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TRANSCRIPT
HCC/RA Basics From ICD 10 to Documentation Requirements
Going back in time…
To the year 1893… a man named Jacques Bertillon, who was the Chief of
Statistical Services in Paris developed a classification system to track causes of
death. The system was called the Bertillon Classification of Causes of Death,
named after the originator.
At the time, committee members wanted to revise it every 10 years and did so
until finally, in 1945 when diplomats met to form the United Nations, they also
implemented the World Health Organization and the WHO was born.
In 1948, the WHO accepted responsibility for the International Classification
system, which at the time, only included causes of death and mortality. Over
the years though, morbidities were integrated into the classification system
because of the research into how morbidities determined so many patient
outcomes.
The “reformation” of 2007
The WHO began what they called, a “reformation” in 2007 to bring health care
[worldwide] into the 21st century and they are continuing to move forward and
are currently working on ICD 11.
This is not expected to make it to the US market for years to come. (Hopefully,
after I retire).
If you would like a great website to learn more about the ICD 10, disease
pathophysiology and how to effectively use the ICD 10 you can check out:
http://apps.who.int/classifications/apps/icd/icd10training/ICD-10%20training/Start/index.html
It will walk you through each chapter in the ICD 10 and tell you about specific
diseases, as well as help you learn more about how to use the ICD 10 to code
more accurately.
Other countries use the ICD 10 for statistical purposes, the United States
uses it for statistical and for reimbursement purposes.
Because CMS has structured future reimbursement around quality of care
and quality measures of chronic conditions for risk, the ICD guidelines
require us to code all comorbid conditions that exist and are currently
being treated or managed.
But, because we use an international classification system, we have to be
very careful in knowing about certain codes and the guidelines for those
codes because they may be classified differently in other countries than
they are here in the US because of the disease process.
For example:
Valve disease:
There are specific guidelines for coding heart valve disease for people living
in the US verses people living in foreign countries or developing countries that
do not have the same availability to medicines.
The guidelines include documentation requirements that specifically state if
the patient has a history of rheumatic fever to establish the code for a
rheumatic valve problem.
Rheumatic fever is a systemic immune process that is a sequela of
streptococcal infection of the pharynx. Strep throat left untreated can
develop into rheumatic fever.
In the US, most of our valve problems originate from atherosclerosis.
Now let’s talk about RA -
CMS states,
“ Risk scores measure individual beneficiaries’ relative risk –
and risk scores are used to adjust payments for
each beneficiary’s anticipated expenditure”
In layman’s terms:
Risk Adjustment is a methodology that is used by third party payers, such as
Medicare or Medicare Advantage Plans to adjust reimbursement based on a
beneficiary or members risk score.
How does it work?
Risk scores are calculated from a member’s demographics, diagnoses and
other data retrieved from claims and encounters.
The claims are submitted from the providers to the MA Plans who in turn
submit them to Medicare.
Medicare puts the received data into an algorithm or equation used to
determine the overall risk score for each member.
Each chronic condition that qualifies on an HCC-RA model is assigned a value.
These chronic condition “values” are totaled for each member and that is
how they receive their final risk score.
The risk scores are used to determine payments that will provide the member
with appropriate care for his/her chronic conditions in the following year.
Payment Models
There are currently 4 payment models in use:
CMS-HCC Hierarchical Chronic Condition Model used by Medicare
specifically for Medicare recipients only.
HHS-HCC Commercial Model using different demographics and
qualifiers/equations than the CMS-HCC model.
CDPS Medicaid model for children, adults and specific individuals.
ESRD End Stage Renal Disease Model
There is also a RxHCC – Prescription drug model that helps to calculate and
predetermine CC’s based on drug use compliance.
CMS –HCC Model This is considered a prospective model because it uses retrospective audits to
predict a cost analysis of what the member will need in the following year.
• CMS-HCC categorizes ICD 10 codes into disease groups.
• Each HCC category includes diagnosis codes that are related clinically and have similar cost implications.
• The most recent HCC version includes 8,800 ICD 10 codes that map to 79 HCC categories.
• CMS-HCC model is solely diagnosis-driven.
• Procedures DO NOT affect the grouping, which is why when you are doing risk adjustment coding, those codes are not taken into consideration for the CPT level of service, unless that’s the reason for the patient seeing the provider.
