Risk Adjustment Methodology 101: How to Make Sense of It All 7_2019... · • A coefficient or “weight” is assigned to each category of chronic complex diagnoses as well as severe

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Risk Adjustment Methodology 101: How to Make Sense of It All

Brett Senor, MD, CRC, CCDSMedical DirectorEnjoinAsheville, NC

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2019 Copyright, HCPro, a division of Simplify Compliance LLC. All rights reserved. These materials may not be copied without written permission.

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Polling Question

Which best represents your organization?

1.ACO

2. Provider in physician office setting

3.Hospital/health system

4. Consulting organization

5.Other

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Learning Objectives

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

– Understand the framework of Hierarchical Condition Categories (HCC)

– Recognize the differences between the 2019 and 2020 CMS‐HCC methodology

– Identify the new HCC categories and documentation tips to support capture

– Acknowledge additional upcoming changes

– Describe the key documentation elements for accurate and valid HCC capture


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HHS Goal: Reward Value, Not Volume

• HHS framework categorizes healthcare payment according tohow providers receive payment for care

• Categories 1–4

• Moving toward higher categories entails two shifts:– (1) Increasing accountability for both quality and total cost of care

– (2) A greater focus on population health management as opposed to payment for specific services

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Risk Adjustment Evolution

Acronyms:RAPS ‐ Risk Adjustment Processing SystemRA – Risk AdjustmentMA – Medicare Advantage


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So Many Changes

• Implementation of extrapolation for RADV findings

• “Pathways to Success” for ACOs

• Special Supplemental Benefits for Chronically Ill (SSBCI)

• Social Determinants of Health (SDoH)

• Changes to CMS‐HCC methodology

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Methodology Changes Within the Bigger Picture

ICD‐10 codes

Methodologies: Risk adjustment (e.g., HCC risk scores)

Programs: ACO, Medicare Advantage, CPC+, MIPS, etc.

Documentation


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Current Methodology

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Current CMS‐HCC Model CharacteristicsCharacteristic Descriptions

Prospective model Uses diagnostic information from a base year to predict Medicare benefit costs for the following year

Site neutral Model does not distinguish payment based on site of care

Diagnostic sources Model recognizes diagnoses from hospital inpatient, hospital outpatient, and physician settings

Multiple chronic diseases considered

Risk‐adjusted payment based on assignment to disease groups (Condition Categories [CC])• Most CCs represent chronic conditions

Models are additive Individual risk scores calculated by adding coefficients associated with each beneficiary’s demographic factors and CCs

Demographic variables Demographic factors include age, sex, original reason for entitlement, Medicaid or low‐income status, disability status

Adapted from: Centers for Medicare and Medicaid Services. Medicare Managed Care Manual. Chapter 7 – Risk Adjustment, 70 – Risk Adjustment Models – Overview.


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Current CMS‐HCC Model Structure

Structure Details

Hierarchical 65% of all HCCs exist in clinically related family of HCCs that are ranked by severity or cost dominance within a hierarchy• When > 2 HCCs within a hierarchy are reported for a patient in a calendar

year, only highest ranked/most severe HCC that is triggered is reported for a patient each year• Process is called “trumping”

Additive Unrelated HCCs are cumulative

Disease interactions

Certain combinations of diseases have been demonstrated to increase costs of careThe model incorporates additional relative factors for disease interactions• Are additive factors and increase payment accuracy

Adapted from: Watson, M. "Documentation and Coding Practices for Risk Adjustment and Hierarchical Condition Categories." Journal of AHIMA 89, no.6 (June 2018): extended online version.

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Risk Adjustment: CMS‐HCC Model

• A coefficient or “weight” is assigned to each category of chronic complex diagnoses as well as severe acute diagnoses

