities only looking at 6 month reviews.

Lack of knowledge around payment. DXHCC

Understand your system

Potential for errors

Lost opportunities

Lack of knowledge

Lack of internal auditing

Facilitate documentation for providers

Utilize EMR as your friend

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Dr combs charts for diagnoses.

Paper super bill list

Send to Data entry clerk to submit onto

RAPS

Coder would then type these into excel sheet

Provided coder with paper list.

Coder would comb list and look for Dx

with supporting Documentation.

Look for codes with payment.

Process Mapping

Dr./NP on face to face visit

generates DX in assessment

section.

Data auto-entered into RAPS

coder would have to interpret

lists of symptoms or

finding into ICD 9/10 codes.

NEW PROCESS

Generate a superbill

documents into EMR

Data clerk enters into

RAPS

PDSA cyclePLAN

Only face to face provider submits codes.

Providers will be educated.

Provider submitting responsible to ensure needed documentation

Ongoing audits

Utilize reports to identify past HCC and missed opportunities.

EMR builds to capture reports eliminate manual data capture.

Build in process to maximize HCC capture. Wounds, nutrition, podiatry,

ADVANTAGES

Eliminates coder from interpreting.

Eliminates steps in process

Standardizes documentation/expectations

Meets CMS compliance

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Financial Impact

$2,000.00

$2,500.00

$3,000.00

Jul-16 Aug-16 Sep-16 Dec-16 Mar-17 Jun-17 Sep-17 Oct-17 Jan 18Projected

Medicare Capitation PMPM

Captitation

Problem started

Financial ImpactIn addition to significantly improving monthly Medicare PMPM, reconciliations were favorable

Mid-Year 2017

Final 2016

Over $1M recouped in total

Future– maintain risk score and minimize size of reconciliations

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You are never done with your Risk Adjustment efforts. Like painting the Golden Gate Bridge, when you finally reach the other side, it’s time to start again. But it’s a wonder to behold.

Thanks for joining us.

Copies of our slides are available by email if you sign up, or by download from NPA website in a couple of weeks.