cdi professionals can drive success - acdis · silo‐based some vbp no risk ... aco mixed payment...

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Angela Carmichael, MBA, RHIA, CDIP, CCS, CCS‐P, CRCDirector, HIM

Kimberly Hopey, PhD, RNDirector, Professional Services

J.A. Thomas & Associates/Nuance Communications

How CDI Professionals Can Drive Success With Risk Adjustment Strategies

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Learning Objectives

• At the completion of this educational activity, the learner will be able to:

– Develop an understanding of risk adjustment, and the CMS‐HCC methodology

– Articulate how to "start the conversation" within your organization on deploying HCC strategies and make the case for why CDI pros should drive the HCC program forward

– Develop successful CMS‐HCC strategies for inpatient, hospital outpatient, and physician office settings

– Employ concurrent processes for CDI, HIM, and coding professionals to work in collaboration for success in risk adjustment

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Risk Adjustment

The who, what, where, when, and why


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What Is Risk Adjustment?

• Risk adjustment is a corrective tool used by actuaries to level the playing field regarding the reporting of patient outcomes, adjusting for the differences in risk among specific patients

• It is the process of adjusting expected volumes to account for the case mix of the facility or category being compared

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Why Is Risk Adjustment Important?

• It’s a necessary tool for managed care programs– Account for changes in severity & case mix over time

– Accurately set performance targets (quality & efficiency)

– Identifies patients for population health initiatives

• It’s relevant– Risk adjustment is an important element in VBP

• It’s fair– Provide incentives to enroll high‐cost individuals into managed care

programs by ensuring health plans/ACOs have the resources needed to provide efficient and effective treatment

• It’s prominent– Risk adjustment payment methodologies are used across a variety of

government (federal & state) private & commercial insurance programs

• It’s here to stay!

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How Is Risk Adjustment Used?

• Uses– Payment methodology

• For example: CMS‐HCCs set Per Member Per Month (PMPM) capitation payments to Managed Medicare plans & ACO Medicare Shared Savings Programs (MSSP)

– Risk adjusts other payment models • HCCs mathematically reconcile the observed rate versus the expected so that the quality of the care can be isolated and understood—an important element of Value‐Based Purchasing

• For example:– The six per capita cost measures and select quality measures included in the 2016 Value Modifier

– Severity of illness (SOI) during the 90 days preceding the Medicare spending per beneficiary episode in Medicare Spending Per Beneficiary (MSPB)


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How Prominent Is Risk Adjustment?

• Risk adjustment payment methodologies are used across a variety of government (federal & state) private & commercial insurance programs

• The four prominent systems:– Ambulatory Care Groups (ACGs)

– Chronic Illness and Disability Payment System (CDPS) (Managed Medicaid)

– Diagnostic Cost Groups (DxCGs)

– Hierarchical Condition Categories (HCCs)

• CMS‐HCCs (Managed Medicare)

• HHS‐HCCs (Managed Commercial in Health Insurance Exchange)

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What Are Hierarchical Condition Categories (HCCs)?

• An actuarial tool used to predict healthcare costs

• Sets capitation payments to health plans to reflect the expected costs of providing care to their members

• Adjustments consider demographic information (age, sex, eligibility) and health status (diagnoses)

• Adjusts approximately 40% of the quality metrics used in Value‐Based Purchasing Alternative Payment Models

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What Are Hierarchical Condition Categories?

• HCCs are a form of case‐mix index (CMI)

• This form of CMI applies to the patient for the calendar year across both inpatient and outpatient settings

• HCCs are diagnostic categories that “bucket” patients into different “categories” based on demographics and the ICD‐10‐CM diagnosis codes

• The categories are designed to group patients that are not only clinically similar but follow similar cost patterns to predict future healthcare costs and allow for quality of care comparisons

– CMS‐HCCs are more predictive of readmissions and future costs than MS‐DRGs


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Introduction to Medicare Part A, B, C, & D

Medicare is a federal health insurance program Medicare consists of 4 parts • Part A

– IP hospital care (LTAC & SNF), home health & hospice

• Part B – Doctor services, office visits, screenings, therapies, preventive services, OP

hospital, emergency care, ambulance, medical/surgical supplies, and durable medical equipment

• Part C (Medicare Advantage/CMS‐HCCs) – Part A & B services

– Additional services such as coverage for extra dental, vision, hearing, and preventive services and some optional supplement services (e.g., gym memberships and exercise classes)

• Part D (RxHCCs)– Pharmacy benefits

– Includes plans with varying out‐of‐pocket requirements

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The Medicare Payment Spectrum

Traditional Pure FFS Pay by service Silo‐based Some VBP No risk

Traditional Pure FFS Pay by service Silo‐based Some VBP No risk

MA Pay for population Full capitation All Part A&B Quality bonus Full risk PCP must refer