• HCC’s are cumulative in nature. Meaning, HCC DX are extrapolated from many
encounters for a beneficiary for a specific time period (e.g.year) that
contribute to a total risk score for the member.
• Even though HCC’s reflect hierarchies among related disease categories,
unrelated categories accumulate for the patient, as well, for a total score.
• So, the patient can have more than one HCC category assigned to him or her.
• The “hierarchy” comes into play when one or more than one DX is within the
same category and one “trumps” the other out.
For example, DM with no complications is lower in “weight” or risk score than
DM with a complication.
The risk is higher when there is a complication and the DM is already being
calculated within the DM complication category, so the lower risk score is
“trumped out” and only the higher risk score is used that contains both
categories.
The patient’s RAF score includes the demographic information, as well as all
applicable chronic condition diagnosis codes, which together contribute to a
member’s risk score.
So, CMS-HCC’s have two components: the hierarchy AND the condition category.
• Hierarchies are imposed among related chronic conditions.
• After the hierarchy occurs, then a chronic condition becomes an HCC.
HCC-17 DM with acute complications
HCC-18 DM with complications
HCC-19 DM with no complications
HHS-HCC It uses concurrent DX to develop the risk score for the member during the
current year.
• This is the risk model used by commercial insurance payers.
• This model uses it’s grouping of chronic conditions to represent member’s
health status and benefit plan selection. All DX/conditions must be
documented within the current year for annual risk adjustment.
• The calculations are set up differently, the approach is different and the
methodology is different from the CMS-HCC model.
• This is a “metal plan” difference – the levels are set up as Gold, Silver,
Bronze, etc. with ratings variations.
• There is a metal combination for each age group, as well as methodology.
(i.e. adult, child, infant) and the metal combinations include Platinum, Gold,
Silver, Bronze, catastrophic.
CMS-HCC and HHS-HCC
CMS-HCC
Medicare Advantage Plans RA
model
Funded by CMS
Prospective Data
Providers document all HCC’s their
patients have in a given year to
substantiate a base year health
profile for each patient that
predicts costs in the following year
79 CMS-HCC Categories
HHS- HCC
Commercial RA Model – the population includes adult, children and infants
Funded by members and supplemented by the government
Concurrent data used – the risk score is calculated based on the DX from the same payment year.
Providers must identify/document all HCC conditions their patients have in that year.
Risk scores are calculated for each member, but applied in aggregate and the funds are redistributed between issuers within the state, when necessary for that payment year.
Getting into the MEAT of things- Documentation Requirements
Chronic condition coding is a requirement, it’s not an “elective”.
CMS is making the move to Value-Based reimbursement in hopes it will promote
and provide quality of care to it’s members.
Right now, these value-based programs reward providers with incentive payments
for the quality of care they provide to patients.
Quality of care extends further than the provider-patient care experience.
Quality of care includes the documentation the provider supplies so that other
providers may view and care for the patient appropriately, but also to the
coding, billing and financial care we provide to patients.
Documentation requirements include:
Must be a face-to-face visit – can be IP or OP.
Labs, radiology, diagnostic testing, etc. do not count as face-to-face visits and
cannot be used in risk adjustment coding.
In order to meet the challenge of accurate and complete documentation, the
acronym MEAT was established to help the coder more accurately determine if a
chronic condition is available in the documentation to code.
There is another acronym TAMPER that is
acceptable as well.
M E A T When reviewing the note, you are looking to see if the provider met any of the
conditions below when trying to determine if you should code a chronic condition
Did the provider -
M Monitor: Signs, symptoms, disease progression and disease
regression
E Evaluate: Medication effectiveness, response to, lack of response,
asking the patient how they are doing or how they feel they are doing in response to one of their chronic conditions; even though the provider may not be managing that specific chronic condition.
A Assess/Address: The provider’s assessment of the condition, did the
provider order any tests, discuss the condition with the patient, review of records, and/or counseling.
T Treatment: Did the provider prescribe any meds, therapies, referrals,
other modalities.
