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STRATEGIC CODING IN THE ERA OF
MACRA:
Impact of Risk Scoring And Attribution
October 2017
Linda Gates-Striby
Increasing Our Focus
• The coding landscape in physician practices is changing quickly as healthcare
shifts towards “value-based care” and quality payment models.
• Coding specificity, accuracy, and compliance is having an increasing impact on
Medicare reimbursement in the years to come.
• We MUST pay greater attention to ICD-10 coding.
• Coders and Clinicians need to understand the specifics required of our “new
world” of value and ensure we are documenting and coding in the most
accurate and appropriate manner.
• Forward thinking practices and coders are already focusing on HCC/RAF and
many are beginning CDI type efforts in the outpt environment
Registry Participation ACC’s PINNACLE Registry
or Diabetes Collaborative
Registry can help you fulfill
MIPS requirements for
Quality, Improvement
Activities and Advancing Care Information.
Free participation
Compatible with over 85 EHRs
Monthly performance and benchmarking reports
Should I Do Anything Different?
• MIPS and Risk Adjustment HCC coding is the system used for Risk Adjustment under MIPS.
• Diagnosis codes (ICD-10) are assigned a weight that measures patient acuity. Medicare expects that patients with higher HCC scores will consume more healthcare dollars and have worse outcomes.
• If 60% of the MIPS score for providers is going to come from risk adjusted quality and resource use scores, it is critically important to accurately reflect the acuity of our patient population.
• Doing so will help quality and cost scores to accurately reflect the excellent care provided by physicians.
• Your diagnosis coding is about to become much more important, both for immediate fee-for-service reimbursement and over the following
What Are The MIPS Elements?
PQRS Program
Value Based Modifier Program
Meaningful Use Program
Medicare Shared Savings
Program
Merit Based
Incentive Program
(MIPS)
2017 First Reporting
Year, effects 2019
Payments
HCC Impact on Sample Contracts
National Quality
Benchmarks
MSSP/ ACO Benchmark
Anthem MA (PMPM and
Savings)
Page 11
Simplified Version
• Using an actuarial tool to plug in a person’s current health conditions and apply data collected since approximately 2004 about those conditions.
• Now apply a forecasting perspective to estimate future financial implications, and more importantly, to predict future patient care management needs and plan for potential complications.
• The thought is to attempt to level the playing field and allow each individual’s health to be reflected as it truly is.
• We each carry a level of risk. The healthiest of us – those without any chronic health conditions, are at the lower end of the risk scale.
• With the addition of some conditions, the risk increases.
• Add even more conditions and the risk continues to rise – and so will that person’s health care needs & “resource use”
Diagnosis Coding – The New RVU?
• Consider that CMS and other payors generally use data that is
two years behind when they implement changes
• What we are submitting now is setting us up for payment
changes in the future in a number of ways – what we don’t know
for sure is exactly how many ways
• We need to be as specific as possible – and present a true and
accurate picture of our patient’s severity
• We need to be thinking about this at each encounter as we
never know for sure if we will see the patient again in the year
Why Should I Care?
• For CMS “MACRA” replaces the flawed SGR and is
scheduled to go into effect in 2019
• Claims submitted in 2017 will be used in the 2019
implementation
• Commercial payors such as Anthem, United, Aetna, Cigna, Humana and
others are also using claims data to determine their “Value” or “resource
use” scores for individual providers
Where Does Documentation & Coding Fit In?
• Builds the “language” to describe overall patient care
• Creates the connections of independent medical conditions
• Requires you to bring “uniqueness” and specificity to each patient encounter
• Rationalizes coverage for increasing complex patients
• Objectifies the claim “my patients are the sickest”
• Will provide the context to use “big data” to plan and execute Population Health – Predictive Analytics
How Does Risk Adjustment Impact You?
• Risk adjustment facilitates more accurate comparisons by accounting for
differences in patient case mix
• Risk adjustment plays a role in quality rankings by estimating an expected
performance on a quality or cost measure based on the case mix and
then comparing that estimate to the actual performance.
• The essential component of these measures is a ratio of actual-to-
expected performance, where the expected performance is reflective of
the clinical complexity
RAF - Risk Adjustment Factor
What Do We Mean By RAF?