• HCCs involving unrelated conditions are cumulativeHCC

Category Description Label Coefficient

HCC 1 HIV/AIDS 0.344

HCC 2 Septicemia, Sepsis, Systemic Inflammatory Response Syndrome/Shock 0.428

HCC 6 Opportunistic Infections 0.446

HCC 8 Metastatic Cancer and Acute Leukemia 2.654

HCC 9 Lung and Other Severe Cancers 1.027

HCC 10 Lymphoma and Other Cancers 0.675

HCC 11 Colorectal, Bladder, and Other Cancers 0.309

HCC 12 Breast, Prostate, and Other Cancers and Tumors 0.153

HCC 17 Diabetes with Acute Complications 0.307

HCC 18 Diabetes with Chronic Complications 0.307

HCC 19 Diabetes without Complications 0.106

HCC 21 Protein‐Calorie Malnutrition 0.554

HCC 22 Morbid Obesity 0.262

HCC 23 Other Significant Endocrine and Metabolic Disorders 0.212

HCC 27 End‐Stage Liver Disease 0.913

HCC 28 Cirrhosis of the Liver 0.381

0.307+0.554+0.2121.073


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Current CMS‐HCC Model Structure


• Each unrelated HCC that applies is additive

Age, sex, disability status, etc.

Health status

Adjusts future

payments

0.307+0.554+0.2121.0730.73

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Current CMS‐HCC Model Structure (cont.)


• Each unrelated HCC that applies is additive

1.803

Risk Adjustment Factor (RAF) Score

Age, sex, disability status, etc.

Health status

Adjusts future

payments

0.307+0.554+0.2121.0730.73


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All conditions precisely documented

84 year old female – nondual aged

.540

COPD J44.9 (HCC 111) .335

Diabetes w/ diabetic CKD E11.22 (HCC 18)

.307

CKD stage 5 N18.5 (HCC 136) .284

Chronic diastolic CHF I50.32 (HCC 85)

.310

Disease interaction (DM + CHF) .152

Disease interaction (CHF + RF) .202

Disease interaction (CHF + COPD)

.191

Total RAF score 2.321

PMPM payment $1,857

Annual payment $22,282

Roberta Smith’s clinical picture: Type 2 diabetic with CKD stage 5, chronic diastolic CHF, & COPD

Demographics

Diagnoses supported in encounter

documentation

Interaction coefficients

added by CMS

Risk score

Risk adjustment payment

Provider impact –based on specificity and comprehensive documentation

Current 2019 v.23 $800 base rate

How It All Adds Up!

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2020 Methodology Changes


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Key Changes That Impact Risk Adjustment

• Alternative Payment Condition Count model (APCC)

• Additional HCCs added to the model

– Ensuring capture and validation of diagnoses

• Risk score calculation percentages

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2019 CMS‐HCC Model Structure

Risk Adjustment Factor (RAF)

Score

Demographics Health status

Trumping conditions+

Other unrelated HCCs+

Disease interactions

Age, sex, disability status,

etc.

Adjusts future

payments



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Risk Adjustment Factor (RAF)

Score

Demographics Health status

Trumping conditions+

Other unrelated HCCs+

Disease interactions+

APCC

Age, sex, disability status,

etc.

Adjusts future

payments


20Source: https://www.cms.gov/Medicare/Health‐Plans/MedicareAdvtgSpecRateStats/Downloads/Announcement2020.pdf

Alternative Payment Condition Count (APCC)

Payment HCC Counts Description Label

Community, Nondual, Aged Pop (Continuous Enrollment)

Weight

< 4 1–3 payment HCCs 0

4 4 payment HCCs .006






> 10 10 or more payment HCCs .505

.036

.088

.247


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All conditions precisely documented

84 year old female – nondualaged

.528

COPD J44.9 (HCC 111) .335

Diabetes w/ diabetic CKD E11.22 (HCC 18)

.302

CKD stage 5 N18.5 (HCC 136) .289

Chronic diastolic CHF I50.32 (HCC 85)

.331

Disease interaction (DM + CHF) .121

Disease interaction (CHF + RF) .156

Disease interaction (CHF + COPD) .155

D4 – 4 payment HCCs .006

Total RAF score 2.223

PMPM payment $1,778

Annual payment $21,341

Roberta Smith’s clinical picture: Type 2 diabetic with CKD stage 5, chronic diastolic CHF, & COPD

Demographics

Diagnoses supported in encounter

documentation

Interaction coefficients

added by CMS

Risk score

Risk adjustment payment

Provider impact –based on specificity and comprehensive documentation

$800 base ratev.23 w APCC

Condition count

How It All Adds Up!

