Presented by: Lee Wil l iams, RHIT, CCS, CCDS, CPCO, CPC, CHONC, CRC

NGHIMA Quarterly Education Meeting12/14/2018

INTRO TO RISK ADJUSTMENT CODING

Risk adjustment (RA) is the method used to adjust bidding and payment to health plans based on demographics (e.g. age and sex) as well as actual health status of a plan’s enrollees. Medicare risk adjustment is prospective, meaning diagnoses from the previous year and demographic information are used to predict future costs, and adjust payment.

Codes are used to assist in forecasting the future needs of the member population and where funds may need to be distributed to care for those needs.

The coder’s role is to identify all active diagnoses that are supported by acceptable medical record documentation so that these diagnoses may be reported back to the payer.

INTRODUCTION

As stated on the previous slide, payment methodology is based on diagnosis codes and the following: Age Gender Socioeconomic status Disability status Insurance status (Medicare, Medicaid, dual-eligible, etc.) Claims data (i.e. Procedure codes, place of service) Special patient-specific circumstances (e.g. ESRD)

INTRODUCTION

Risk adjustment scores are higher for a patient with a greater disease burden, and less for a healthier patient.

The diagnosis codes reported on claims determine a patient’s disease burden and risk score.

Chronic conditions must be reported at least once per year. Each January 1, the RA slate is wiped clean and every chronic condition must be reported again.

CMS requires that all applicable diagnosis codes be reported and coded to the highest level of specificity.

ICD10-CM guidelines are to code all documented conditions that coexist at the time of the encounter/visit and require or affect patient care, treatment or management.

INTRODUCTION

It is important to remember risk adjustment coding is all about reporting all current active diagnosis codes.

Coders are accustomed to reporting diagnosis codes to support services rendered for purposes of reimbursement. This is a little dif ferent in terms of risk adjustment.

When coding for risk adjustment, the goal is to report all active diagnosis codes documented within the face-to-face encounter that impacts the patient.

INTRODUCTION

Risk adjustment review can occur retrospectively, concurrently or prospectively.

There are many dif ferent types risk adjustment models, the most recognized being Medicare’s Hierarchal Condition Categories (HCC).

The model assigns diagnoses codes into groups and then into condition categories.

These condition categories make up a ‘family’ – Hierarchy. The hierarchies are based on severity of il lness (SI) which translates to a risk adjustment factor (RAF value) – Risk Score.

Hierarchies are used in Medicare, and some Medicaid and commercial models for payment.

INTRODUCTION

RISK ADJUSTMENT AS THE FUTURE PAYMENT MODEL

Predictive modeling can help providers identify patients with chronic illnesses who would benefit from disease management education and coordination of care.

Diagnosis-based:

Health and Human Services Hierarchical Condition Category (HHS HCC)-Commercial, Individual and Small Group

Medicaid Chronic I l lness and Disabil ity Payment Systems (CDPS) Medicare Hierarchical Condition Category, Par t C (Medicare HCC-C

/CMS-HCC) Diagnosis Related Groups (DRG) – Inpatient Adjusted Cl inical Groups (ACG) – Outpatient

Prescription-based: MedicaidRx (UCSD) RxGroups (DxCG) Medicare Hierarchical Condit ion Category, Par t D (RxHCC) Health and Human Services Hierarchical Condition Category (HHS HCC)

TYPES OF RISK ADJUSTMENT MODELS

HCC is a model implemented by Medicare in 2004 to adjust capitation payments to private healthcare plans for the health expenditure risk of their enrollees.

The CMS risk adjustment model measures the disease burden that includes 79 HCCs, which correlates to diagnosis codes.

The HCC model is made up of the 70,000+ ICD10-CM codes that typically represents costly, chronic conditions. These codes funnel into 805 diagnostic groups, then is further specified into 189 condition categories. The 79 HCCs comes from the 189 condition categories.

Each HCC has an associated value called the Relative Factor (RF).

HIERARCHICAL CONDITION CATEGORIES (HCC)

HCC CHARACTERISTICS

Hierarchies set a value based on how sick the patient is (SI). The sicker the patient, the higher the risk score.

Diagnoses within the family or hierarchy are inclusive of each other (e.g. diabetes [E11.9], DM w/nephropathy [E11.21]) and not raise the RF.

Additional diagnoses from other hierarchies or stand-alone diagnoses would increase the RF.

Some HCC’s over-rule others. Example “A patient with metastatic lung cancer (C78.00-HCC8) and cancer of the lower third esophagus (C15-HCC9), HCC8 trumps HCC9 because the value of HCC8 is higher ( A A P C C R C S t u d y G u i d e , 2 0 1 7 ) .

