A Deep Dive Into HCCs This is the Full Title of a Session ... 3... · Title: Microsoft PowerPoint -...

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This is the Full Title of a Session

A Deep Dive Into HCCs

Shannon McCall, RHIA, CCS, CCS‐P, CPC, CEMC, CRC, CCDS, CCDS‐ODirector of HIM/CodingHCProMiddleton, MA

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Learning Objectives

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

– Explain the importance of HCCs

– Calculate risk adjustment factor (RAF) score

– Identify high‐yield HCCs

– Describe outpatient coding guidelines

– Identify common metrics for tracking efficacy of an HCC‐focused CDI program

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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Definition of Risk

• Risk <Merriam‐Webster>

– Possibility of loss or injury

– The degree of probability of such loss

– A person or thing that is a specified hazard to an insurer

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How It Works – Fee‐for‐Service Medicare

$$ Direct From

Medicare

Inpatient/DRG

Outpatient/APCs

Provider/Fee Schedule


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How It Works – Medicare Advantage Plans

$$ Direct From Med Advantage

Plan

Inpatient/DRG

Outpatient/APCs

Provider/Fee Schedule

Funds to pay the claims come from

Medicare

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Measuring RiskEstimating Costs

How do you measure a driver’s risk?

• Demographics

– Age, sex

– Geographic location

– Vehicle (make/model)

• History

– Claims data (i.e., accidents)

– Traffic violations

– License suspensions

How do you measure a patient’s risk?

• Demographics– Age, sex

– Disability

– Living circumstances

– Dual eligibility status (Medicare/Medicaid)

• History– Claims data (Parts A & B)

• Reported diagnoses

• Hierarchical Condition Categories


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Risk Adjustment for CMS Programs

• Risk adjustment is the process of modifying payments and benchmarks to reflect the degree of illness, which in turn allows the Centers for Medicare & Medicaid Services (CMS) to estimate future spending or potential for adverse outcome, allowing providers to understand the health characteristics of their managed population or a patient cohort

• Risk adjustment is used to determine

– Prospective payments in some reimbursement models

– Normalize the patient population across Medicare providers to determine performance on quality measures

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CMS‐Hierarchical Condition Categories

• Prospective in nature

– Reviews health status in a base year to predict costs in the next year

• Limited to diagnoses

– More than 9,500 ICD‐10 codes (~13%) map to 86 possible HCCs

– Contribute to computation of a patient’s risk score

– Mainly chronic diseases that statistically support increased costs related to care

– HCCs reflect hierarchies among related disease categories


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• The Official Guidelines– Published by the four Cooperating Parties:

• CMS• AHIMA• AHA• NCHS

– Provides guidance and additional information regarding code assignment based off setting type:• Section I – Applicable to all settings (inpatient, outpatient/professional)

• Section II–III – Inpatient guidelines

• Section IV – Outpatient/professional service guidelines

– Weblink: https://www.cms.gov/medicare/coding/icd10/2020‐icd‐10‐cm.html

ICD‐10‐CM Coding Source Authority

Section I and IV are applicable for OP/providers

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Official Guidelines for Coding & Reporting

• The guidelines state,

• Cooperating Parties (designated by the Dept. of Health & Human Services)

– The American Health Information Management Association (AHIMA)

– The American Hospital Association (AHA)

– The Centers for Medicare and Medicaid Services (CMS)

– The National Center for Health Statistics (NCHS)

ICD‐10‐CM Official Guidelines for Coding and Reporting

“These guidelines have been approved by the four organizations that make up the Cooperating Parties for the ICD‐10‐CM”


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Official Guidelines for Coding & Reporting (cont.)

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Official Guidelines for Coding & Reporting (cont.)


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Uncertain Diagnoses – Outpatient and Professional Services

• Do not code diagnoses that are documented as:

– Probable

– Suspected

– Questionable

– Rule out

– Consistent with

– Compatible with

• Rather, code to the highest degree of certainty possible based on documented signs and symptoms

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Definite vs. Uncertain

Uncertain Definite

“Suggestive of …” “Evidence of …”

“Compatible with …” “Treating …”

“Likely …” “Early …”

“Suspicious for …” “Results demonstrate …”

“Probable …” “Significant for …”

“Concern for” “Element of …”

It is important for CDI specialists to understand howthese terms are understood by their specific coding staff


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Coding “Rules” for HCCs

• Medicare Advantage organizations MUST … Ensure the accuracy and integrity of risk adjustment data submitted to CMS. All diagnosis codes submitted must be documented in the medical record and must be documented as a result of a face‐to‐face visit. The diagnosis must be coded according to International Classification of Diseases, (ICD) Clinical Modification Guidelines for Coding and Reporting. <Medicare Managed Care Manual,

Chapter 7>

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• The American Hospital Association publishes a quarterly newsletter called Coding Clinic® for ICD‐10‐CM/PCS, which is generally considered an authoritative source of information on ICD‐10‐CM/PCS coding

ICD‐10‐CM Coding Source Authority


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The Hierarchy of Guidance

Coding Conventions

Official Guidelines

AHA Coding Clinic

If coding professionals feel that published advice is in conflict withcoding guidelines or the ICD‐10‐CM/PCS classification, please submit a specific case example to the AHA Central Office, with potential for submission to the Coding Clinic Editorial Advisory Board for review. <AHA Coding Clinic, Q4 2018>

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The Hierarchical Condition Categories

The basic HCC categories include:

• Infection

• Neoplasm

• Diabetes

• Metabolic

• Liver

• Gastrointestinal

• Musculoskeletal

• Openings

• Amputations

• Cerebrovascular disease

• Blood

• Substance abuse

• Psychiatric

• Spinal

• Neurological

• Arrest

• Heart

• Vascular

• Lung

• Eye

• Kidney

• Skin

• Injury

• Complications

• Transplants


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Medicare Advantage (MA) Program