MA Pay for population Full capitation All Part A&B Quality bonus Full risk PCP must refer

Payment & delivery system integrationPayment & delivery system integration

ACO Mixed payment FFS +/‐ shared savings All Part A&B Quality incentive Limited risk Patients can self‐refer

ACO Mixed payment FFS +/‐ shared savings All Part A&B Quality incentive Limited risk Patients can self‐refer

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Diagnosis Sources: Provider Types

• Diagnoses documented by select provider types are appropriate for coding and reporting for MA coding

– MD or DO

– OD = doctor of optometry

– DC = doctor of chiropractor

– DDS = doctor of dental surgery

– DO = doctor of osteopathy

– DPM = doctor of podiatry

• All nurse practitioners, certified nurse specialists, CRNAs

• Physician’s assistants

• Therapists; speech, physical, occupational (except “respiratory”)

• Licensed clinical social worker or clinical social worker

• Certified wound care and/or ostomy nurse

Note: This is not an exhaustive list Note: This is not an exhaustive list


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Diagnosis Sources: Provider Settings

Acceptable provider settings for CMS‐HCCs• Short‐term (general & specialty) hospitals

• Critical access hospitals

• Children’s hospitals

• Long‐term hospitals

• Rehabilitation hospitals

• Psychiatric hospitals

• Religious non‐medical healthcare institutions

• Community mental health centers

• Federally qualified health centers

• Rural health clinics (freestanding & provider‐based)

Non‐covered settings: Hospital inpatient swing beds, freestanding ambulatory surgery centers, skilled nursing facilities, intermediate care facilities, respite care, hospice, home health care, freestanding renal dialysis facilities

Non‐covered services: Ambulance, lab, radiology, DME, prosthetics, orthotics, supplies

IP & OP servicesIP & OP services

OP services onlyOP services only

Note: This is not an exhaustive list

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CMS HCC Risk‐Adjusted Payment Model

• 3 programs:– Medicare Advantage

– Dual Demonstration

– Medicare MSSP for ACOs

• 3 models:– Model 22 (current)

– Model 21 for PACE & ESRD

• Budget/payment mechanism– Funded by CMS

– Applied to each individual

– Used to calibrate monthly premiums

– PMPM payment from CMS

– Patients pay monthly premium

– Medicare Advantage plans on average received about $9,900 per person in 2011

• ICD‐10‐CM codes: 9,548– 42% are CCs

– 16% are MCCs

– 42% are neither CC or MCC

• HCCs: 79

• HCC range: 1–189

• Accepted provider types:– Specified by CMS

• Data linkages: – Not tied to a particular procedure

– MA: Claim‐based, home assessments, & retrospective review

– ACO: Claim‐based only

CMS‐HCC (Medicare) overview


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Comparing HCCs to MS‐DRGs: Differences

MS‐DRGs

• More than 1 HCC can be assigned per encounter

• No sequencing involved

• Not all diagnoses map to an HCC

• Procedures not included

• Various provider types’ & specialties’ documentation can be used

• Various settings involved

CMS‐HCCs

• Only 1 assigned per IP discharge

• Sequencing is a critical component

• All appropriate principal diagnoses map to a MS‐DRG

• Procedures can impact assignment

• Code only from physician documentation with few exceptions

• Only applicable to IP care

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Deploying HCC Strategies in Your Organization

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Managing CMS HCC Opportunities

• Determine scope & depth of opportunity

– Varies based on patient population/insurance type

– Does your organization offer their own provider‐sponsored Medicare Advantage plan? (aka “Medicare HMO”)

– Does your organization receive incentives from insurers offering a Medicare Advantage Plan if you improve risk scores?

– Is your facility part of an accountable care organization (ACO)?


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Pertinent Guidelines

• Payment methodology– CMS‐HCCs, HHS‐HCCs, CDPS, etc.

– Sub models

– Rate year risk factors & mapping tables

• Code sets– ICD‐10‐CM

• Official Coding Guidelines – Coding conventions

– Official Coding Guidelines published by the National Center for Health Statistics

– Coding Clinic published by the American Hospital Association

– CMS Risk Adjustment Participant’s Guide

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What Type of Conditions Map to a CMS HCC?

