RISK ADJUSTMENT CODING

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RISK ADJUSTMENT CODING

• Hierarchical Condition Categories

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AGENDA

• What is Medicare Park C?
• What is Risk Adjustment?
• Who is being Risk Adjusted?
• How are they being Risk Adjusted?
• What is an HCC?
• How does HCC coding differ from inpatient or
  outpatient coding in a facility?
• What is a RADV audit?

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MEDICARE PART C

• CALLED MEDICARE ADVANTAGE PLANS
• They are similar to private health plans and take
  the place of Original Medicare.
• These plans must be approved by Medicare and
  follow Medicare rules. Medicare pays a fixed
  amount each month to the company offering the MA
  plan.

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What is Risk Adjustment?

• The process of accommodating chronic conditions
  to determine the amount of reimbursement to the
  health plans
• It is used to determine the clinical acuity of
  patients, in other words, their diagnostic
  profile
• It can be done prospectively, concurrently or
  retrospectively

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Risk Adjustment cont.

• Risk Adjustment allow CMS to pay insurance plans
  for the risk of the beneficiaries, allowing
  Medicare to make appropriate and accurate
  payments for enrollees with differences in
  expected costs.
• RA coding for Medicare Advantage Plans began in
  2004, with 100 risk adjusted payment completed
  in 2004

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WHO IS BEING RISK ADJUSTED?

• Those participants eligible for Medicare
• Dual eligible special needs patients that are
  entitled to medical assistance under a Medicaid
  state plan
• ESRD patients
• The patients can be on or off the Health
  Insurance Exchange or belong to an Accountable
  Care Organization

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WHO? CONT.

• Members of PACE programs
• PACE is the acronym for Program for All
  Inclusive Care of the Elderly
• Their risk score is based on a participants
  demographic factors and diagnoses codes. A
  frailty factor is also used to determine the
  Medicare payment.

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How are patients Risk Adjusted?

• Payment is based on the expected health care
  costs using diagnoses from the previous year and
• Age
• Sex
• Medicaid Status
• Original reason for entitlement
• Institutionalized
• Frailty

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Prospective Risk Adjustment

• Involves coding diagnoses from a Health Risk
  Assessment Tool
• The HRA can be completed in the home by a
  provider or by the patients PCP
• The HRA covers HCC and Non HCC diagnoses. The
  HRA also takes in to account HEDIS review
  measures
• An Annual wellness visit is mandatory

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CONCURRENT/RETROSPECTIVE REVIEWS

• Clinical Reviewers on site for a practice under
  the MA insurance plan or at a PACE site
• Paper copies faxed or copied and mailed
• PDFs
• EMRs either on site or remote access

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SO WHAT EXACTLY IS A CMS HCC?

• Hierarchical Condition Category
• Essentially a category of ICD-9 codes that fall
  in to a related disease process or condition.
  CMS will provide payments for the most severe
  manifestation of a disease process. Not all
  codes fall in to an HCC!
• RX HCCs

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THE CMS MODEL TABLE

• The Risk Adjustment models change each year
• Payments differ between MA models and PACE models
• This year there is a blended model for MA plans
  to determine the risk score

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HCC PAYMENT VALUES

• The lower the HCC number, the higher the acuity
  and therefore a higher payment is made to the
  plan
• PACE AND ERSD use the same payment model
• Some HCCs trump other HCCs

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WHAT TO CODE FOR RA?

• DO CODE
• ALL CHRONIC CONDITIONS THAT ARE BEING TREATED!
• DONT CODE
• HISTORY OF CODES OF CONDITIONS NOT CURRENTLY
  BEING TREATED ( OR IN YOUR REVIEW YEAR)
• CODES THAT DO NOT FALL IN TO AN HCC

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ACCEPTABLE DOCUMENTATION

• FACE TO FACE VISITS THAT ARE
• LEGIBLE !!!
• SIGNED !!!
• CLEAR, CONSISTENT AND COMPLETE !!!
• FROM AN ACCEPTABLE PROVIDER TYPE AND FACILITY
• MDS AND EXTENDERS
• PT, OT
• OTHER PROVIDERS AND FACILITIES ON CMS ACCEPTABLE
  LISTS

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CLEAR AND CONCISE ??

• The interpreter speaks her diuretic
• Social history He was fishing all day today
  and caught a few fish
• She does have some ovaries left
• He does not need any preventative stuff at his
  age 87

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HCC CODING

• HCC coding uses Outpatient coding guidelines
  cannot use any suspected, probable, possible,
  rule out, etc.
• Cannot code directly from a diagnostic test, the
  provider must verify the diagnosis
• Must code from the exact narrative documented by
  the provider and not make assumptions or diagnose
• Only code to the highest degree of specificity

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Benchmark and Target Dx

• Benchmark data is compiled from the dx codes
  submitted to CMS for payment from previous years
  PCP offices, hospitals, prescriptions filled, DME
  provided
• Target dx are those that informatics may
  determine would be logically present, but not
  captured and submitted
• Other conditions that are being monitored,
  evaluated, assessed and treated (MEAT)

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ADDENDS

• These are similar to physician inquiries where
  the reviewer sees incomplete documentation
  regarding a chronic condition that the provider
  should be reimbursed for treating.
• Chronic conditions that are monitored, evaluated,
  assessed or treated need to be documented in the
  record at least once in the review (payment)year

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RADV AUDITS

• RADV stands for Risk Adjustment Data Validation
• These are annual audits conducted by CMS to
  verify a plans risk adjustment payments
• There are two types
• National Several plans are asked to submit a
  small sample of documentation with no financial
  impact
• Targeted 30 plans, both MA and PACE per review
  year with financial implications

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RADV AUDIT CONT.

• The goal of these audits are to determine the
  national payment error rate for MA programs and
  to assess the quality of the data submitted for
  payment
• The audits use enrollee based stratification
  data those with the highest risk scores, lowest
  risk scores and the middle stratum. The data is
  collected from these three stratums so as to
  reduce the variability that a random sample would
  have

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QUESTIONS?
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