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MRA Overview

Yasmin McLaughlin,CPC

SER Manager

For internal use only

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What is MRA?

• The Medicare Risk Adjustment payment system uses clinical coding information (HCCs) to calculate risk premiums for Medicare Advantage plans enrollees

• MRA activity is the key process to ensure accurate payment from CMS for Humana Medicare Advantage enrollees based on the CMS-HCC payment model

• The primary focus of the MRA department is to obtain accurate healthcare information from providers in order to maintain accurate payment levels through chart reviews and provider education

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Humana’s MRA Team

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Market Team’s work with Providers

• Review Medical Records

• Provide feedback to providers regarding documentation.

• Coding Seminars are conducted to help practices in their coding efforts.

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Providers must be engaged in MRA

Goal = Properly Reflect the Member’s Health Status

• Fully Assess All Chronic Conditions …every six months

• Thoroughly Document in the Chart ALL conditions evaluated each visit

• Code to the Highest Level of Specificity (fully utilize the ICD-9 Diagnosis Coding System)

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Ok, I understand the elements…

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Medicare’s guidelines state:

“Code all documented conditions which co-exist at the time of the visit that require or affect

patient care or treatment”

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Best Practices for Excellent Documentation

Document at least once a year:

Chronic Conditions (CHF, COPD, DM)Active Status conditions (amputations, colostomy)Pertinent past conditions (Old MI)All conditions that require medicationConditions that affect the patient’s day to day life.

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Best Practices for Excellent Documentation

BE SPECIFICBE SPECIFIC(when applicable)

“Major Depression”, not “depression”“Chronic bronchitis”, not “bronchitis”“Atrial Fibrillation”, not “cardiac dysrhythmia”“Malnutrition”, not “loss of weight”“History of MI”, not “CAD”

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Documentation

• Be complete and legible—it has to be readable to someone else. • Include patient name, DOB and date of service on every page. • Note chief complaint (CC), reason for visit, assessment, and plan

of care. • Specify basis for ordering ancillary/diagnostic services• Indicate appropriate health risk factors. • Indicate past and present diagnoses if still of any medical

significance.• Show patient’s progress or lack of progress. • Substantiate service rendered. • Sign the progress note with full name and credentials. • Problem list should be up-to-date and include onset AND end

dates.

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Documentation Tips

• Always document the status of each diagnosis using specific and descriptive words to document the problem.

• Use the word history to mean that the condition no longer exists, not the medical history of the patient includes these conditions.

• All medications listed should have the reason they are taking it listed also.

• AlwaysAlways use an approved abbreviations list!

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“Why is thorough and specific documentation so important?”

If it isn’t documented, it hasn’t been done.

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Medicare Risk Adjustment

Wrap UpQuestions