• High‐cost medical condition (current cancer, heart disease, hip fracture)– Highest weighted: HIV, sepsis, opportunistic infections & cancers

• Acute, chronic, status codes, etiology & manifestation– Hip fracture, COPD, status amputation of great toe, diabetic neuropathy

• Common conditions, rare conditions, conditions that can be cured, non‐curable, congenital and acquired, but …– Must be current & impact the encounter in terms of requiring either …

• Monitoring, evaluation, assessment, or treatment

• Diagnoses are excluded from mapping when …– They do not predict future cost (e.g., appendicitis)

– There is a high degree of discretion or variability in diagnosis, diagnostic coding, or treatment (e.g., symptoms, osteoarthritis)

• Diagnosis codes from lab, radiology, and home health claims are not used because they are not reliable and may indicate rule‐out diagnoses

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HCC Strategies Across the Care Continuum


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Common Challenges

• Medical record requirements

• Documentation

– Mapping diagnoses

– Clinical support for each mapping diagnosis

• Coding

• Billing/reporting

• Compliance with all guidelines

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What Kind of Documentation Do We Need?

• Diagnoses must be documented—there can be no assumptions– Coders cannot interpret labs

– Coders cannot assume a diagnosis based on meds provided or orders

• Diagnoses must be documented to the highest level of specificity– Increases the likelihood of mapping (Example: Depression)

– Increases the likelihood of the condition mapping to a higher‐weighted HCC (Example: Diabetes)

• Diagnoses must be documented in a part/section/document coders are permitted to code from– We can’t code current conditions from problem lists, medical history, or

super bills

• Supporting clinical documentation for all reported diagnoses, aka MEAT … Monitor, Evaluate, Assess, Treatment

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Where Is the MEAT?

Ensure “MEAT” is met

• M = Monitoring

• E = Evaluation

• A = Assess/Address

• T = Treatment

• Only 1 element of MEAT is required to support a diagnosis—not all 4

• 2 elements is better

• 3 elements is better still

MEAT can be found in any section of the patient record


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MEAT for the Chronic Condition

• Signs, symptoms, disease progression, disease regression

MonitorMonitor

• Review of test results, medication effectiveness, response to treatment (“stable,” “improving,” “exacerbation,” “worsening,” “poor”)

EvaluateEvaluate

• Ordering tests, discussion, review records, counseling

Assess/addressAssess/address

• Referral, medication(s), planned surgery, therapies, other modalities

TreatmentTreatment

Examples:• “CHF symptoms well controlled with Lasix and ACE inhibitor. Will continue current medications.”• “Major depression recurrent episode. Patient continues with feelings of hopelessness and anhedonia despite current regiment of Zoloft 50 mg daily. Will increase dose to 100 mg daily and monitor.”

Examples:• “CHF symptoms well controlled with Lasix and ACE inhibitor. Will continue current medications.”• “Major depression recurrent episode. Patient continues with feelings of hopelessness and anhedonia despite current regiment of Zoloft 50 mg daily. Will increase dose to 100 mg daily and monitor.”

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Common CMS HCC Diagnoses/Code Families

• Diabetes

• Atrial fib/flutter/PAT

• COPD

• CHF

• Long‐term use of insulin

• PVD

• Rheumatoid arthritis

• BMI > 40/morbid obesity

• Cardiomyopathy

• Angina

• Cor pulmonale

• Epilepsy/convulsions

• Parkinson's

• Major depression

• Bipolar disorder

• Acute renal failure/ESRD/CKD/Stage 4 or higher

• Aortic atherosclerosis/abdominal aortic aneurysm

• Malignant neoplasm of prostate or breast

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CDI Processes Across the Care Continuum

• Inpatient setting

– DRGs + CMS‐HCCs

• Hospital outpatient setting

– Outpatients in a bed

• Provider office setting

– Greatest opportunity

– Focus on PCP first

– Collaboration & workflow is critical

– Data analytics improve scalability


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Common Challenges: Inpatient Setting

Are you reviewing Medicare Advantage & ACO member admissions?

• Analyze the HCC tables to ensure you are capturing all conditions that map to a CMS‐HCC and meet reporting criteria

– Severity of illness & risk of mortality clarifications are critical to HCC success—but they alone are not enough

– Approximately 58% of diagnoses that map to a CMS HCC are CCs/MCCs too—but that leaves 42% that are not

• Develop CDI, coding, and abstraction policies for risk‐adjusted contracts

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Common Challenges: Hospital Outpatient Setting

Emergency department, observation, outpatient surgery:

• Think beyond medical necessity or reason for encounter

• Encourage documentation of all comorbid conditions to capture disease burden– Chronic diseases treated on an ongoing basis may be reported as many

times as the patient receives monitoring, evaluation, assessment, or treatment. If the condition impacted medical decision‐making (MDM), report it for that DOS.

• Documentation should specifically link manifestations to their etiology

• Ensure diagnosis coding is accurate, complete, & consistent– Develop coding and abstraction policies for risk‐adjusted contracts

– Invest in outpatient coder education and professional development

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Common Challenges: Physician Office

• Greatest risk area is the physician office– Documentation, coding, billing, & medical record deficiencies

– Improving coding alone will only get you so far

• Approximately one‐third of the opportunity requires CDI remedy

– Who is performing the coding?