• Used to access the clinical complexity of a patient and predict the burden of illness for individuals and populations
• Acts as a multiplier when calculating CMS payments in a year
• Factors into bidding and payment of MA plans
• Focuses on identification, management, and treatment of chronic conditions
• Provides a payer with additional resources to manage the health of a riskier population
Additional Resources
• More accurate coding leads to improved practice modeling and stratification of a population
Better Analytics
• Encourages regular outreach to patients who aren’t coming in regularly but may need follow-up
Encourages Regular
Management
HCC – Hierarchical Condition Category 101
The Least You Need To Know
Model Is Here To
Stay In One Form
Or Another
Goes To A Blank
Slate Every
Calendar Year
Subject To Data
Validation
Sampling
The HCC & RAF Connection 79 to 3,000
The CMS model is
accumulative – a patient
can have more than one
HCC category assigned to
them. Some categories
override others and there is
a hierarchy of categories.
The HCC must be captured
using claims data every 12
months.
The HCC must be documented and supported in the medical record and this can be subject to a “data validation” review
The plan must submit the “one best medical record” that supports the patient’s HCC scoring if identified for validation.
The HCC model has
been the basis for
reimbursement to
MAO plans since 2004.
Due to it’s proven
success in predicting
resource use it is now
being used to
determine much more
and by more payors.
Patients with multiple HCCs in a single category will be scored at the highest level
*Additional risk is scored when certain conditions coexist
When multiple conditions are present in the same patient a higher score will be used . i.e. CHF & COPD or CHF and CRF
Sample Encounter And The Accumulative Impact
HPI
•Mickey comes in for a follow up of his CHF.
He also has DM and CRF stage IV.
A/P
1.Chronic Systolic HF – Currently Stable, to
continue current dose of Lasix
2.Type II DM and Stage IV CKD – Stable,
scheduled to see nephrologist in 2 weeks
Sample Patient - Mickey M
Financial Metrics
All 3 conditions result in an extra $816 per month + $9,792
Reporting CHF only would provide an extra
$312 per month
+$3,744
Add’l for 12
months
HCC/RAF Scoring
This pt has 3 HCC categories, all three
codes risk adjust and would represent an
accumulative “scoring”. This Pt’s RAF
Score would be .960
If the anticipated monthly cost was $850
this now becomes $850 x .960 = $1,666
What If Mickey Also Had A Skin Ulcer? HCC Condition RAF
Score
HCC
157
Pressure ulcer of skin
with necrosis through to
muscle tendon or bone
2.551
HCC
158
Pressure ulcer of skin
with full thickness skin
loss
1.371
HCC
161
Chronic ulcer of skin
except pressure
.549
HCC
162
Severe skin burn or
condition
.422
A patient with HCC 157 will be spending $2,168 more each month (2.551 X $850)
A patient with HCC 158 will spend $1,165 more per month (1.371 X $850)
A patient with HCC 161 will spend only $466 more per month (.549 X $850) and
A patient with HCC 162 will spend only $358 more per month (.422 X $850).
What Does Coding Correctly Mean?
“Don’t Miss” Chronic Conditions
• DM & complications
• CHF
• COPD
• A Fib
• Morbid Obesity
• HTN & complications (HTN alone does not have a RAF score)
• Major Depression
• PVD
• Malnutrition
Use ICD-10 Appropriately I.E. as specific as possible
Provider’s role is to accurately capture the conditions that are treated, managed, or impact care
Coded conditions must be documented – i.e. “MEAT” – manage, evaluate, assessment, treatment plan
Accurate coding and documentation is critical to risk scoring and our future
What Does And Does Not Risk Adjust Does
• CKD stage IV & V
• Morbid Severe Obesity
• Angina, Unstable Angina
• Complete AV Block
• ASCVD with intermittent claudication
Seeing a pattern?
Does Not
• CKD Stage I, II, and III
• Obesity Unspecified
• Chest Pain
• AV Block 1st or 2nd degree
• ASCVD unspecified
Don’t code to a greater
degree than you
document!
Documentation & Coding Guidelines
Access all
conditions that
coexist that day
are treated,
managed, & affect
patient care
Consider, document
and report the
disease as
accurately as
possible – use
specificity codes
Ensure you are
addressing and
reporting/coding
these conditions at
least once per
calendar year
Per ICD-10 Official Guidelines for coding and reporting “Code
all documented conditions that coexist at the time of the
encounter/visit, and require or affect patient care treatment or
management.”
Capturing Comorbidities Is Essential
• In our Fee-for-Service model we have gotten used to making sure a diagnosis justifies medical necessity for the CPT codes on a claim.