Generally, coders do not have to know the individual risk score for the HCC’s.

HIERARCHICAL CONDITION CATEGORIES (HCC)

There are many HCC codes, and the model may change (sl ightly) from year to year.

Below is a l ist of chronic conditions that do not change from year-to-year: Diabetes COPD Emphysema CHF A-Fib* MS Parkinson’s Chronic Hepatitis AIDS Cerebral Palsy RA Lupus

CHRONIC CONDITIONS

Face-to-face visit Physician/NPP Patient name and Visit/Encounter date Diagnosis must be supported/addressed Provider signature required Outpatient or Inpatient setting Non-covered: Lab service, DME, radiology Do not code from stand-alone problem lists Remember MEAT (monitor, evaluate, assess, treat) and/or

TAMPER (treat, assess, monitor/medicate, plan, evaluate, refer)

DOCUMENTATION REQUIREMENTS

Hospital inpatient records must contain an admission date, discharge date, and signed discharge summary.

Consultation notes should include a consult date. Stand-alone discharge summaries must contain the discharge

date. Principal diagnosis defined – condition established after

study to be chiefly responsible for occasioning the admission.

DOCUMENTATION REQUIREMENTS

MEAT

TAMPERT M

ACCEPTABLE PROVIDERS (2018 PAYMENT YEAR)

ACCEPTABLE DOCUMENT SOURCES (FACILITIES)

Risk Adjustment Data Validation (RADV) permits 5 medical records to be submitted for each HCC to be validated.

RADV guidelines state the best medical records contains documentation supporting HCC and proper documentation practices.

When submitting documentation for RADV/IVA, the submission should be the single DOS for physician and other outpatient records, and the full hospital record from admission to discharge for inpatient records supporting a diagnosis.

Records should contain the provider signature, credentials, and 2 patient ID’s.

MEDICAL RECORDS REVIEW

Retrospective audits generally includes finding additional diagnoses. CMS states the deletion of conditions should be a part of these audits because some plans may try to remove codes. Potential loss of revenue Billing compliance issues may surface

HCC RF is spread across all members in a plan. If Member A had HCC22 for validation, and the value of HCC22 is $3, and it could not be validated. The cost would be spread across the plan, so if the plan had 200 members, the monies to be extrapolated would be $600.00.

MEDICAL RECORDS REVIEW

The record does not contain a legible signature with credential.

The electronic health record (EHR) was unauthenticated (not electronically signed).

The highest degree of specificity was not assigned the most precise ICD-9-CM code to fully explain the narrative description of the symptom or diagnosis in the medical chart.

A discrepancy was found between the diagnosis codes being billed versus the actual written description in the medical record.

Documentation does not indicate the diagnoses are being monitored, evaluated, assessed/addressed, or treated (MEAT).

TOP 10 RA DOCUMENTATION/CODING ERRORS

Status of cancer is unclear. Treatment is not documented. Chronic conditions, such as hepatitis or renal insufficiency,

are not documented as chronic. Lack of specificity (e.g., an unspecified arrhythmia is coded

rather than the specific type of arrhythmia). Chronic conditions or status codes aren’t documented in the

medical record at least once per year. A link or cause relationship is missing for a diabetic

complication, or there is a failure to report a mandatory manifestation code.

TOP 10 RA DOCUMENTATION/CODING ERRORS

Clinical Documentation & Frequently Coded Conditions

CODING GUIDELINES

Very few signs /symptoms codes map to an HCC/RxHCC Only code signs and symptoms when a related definitive

diagnosis has not been established (this is a general coding guideline). However, signs/symptoms that are not routinely associated with a definitive diagnosis may be coded separately when appropriate.

Examples: Chest pain with a diagnosis of acute MI – DO NOT code the CP. Jaundice with a diagnosis of hepatitis – DO NOT code the jaundice Jaundice with a diagnosis of pancreatitis – DO CODE the jaundice

(jaundice is only prevalent in a 3rd of cases) Do not code signs/symptoms that are integral to a disease

process, unless otherwise instructed by the guidelines. Example: Sickle cell disorders (D57.-) instructs you to use an additional code for

any associated fever. In this case, code doth the disorder and the fever.

SYMPTOMS, SIGNS, AND ILL-DEFINED CONDITIONS

Here is a list of symptoms/signs that maps to an HCC or RxHCC:

SYMPTOMS, SIGNS, AND ILL-DEFINED CONDITIONS

HIV causes AIDS, but is not synonymous with AIDS. Code Z21 (HIV status) is for HIV+ patients without symptoms

or opportunistic infections. Code B20 (HIV Disease/AIDS) is for documented cases of

AIDS, HIV disease or having at least one opportunistic infection.