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Hierarchy involving new HCCs for dementia and pressure ulcers

HCC HCC Title Trumps

51 Dementia with Complications (2020 HCC) 52

52 Dementia without Complications (2020 HCC) none

157 Pressure Ulcer of Skin with Necrosis Through to Muscle, Tendon, or Bone

158, 159, 161

158 Pressure Ulcer of Skin with Full Thickness Skin Loss

159, 161

159 Pressure Ulcer of Skin with Partial Thickness Skin Loss (2020 HCC)

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161 Chronic Ulcer of Skin, Except Pressure noneSource: https://www.cms.gov/Medicare/Health‐Plans/MedicareAdvtgSpecRateStats/Downloads/Announcement2020.pdf

2020 Changes to CMS‐HCC Risk Adjustment Methodology: Alternative Payment Condition Count Model (APCC)


23Source: https://www.cms.gov/Medicare/Health‐Plans/MedicareAdvtgSpecRateStats/Downloads/Announcement2020.pdf

Key Changes That Impact Risk Adjustment

• Data used to calculate risk scores

• 50% calculated with 2017 CMS‐HCC model and diagnoses submitted on RAPS and FFS claims

• 50% calculated with alternative payment condition count model, using diagnoses submitted on encounter data records, RAPS inpatient records, and FFS claims

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Key Changes: Encounter Data TransitionTransition plan

2015

RAPS EDS

2016

RAPS EDS

2017

RAPS EDS

2018

RAPS EDS

2019

RAPS EDS

2020

RAPS EDS

2015

RAPS EDS

2016

RAPS EDS

2017

RAPS EDS

2018

RAPS EDS

2019

RAPS EDS

Actual

Centers for Medicare & Medicaid Services’ Transition from Risk Adjustment Processing System (RAPS) Data to Medicare Advantage (MA) Encounter Data for Risk Score Calculation; GAO‐17‐223Medicare Advantage Rates & Statistics; Announcements 2015‐2020; https://www.cms.gov/Medicare/Health‐Plans/MedicareAdvtgSpecRateStats/Announcements‐and‐Documents.html?DLSort=2&DLEntries=10&DLPage=1&DLSortDir=descending.

2020

RAPS EDS


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What’s the Effect of the Transition?

• Study conducted in 2017 with eight Medicare Advantage payers accounting for approx. 1 million beneficiaries to compare difference in scores and HCC capture based on methodologies

RAPS• Prevalence rate for top 10 HCCs

‒ 11.5% in 2014 ‒ 12.2% in 2015

• % of HCCs per patient‒ 28.2% with 0 HCCs‒ 25.3% with 1 HCC‒ 15.5% with 2 HCCs‒ 29.0% with 3 or more HCCs

EDS• Prevalence rate for top 10 HCCs

‒ 6.9% in 2014‒ 9.2% in 2015

• % of HCCs per patient‒ 39.3% with 0 HCCs‒ 24.7% with 1 HCC‒ 15.3% with 2 HCCs‒ 20.7% with 3 or more HCCs

RAPS to EDS Collaboration: A Data‐Driven Analysis; National Medicare Advantage Summit; April 2017

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Ensuring HCC Capture


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Hierarchy involving new HCCs for dementia and pressure ulcers

HCC HCC Title Trumps

51 Dementia with Complications (2020 HCC) 52

52 Dementia without Complications (2020 HCC) none

157 Pressure Ulcer of Skin with Necrosis Through to Muscle, Tendon, or Bone

158, 159, 161

158 Pressure Ulcer of Skin with Full Thickness Skin Loss

159, 161

159 Pressure Ulcer of Skin with Partial Thickness Skin Loss (2020 HCC)

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161 Chronic Ulcer of Skin, Except Pressure noneSource: https://www.cms.gov/Medicare/Health‐Plans/MedicareAdvtgSpecRateStats/Downloads/Announcement2020.pdf

2020 Changes to CMS‐HCC Risk Adjustment Methodology: Alternative Payment Condition Count Model (APCC)

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CMS‐HCCs 51 and 52: Dementia With and Without Complications

HCC 51: Dementia with ComplicationsExamples:• Vascular dementia with behavioral disturbance