• Many practices stop short of documenting and capturing comorbidities that show complicated medical decision making, treatment plans, and more accurately reflect the condition of the patient.
• These comorbidities have not been required for proper reimbursement, and many practices say that they do not always code comorbidities
• In contrast – the majority of practices indicate that their physicians do a good job of documenting these comorbidities in the note.
• The change may not be one of documentation, but more of a coding change that is needed. Practices who want to more accurately reflect patient acuity need to do a better job of coding comorbidities
Documentation Guidelines • Chronic condition ______ is stable will continue with current treatment
regime
• Chronic condition ______ now requires the following changes in
management….
• Chronic condition ______ is being managed by specialist______ and
the patient is scheduled for follow up on _______
29
More is More?
Statements such as this will support your consideration on that
visit, and adding the code to your claim.
This could also support a “risk” element in your medical decision
making **
Top Conditions That Are Represented in
HCC Categories and RAF Scores • Diabetes with complications
• Morbid obesity
• Multiple cancers
• Cirrhosis & end stage liver disease
• Protein-calorie malnutrition
• Rheumatoid Arthritis
• Drug and Alcohol dependence
• Major depressive, Bipolar, & paranoid disorders
• Quadriplegia & paraplegia
• CHF
• Acute MI
• Unstable angina & acute Ischemic disease
• Atrial flutter and fib
• Vascular disease with complications
• COPD
• CKD – stage 4, 5, dialysis status
• Parkinson’s
• Cerebral palsy
• Hemiplegia/hemiparesis
The Coding Path To Readiness ? • Continue to educate and
reinforce with providers the importance of accurately coding the patient’s condition(s)
• Identify providers with high use of unspecified codes and low use of typical chronic conditions
• Share individual provider RAF scoring patterns
• Begin to monitor high cost of care numbers per provider and rule out underlying coding issues
• Build accurate HCC profiles on assigned patients
• Get patients in for their annual wellness visits (PCP) • Reaffirm old dxs
• Establish appropriate new dxs
• Clarify & code disease interactions & relationships
• Specify the unspecified as soon as you know
Areas To Review
• Show current state of disease process for accurate reporting: • Acute, chronic, compensated, decompensated, exacerbated
• If ruled out/resolved, state it
• Cause of condition should be reported, if known
• Show relationship in diagnoses to other disease process through linking conditions’, providing linking terms between diagnoses, such as: • With
• Due to
• Caused by
• Secondary to
More Resources • HCC University – excellent resource with lists of all HCC
categories and weight of each code available for download
• CMS MACRA webinar series (https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/Value-Based-Programs/MACRA-MIPS-and-APMs/Quality-Payment-Program-Events.html)
• MGMA MACRA Resource Center (http://www.mgma.com/government-affairs/issues-overview/medicare-payment-policies/macra)
CMS Attribution Of Beneficiaries
• The Value-Based Payment Modifier (Value Modifier) Program evaluates the performance of solo practitioners and groups, as identified by their Medicare Taxpayer Identification Number (TIN), on the quality and cost of care they provide to their Medicare Fee-for-Service (FFS) beneficiaries. The Centers for Medicare & Medicaid Services (CMS) disseminates this information to TINs in confidential Quality and Resource Use Reports (QRURs). For each TIN subject to the Value Modifier, CMS also uses these data to calculate a Value Modifier that adjusts the TIN’s physicians’ Medicare Physician Fee Schedule payments upward, downward, or not at all, based on the TIN’s performance.
• In assessing performance on several of the quality and cost measures included in the QRUR and Value Modifier, CMS uses a two-step attribution process to associate beneficiaries with TINs during the year performance is assessed. The attribution methodology determines which beneficiaries are included in the calculation of each TIN’s quality and cost performance and payment adjustment under the Value Modifier.
If You Have Seen One Form of Attribution…..
CMS Attribution Basics
Attribution Depends on Who Provides “Plurality of Primary Care Services”
Medicare uses a two-step process for determining which patients are tied to a provider
and who will constitute the spending-per-beneficiary and claims-based-quality-measure
denominators.
Medicare is now aligning the methods used in ACO patient attribution with the VBPM
patient attribution – This is intended to create consistency between Medicare’s Value-
Based Payment initiatives.