T A M P E R
T Treatment
A Assessment
M Monitor/Medicate
P Plan
E Evaluate
R Referral
Documentation Examples: Looking at it with MEAT-
CHF: “Symptoms well controlled with Lasix and ACE inhibitor. Continue
meds”.
Using the MEAT acronym – The provider Monitored that the symptoms are well
controlled and Evaluated the symptoms are being
controlled by the current med regime.
Major Depression: “Patient continues with feelings of hopelessness and
anhedonia despite Zoloft 50 mg daily. Will increase
dose to 100 mg daily and monitor.
Provider assessed how the patient is doing with
symptoms, treated with an increase in meds.
Atrial Fibrillation: “Controlled with Warfarin, will continue to monitor INR.
Or it could be stated – INR being monitored in Coumadin
clinic. Monitoring weekly.
DM : “stable on meds, no complications noted, order labs,
refilled prescriptions for lancets and Metformin.
Prostate CA: no change in condition, being seen by Dr. Watts in
Oncology, on watchful waiting.
Code the Note:
Patient: Sally Jones DOB 12/01/38 DOS 05/03/17
Patient is a 72 year old female with UTI like symptoms. Patient c/o fatigue, low energy and poor appetite. Patient is status post MI 18 months ago. Patient appears frail and with mild malnutrition. Has lost 23 pounds in the last 4 months. Patient has been complaining of pain with urination, weakness, and has had dry, itchy skin for the past several months. U/A done today shows WBC’s, leukocyte esterase, and microalbuminuria. Serum creatinine is 1.5.
PMH: Type II DM, CKD secondary to DM, history of BKA-skin intact at stump, no erythema. History of MI. Previous UTI 4 months ago with a serum creatinine of 1.6. Lab results at that time revealed stage 2 CKD.
A/P:
DM – Metformin 500 mg, b.i.d
Bactrim for UTI
Malnutrition (documented as Mild in HPI) Ensure b.i.d. and nutrition consult
RTC in 6 weeks. Referral made to Dr. Smith (Nephrologist) for CKD.
Note electronically signed by John Jacob Jinglehimerschmidt, MD 05/04/17
Coding:
UTI –: N39.0 (Does not map to an HCC) – reason for the visit
to provider today
DM w/CKD: E11.22
CKD–Stage 2: N18.2
Oral DM Med: Z79.84
Malnutrition-Mild: E44.1
BKA, unspec: Z89.519
Old MI: I25.2 ( Maps to the RxHCC)
NOTE: If I were coding this in “real life”, I would take a moment to review
previous documentation to code a more specific code for the unspec BKA.
Final Thoughts:
It is acceptable to include a “history of” as a chronic condition, if it affects the
current treatment or plan, or is supported as a current dx.
For example: A history of melanoma when ordering a biopsy for suspicious skin
lesions.
But, there is a caveat that should not be overlooked; stating “history of” is often
interpreted by CMS and Recovery Audit Contractors (RAC) to mean the patient no
longer has that condition. This can lead to a denial of payment.
This can be averted, if the condition really does exist and is still being treated,
as well as PROPERLY DOCUMENTED.
Using the M.E.A.T. criteria helps ensure that documentation satisfactorily meets CMS requirements for supported diagnoses.
Any condition addressed or considered by the provider as relevant to treatment at the time of the encounter should be documented, preferably, in the Assessment and Plan.
Each diagnosis listed should be properly documented with evaluation and/or treatment. (You may see the notation in another location within the note.)
A list of diagnoses is not acceptable evidence that the diagnosis affected patient care.
Following these documentation principles will ensure accurate documentation, improve patient care delivery and data integrity by validating diagnosis codes while reducing risk to the organization.
RA Risk Adjustment
HCC Hierarchical Chronic Conditions
RAF Risk Adjustment Factor
RADV Risk Adjustment Data Validation
RAPS Risk Adjustment Processing System
RAS Risk Adjustment System
RxHCC Prescription Drug Hierarchical
Condition Category
DHHS/HHS Department of Health & Human Svcs
EDI Electronic Data Interchange
ESRD End stage renal disease
FERAS Front End Risk Adjustment System
HMO Health Maintenance Organization
IVC Initial Validation Contractor
MA Medicare Advantage
MCO Managed Care Organization
MMR Monthly Membership Report
List of RA/HCC Acronyms