• Dementia in other diseases classified elsewhere with behavioral disturbance

• Unspecified dementia with behavioral disturbance

• Hydrocephalus – multiple types

‒ Includes normal pressure hydrocephalus

HCC 52: Dementia without Complications Examples: • Alzheimer's disease

‒ Early onset‒ Late onset‒ Other Alzheimer's disease‒ Unspecified

• Dementia with Lewy bodies• Vascular dementia without behavioral disturbance • Unspecified dementia without

behavioral disturbance• Dementia in other diseases classified elsewhere

without behavioral disturbance • Pick's disease• Creutzfeldt‐Jakob disease


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CMS‐HCC 159: Pressure Ulcer of Skin with Partial Thickness Skin Loss

Pressure‐induced injury staging:

Stage 1 – Skin intact but with nonblanchable redness

• Non‐HCC

Stage 2 – Partial‐thickness loss of skin with exposed dermis

• New HCC

Stage 3 – Full‐thickness loss of skin, in which adipose (fat) is visible in the ulcer and granulation tissue and epibole (rolled wound edges) are often present

• HCC 158

Stage 4 – Full‐thickness skin and tissue loss with exposed or directly palpable fascia, muscle, tendon, ligament, cartilage, or bone in the ulcer

• HCC 157

Unstageable ulcers (HCC 158)

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Step 1Document diagnosis with specificity

Step 2Link diagnosis to MEAT criteria component in note

Step 3Submit diagnosis with proper ICD‐10‐CM code to claim

Monitor EvaluateAssessTreat

Or

Or

Or

Documentation Requirements for HCC Assignment


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Diagnosis

Documentation demonstrating your addressed

diagnosis

The Importance of Linking: The MEAT Criteria

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Monitor

Evaluate

Assess

Treat

Examples:

• Essential HTN: Stable on lisinopril (assess and treat)

• Chronic systolic heart failure: Well compensated (assess)

• COPD: Worsening sx, will check PFTs, add inhaled steroid (evaluate, assess, treat)

Or

Or

Or

Documentation Requirements for HCC Assignment


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Documentation Scenario

CC: Weight loss

HPI: 68‐year‐old female with carotid stenosis, HTN, and hyperlipidemia who has residual right hemiplegia since 2013 stroke. Has been frequently bedbound with minimal help with ADLs for past 6 months. Didn't like home health caregivers so fired them after 3 weeks. Poor po intake with unintentional 14 lb. weight loss over this same period.

PMH:

Stroke 2013

HTN

Hyperlipidemia

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ROS: As above. Otherwise was evaluated by wound care team recently.

Exam: BP 150/60 HR 68 reg R 16 T afebrile BMI 17

General: Cachectic‐appearing pale female.

CV: Cor RRR with occasional ectopy. Pulses diminished at feet.

Neuro: Right upper extremity with 3/5 grip and arm strength. RLE 2/5 strength throughout.

Skin: Coccyx with pink, moist wound bed measuring 4x5 cm (wider than 4 months ago). Partial‐thickness skin loss with no exposed adipose or deeper tissue. No infectious signs.


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Visit diagnoses:

1. Cachexia

2. Coccyx pressure injury with partial‐thickness skin loss

3. Stroke 2013

4. Right hemiplegia due to above

Plan:

1. Encouraged to increase caloric intake

2. Refer for home health caregiver

3. F/u with wound care team

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Ques ons:

• Is MEAT sa sfied for the coccyx pressure injury? ‒ Yes. The wound was assessed and described adequately.

• Skin: Coccyx with pink, moist wound bed measuring 4x5 cm (wider than 4 months ago). Partial‐thickness skin loss with no exposed adipose or deeper tissue. No infectious signs.

• Does a partial‐thickness (stage 2) pressure ulcer trigger an HCC in 2019? ‒ Not yet. It will in 2020 as part of the APCC implementa on .

• What additional step should providers be encouraged to do to enhance likelihood of HCC capture? ‒ Submit proper code for each diagnosis satisfying MEAT criteria.

• L89.152 Pressure ulcer of sacral region, stage 2


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What’s Coming?

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• Implementation of extrapolation for RADV findings• Different platforms for patient engagement

‒ Home/mobile care‒ Telehealth‒ Retail care‒ Telephone support

• Social Determinants of Health (SDoH)‒ Are there codes for that?