• Ensure coding is accurate, complete, & consistent

– Problem‐focused visits should include diagnoses that meet the MEAT criteria

• Think beyond evaluation & management (E/M) & chief complaint (CC)

– Ensure members are seen at least once annually

• New patient & annual wellness visits are a great opportunity to capture chronic non‐resolving diagnoses

– Even with great documentation, coding, & billing, you are not protected from compliance reviews

• Eradicate medical record deficiencies


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Common CDI Clarifications in PCP Office

• Morbid obesity

• Major depression

• Diabetes & manifestations

• COPD

• CHF

• Peripheral artery disease

• Opioid dependency uncomplicated

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Commonly Unreported Diagnoses

• Do not report conditions that were previously treated & no longer exist

• However … do report the following status/conditions when they meet the reporting criteria for the encounter (aka “MEAT”):– BMI over 40– Long‐term use of insulin– Ostomy status or “attention to” ostomy– Amputation status– Asymptomatic HIV– Transplant status– Dependence on dialysis or respirator– Monoplegia & hemiplegia

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The Power of CDI & the Impact on Risk Scores

Patient risk score is a composite of the demographic RAF + disease RAF.Risk adjustment factor (RAF) reflects the age, sex, eligibility status, beneficiary type, risk model, & disease burden of the patient.

CMS‐HCC Example for V22 PY 2014–2016. Based on Bid Rate of $750 PMPM/$9,000 yr.


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Concurrent Processes Drive Success

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A New Year – A Clean Slate

• Only CMS‐HCC mapping diagnoses submitted on claims from specific settings as a result of a face‐to‐face encounter with a qualified practitioner during the calendar year(s) under consideration will influence the member’s risk score

• Each January 1 starts a “clean slate” and the documentation of the mapping diagnoses must be documented & billed again to influence the risk score

• If not—we call this “falling off”

A New YearA Clean Slate

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Why More Really Is Better

• Even though each mapping diagnosis only needs to be reported once in the calendar year, during a RADV you are able to submit up to 5 DOS to support any 1 HCC

• Even if the diagnosis is documented clearly & coded correctly—a medical record deficiency could make the encounter invalid

• Stack the deck in your favor!

• Your goal is to report each mapping diagnosis as oftenas it meets reporting guidelines


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Medical Record Requirements

• Two patient identifiers on each page of every document:

– Example: Patient’s name, date of birth, medical record number

• Date of service (complete month/day/year & legible)

• Face‐to‐face encounter with acceptable type provider & setting

• Acceptable provider signature, with credential

• Legibility: Documentation, signature, & credentials must be legible to the auditor validating the risk score

• Documentation should be clear, concise, consistent, complete, & legible

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The Balancing Act: Managing Opportunity & Risk

• In the reporting of disease burden via claims or retrospective submission, mistakes are common and trigger billions of dollars in “improper payments” every year, mostly overcharges

• CMS‐HCC data validation error rates:

– CMS‐HCC error rate approximately 33%

– OIG results indicate even higher error rates

– 2006 PY extrapolated results for overpayments indicated $3 billion in overpayments

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Compliance

• Risk Adjustment Data Validation (RADV) annual audits are supposed to keep the industry honest– Two types; national & targeted – Applicable to Medicare Advantage & Medicare Shared Savings

Program for ACOs– Regulated by CMS and performed annually – CMS contracts with coders to perform these annual reviews

• Financial impact:– Payment recovery, if applicable

– Results may be extrapolated against total enrollment

– False Claims Act violation—triple damages plus $5,500 to $11,000 per claim penalties

• OIG Work Plan since 2012 (Part C & D) • RAC reviews Part D claims & is expected to add Part C

claims to their SOW in near future


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Top 10 RADV Risks

1. Lack of two patient identifiers & date of service on every page of the assessment form

2. Lack of an acceptable provider signature

3. Lack of code specificity as compared to the written description in the medical record

4. A discrepancy between the codes billed & the actual written description in the medical record

5. Lack of MEAT to support billed diagnosis

6. Status of cancer is unclear

7. Chronic conditions are not documented as chronic (e.g., viral hepatitis)

8. Lack of specificity (e.g., an unspecified arrhythmia is coded rather than the specific type of arrhythmia)

9. Chronic conditions or status codes aren’t documented in the medical record at least once per year

10. A link or causal relationship is missing for a diabetic manifestation, or there is a failure to report a mandatory manifestation code

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Thank you. Questions?

[email protected]@jathomas.com

In order to receive your continuing education certificate(s) for this program, you must complete the online evaluation. The link can be found in the continuing education section at the front of the program guide.

cdi professionals can drive success - acdis · silo‐based some vbp no risk ... aco mixed payment...

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