The provider’s statement alone that the patient is ‘HIV+,’ has ‘AIDS,’ or an ‘AIDS related il lness’ is sufficient to assign a code.

Code (in addition) all manifestations/opportunistic infections present.

If documented, use an additional code to identify HIV-2 infection (B97.35) in addition to T-cell deficiency (D83.1).

INFECTIOUS & PARASITIC DISEASES

INFECTIOUS & PARASITIC DISEASES

ENDOCRINE, NUTRITIONAL, METABOLIC DISEASES

The acronym ‘IDDM’ alone is not sufficient to code as Type I DM, but is sufficient to pick up the insulin code – Z79.4.

Sub-terms ‘poorly controlled,’ ‘ inadequately controlled,’ or ‘out of control’ can be found in the ICD-10-CM index which leads us to DM (by type) with hyperglycemia.

ICD-10-CM does not recognize ‘uncontrolled’ DM. If documented as such query the provider or code to E11.9 (DM, unspecified). ‘Uncontrolled’ can be characterized as either hyperglycemia or hypoglycemia.

It is acceptable to use ‘WITH’ as a link between DM and manifestations (unless the provider establishes another causal relationship).

ENDOCRINE, NUTRITIONAL, METABOLIC DISEASES

The acronym ‘IDDM’ alone is not sufficient to code as Type I DM, but is sufficient to pick up the insulin code – Z79.4.

Sub-terms ‘poorly controlled,’ ‘ inadequately controlled,’ or ‘out of control’ can be found in the ICD-10-CM index which leads us to DM (by type) with hyperglycemia.

ICD-10-CM does not recognize ‘uncontrolled’ DM. If documented as such query the provider or code to E11.9 (DM, unspecified). ‘Uncontrolled’ can be characterized as either hyperglycemia or hypoglycemia.

It is acceptable to use ‘WITH’ as a link between DM and manifestations (unless the provider establishes another causal relationship).

MENTAL DISORDERS

DISEASES OF THE CIRCULATORY SYSTEM

A diagnosis of hypertension or high blood pressure codes to I10. Incidental high BP reading or elevated BP w/o a diagnosis of HTN

codes to R03.0. Do not code HTN/HBP (I10) if it is not documented by the

provider. Do not use a BP reading and antihypertensive drug to assume a

diagnosis of HTN. You may query the provider in such circumstances.

There is a presumed relationship between HTN and heart involvement (HF) and between HTN and kidney involvement (CKD). These conditions should be coded as related even in the absence of provider documentation explicitly l inking them, unless the documentation clearly states the conditions are unrelated.

Assign a code from category I16 (Hypertensive crisis) for documented hypertensive urgency, emergency or unspecified crisis.

DISEASES OF THE GU SYSTEM

NEOPLASMS

Documentation supporting assignment of active cancer code: Current anti-neoplastic drug therapy Current chemotherapy/radiation therapy Referral to a specialist for

consultation/treatment/management Affirmation of current disease management Existing metastasis of cancer Refusal of treatment by patient Watchful waiting Terminal cancer (i .e. hospice/palliative care)

NEOPLASMS

Documentation supporting assignment of active cancer code: Prostate cancer on Lupron. History of prostate cancer on Lupron. Breast cancer on aromasin.

Do not code as active if when documentation states the drug is being administered prophylactically or preventatively. Breast cancer, s/p double mastectomy in 2001,

chemotherapy/radiation. Pt completed 10 years of tamoxifen in 2013.

NEOPLASMS

Coding Clinic, Second Quar ter 1992, Pg. 12 – “Assign a code from subcategory Z85.6 (Personal Hx of Leukemia) only when the physician documents that the patient has been completely cured. A patient in remission st i l l has leukemia.”

‘ In Remission’ does not mean ‘history of . ’

Coding lymphoma/myeloma is similar to coding leukemia – a lymphoma/myeloma patient in remission is st i l l considered to have lymphoma.

Documentation of ‘history of ’ with no evidence patient is st i l l being treated codes to history of .

Multiple myeloma is sometimes described as metastatic to the bone, but because this is par t of the disease, the bone metastasis should not be repor ted separately as a secondary malignant neoplasm.

FINANCIAL IMPACT

FINANCIAL IMPACT

Bonus/Penalties to providers & facilities (QPMs) Extra compensation to MCOs/Reduce compensation for

incorrect code reporting Extrapolation for incorrect coding

QUESTIONS

QUESTIONS

Thank you!

Lee Williams, RHIT, CCS, CCDS, CPCO, CPC, CEMC, CHONC, CRC

Phone: (404) 397-7851

Email: ljwcoding@gmail.com