Beginning in 2017 CMS is also
reviewing APPs such an NP, PA, CNS in
the equation for “Plurality of Services”
Team Based Care
Medicare’s 2 Step Approach
Step 1
Step 2
Step 1: Beneficiaries are assigned to the primary care provider (whether physician,
NP, PA, or CNS) who provided the “plurality of primary care services” to the patient,
as measured by allowed charges – i.e. E/M visits .
But what if they were not seeing a PCP?
Step 2: Beneficiaries are assigned to the practice whose non-primary care
providers (i.e. specialists) provided the “plurality of primary care services”
to the patient, as measured by allowed charges – again – E/M visits
But wait… there’s more: “Primary Care Services” may include services that
a specialist provides, but which are unrelated to the conditions and events
that Medicare is tracking.
Specific Patient Names
Are Available
Take The Time To Do Deeper Dive What About The PCP Provider?
Is There A PCP Provider?
You don’t have to
guess - review your
QRUR report- it lists all
of the patient’s
Shows your total
patient cost – and from
where
Were these episodes
you controlled?
Are there other provider
costs that are hurting
your score?
This can be an eye
opening experience!
The data is based on Medicare
claim data
If there are providers not in your
network – this may be one of the
only ways you will see their costs
You may see the patient has
providers they are seeing that you
were never made aware of
The ACC has provided extensive web
sessions on how to use your QRUR reports
One thing specialists can do is consider
confirming that the patient has a PCP
If they have a PCP – make sure they are seeing
them at least once per calendar year
Finding out a patient with COPD for example
is assigned to you can actually signify a gap in
care – and no one may be managing that
condition.
A quick review may not only avoid attribution
errors – but could lead to better patient
outcomes all around around
Who Are You Accountable For?
Metrics Are Patient Centered
One way to help with appropriate attribution is is to ensure the PCP provider is conducting and billing for the Medicare Annual Wellness visit
This can help ensure that the patient stays connected to the PCP both clinically and through the attribution process
This also provides an opportunity to ensure that chronic conditions are addressed and hopefully coded and billed once per calendar year (HCC & RAF Scoring
This also provides an opportunity to ensure that chronic conditions are addressed and hopefully coded and billed once per calendar year (HCC & RAF Scoring)
In a P4P world it doesn’t always matter if you are the specialist or the PCP - you need to know what care your patients are receiving. You simply can’t stop with providing the best possible care in your field and sending patients out the door.
If You Remember Nothing Else….. • The claims we are submitting in 2017 will be used in
the 2019 implementation • How many patients have you already seen this year that you might
not see again before year end? – Did you code to the specificity you should have?
– Did you report the chronic conditions you evaluated that impacted your decisions?
PINNACLE: Largest outpatient CV registry in the U.S.
Founded in 2008 with more than 9,000 providers submitting data
from 3000 office
locations
* Data as of August 2017
Over 50 million records from 12 million unique patient lives to-
date
ACC2017 ACC2017
Diabetes Collaborative Registry Footprint to date
Confidential. Not for Distribution. (c)2017
7232 contracted providers from 2531 practice locations
across 47 states in the United States
As of August 2017 N = 1,278 sites with signed contracts * many are practices with multiple geographic locations
Registry Participation ACC’s PINNACLE Registry
or Diabetes Collaborative
Registry can help you fulfill
MIPS requirements for
Quality, Improvement
Activities and Advancing Care Information.
Free participation
Compatible with over 85 EHRs
Monthly performance and benchmarking reports
QCDR Participation
• As a QCDR, the registries submit data for the MIPS Quality category,
which accounts for 60 percent of the overall MIPS score.
• You can also earn bonus points for reporting additional
outcome and high priority measures!
• It’s easy to use and simplifies MIPS reporting. Data is captured
seamlessly through the electronic health record, and the ACC
transmits it to CMS for you.
• Avoid penalties for non-participation in MIPS by making reporting
easy and convenient.
Merit-based Incentive Payment System (MIPS) Reporting • Quality (60% score)
– 19 measures available
– ACC will submit on behalf or providers with consent
• Improvement Activities (15% of score) – 7 Registry Favorites
– Self-attestation tool via dashboard
• Advancing Care Information (25% of score) – Self-attestation tool via dashboard
Successful Reporting • Approved by CMS as QCDR for program years 2017, 2016, 2015
and 2014
• 2016 PQRS • Reported for over 2200 providers including:
• 26 Group Practices
• 16 measures available