Other Buzz in the Industry


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Is There a Code for That?

Z56.0 Unemployment, unspecified

Z59.0 Homelessness

Z59.1 Inadequate housing

Z59.4 Lack of adequate food and safe drinking water

Z59.5 Extreme poverty

Z59.6 Low income

Z59.7 Insufficient social insurance and welfare support

Z59.8 Other problems related to housing and economic circumstances

Z59.9 Problem related to housing and economic circumstances, unspecified

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• Implementation of extrapolation for RADV findings

• Different platforms for patient engagement ‒ Home/mobile care‒ Telehealth‒ Retail care‒ Telephone support

• Social Determinants of Health (SDoH)‒ Are there codes for that? YES, although vague‒ Additional codes with specificity proposed for 2020

• Z59.61 Unable to pay for prescriptions• Z59.64 Unable to pay for transportation• Z60.82 Inadequate social interaction

https://www.cdc.gov/nchs/data/icd/Topic‐packet‐March‐2019‐Part‐2Vs3.pdf

Other Buzz in the Industry


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• Engage your providers!‒ How do you do that?

• Keep apprised of changes‒ How do you do that?

• Start education now for 2020 changes‒ Why do that?

• Start building processes to support HCC capture‒ Why do that?

What Should You Be Doing Now?

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References• Centers for Medicare and Medicaid Services. Medicare Managed Care Manual. Chapter 7 – Risk Adjustment, 70 – Risk Adjustment Models – Overview.

• CMS.gov HHS‐Developed Risk Adjustment Model Algorithm "Do It Yourself (DIY)" Software Instructions.

• Gilmer, T. Risk Adjustment Using CDPS. Research Data Assistance Center; cdps.ucsd.edu

• Medicare Advantage Rates & Statistics; “Announcements” 2015–2020. https://www.cms.gov/Medicare/Health‐Plans/MedicareAdvtgSpecRateStats/Announcements‐and‐Documents.html?DLSort=2&DLEntries=10&DLPage=1&DLSortDir=descending.

• Murrin, S. “Medicare Advantage Encounter Data Show Promise for Program Oversight, But Improvements Are Needed.” DHHS Office of Inspector General (OEI‐03‐15‐00060), January 2018. https://oig.hhs.gov/oei/reports/oei‐03‐15‐00060.asp

• Palmetto GBA. “Medicare Advantage & Part D Communications Handbook.” August 2018. https://www.csscoperations.com/internet/cssc4.nsf/files/Medicare%20Advantage%20Communications%20Handbook%2020180810.pdf/$FIle/Medicare%20Advantage%20Communications%20Handbook%2020180810.pdf

• Risk Adjustment for EDS & RAPS User Group. April 19, 2018. https://www.csscoperations.com/internet/cssc4.nsf/DocsCat/CSSC~CSSC%20Operations~Medicare%20Advantage%20Encounter%20Data%20and%20RAPS%20Data~User%20Group~AZJ8PF0127?open&navmenu=MedicareÂdvantageÊncounter^Dataând^RAPS^Data||||

• Risk Adjustment for EDS & RAPS User Group. May 17, 2018. https://www.csscoperations.com/internet/cssc4.nsf/DocsCat/CSSC~CSSC%20Operations~Medicare%20Advantage%20Encounter%20Data%20and%20RAPS%20Data~User%20Group~AZJ8TX8643?open&navmenu=MedicareÂdvantageÊncounter^Dataând^RAPS^Data||||

• Swadi, A. “RAPS to EDS Collaboration: A Data‐Driven Analysis.” National Medicare Advantage Summit. April 6, 2017. http://www.ehcca.com/presentations/medadvsummit/swadi_ms2.pdf

• The Henry J. Kaiser Family Foundation. “Medicare Advantage” Fact Sheet. October 2017. https://www.kff.org/medicare/fact‐sheet/medicare‐advantage/

• United States Government Accountability Office. “Medicare Advantage: Limited Progress Made to Validate Encounter Data Used to Ensure Proper Payments.” GAO‐17‐223, January 2017. https://www.gao.gov/assets/690/682145.pdf


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