• Risk adjustment using diagnoses provides more accurate payments for MA organizations

– Higher payments for enrollees at risk for being sicker

– Lower payments for enrollees predicted to be healthier

• Risk adjustment allows CMS to pay plans based on the risk of the beneficiaries they enroll, instead of an average amount for Medicare beneficiaries

– However, the plan must submit the qualifying diagnoses, which are subject to verification

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ICD‐10‐CM – Mapped Into HCCs


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Classification Systems

• There are 9,702 ICD‐10‐CM codes included in the CMS‐HCC version 24 risk adjustment model, equating to about 13% of all possible codes

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Relative Factors Contribute to Individual Risk Score

• Each HCC has an associated value (relative factor)

• Relative factor values are additive

• Individual risk scores are computed based on the sum of the assigned HCC’s relative factors and demographic considerations

– High scores reflect:

• The most complicated patients

• High consumption of resources

HCC HCC DescriptionRelativeFactor

18Diabetes with Chronic Complications

0.302

9Lung and Other Severe Cancers

1.024

189Amputation Status, Lower Limb/Amputation Complications

0.519


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Hierarchy Within the Mental Disorders Condition Category

HCC 60 Personality Disorders

Relative factor 0.309

HCC 59 Major Depressive, Bipolar and Paranoid Disorders


HCC 58 Reactive and Unspecified Psychosis


HCC 57 Schizophrenia


Typically HCCs accumulate each calendar year

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The “Drop” List


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Determining Payment

• The CMS‐HCC risk adjustment models are used to calculate risk scores, which predict individual beneficiaries’ healthcare expenditures relative to the average beneficiary

• Risk scores are used to adjust payments based on the health status (diagnostic data) and demographic characteristics (such as age and gender) of an enrollee

– Risk adjustment factor (RAF) score < 1

• A patient with average Medicare healthcare needs has a RAF score of 1

• The higher the score, the greater the complexity = higher payment

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Monetary Value of Risk Score

• The sum of relative factors assigned to a beneficiary is the risk score, and the average FFS risk score is set at 1.0 in the denominator year

• In payment year 2020, the denominator used to create relative factors for all segments of the CMS‐HCC model is $9,365.50

Example: A patient with a total risk score of 1.000 would lead to a CMS payment to the Medicare Advantage plan of $9,365.50 (approx. $780/monthly) to cover the care delivered in payment year 2020.


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MA Plans Paying Providers – Per Member Per Month (PMPM)

• Describes the average dollar amount paid to a provider (hospital or healthcare worker) each month for each person for whom the provider is responsible for providing services

• Per member per month forms the basis upon which managed care organizations contract payment to providers under capitation revenue stream or cost for each enrolled member each month

– Capitation describes a system of medical reimbursement wherein the provider is paid an annual fee per covered patient by an insurer or other financial source; the aggregate fees are intended to reimburse all provided services

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Translating Risk Adjustment to PaymentNo Diagnoses Incomplete Documentation Complete Documentation

76 year old female, community, aged



Medicaid full benefits 0.593 Medicaid FB 0.593 Medicaid eligible 0.593

CKD stage 4 (HCC 137) 0.260 CKD stage 4 (HCC 137) 0.260

Heart failure (HCC 85) 0.371 Heart failure (HCC 85) 0.371

Diabetes (HCC 19) 0.107Diabetes w/renal complications (HCC 18)

0.340

Hemiplegia (HCC 103) 0.487

BKA status (HCC 189) 0.795

PEG status (HCC 188) 0.742

DM + HF + CKD 0.379 DM + HF + CKD 0.379

RAF 0.593 RAF 1.710 RAF 3.967

Estimated annual payment

$5,550Estimated annual payment

$16,006Estimated annual payment

$37,131

PMPM = $780


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Query Impact PMPM – Let’s Do the Math!

• Provider query results in the addition of HCC 22 (morbid obesity) to a patient’s risk score. Relative factor = .250

• What is the increase in annual payment?

• .250 (Relative factor) x $780 (PMPM) = $195

• $195 x 12 months = $2,340

PMPM = $780

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Condition‐Specific Impact PMPM – Let’s Do the Math!

• Plan: PMPM is $780

• Number of members: 1000

• 20% or 200 patients with diagnosis of morbid obesity (HCC 22 relative factor: .250)

• Record reviews and query increase the capture of morbid obesity, adding on 50 more patients with HCC 22

.250 x 50 patients = 12.50 (relative weight x number of patients) x $780 = $9,750 (12.50 x the PMPM)$9,750 x 12 months = $117,000 increase over one year


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Disclaimer

To help protect your privacy, PowerPoint has blocked automatic download of this picture.

• Although these examples of computing risk scores help demonstrate how efforts can provide impact, they are a bit oversimplified.

• There is a complicated formula used to calculate a risk score that includes a great deal of information we cannot easily provide.

• We offer these examples to facilitate learning but recognize that in your daily practice you cannot easily determine a patient’s risk score.

Nothing is ever simple …

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Worth the Effort!

• Highly weighted diagnoses

– Metastatic cancer sites (cancers in general)

– Malnutrition

– Hemiplegia/paraplegia/quadriplegia

– Tracheostomy status/respirator dependence

– Atherosclerosis of the extremities with ulceration or gangrene

– Pressure ulcers

Medical conditions


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Fundamental Differences: Inpatient vs. Outpatient

• Huge volume difference—thousands of inpatient encounters vs. 100,000’s of outpatient encounters

• Potential for large geographic spread of locations vs. confines of an inpatient facility

• 100’s if not 1000’s of ambulatory providers—far greater than inpatient experience

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Fundamental Differences: Inpatient vs. Outpatient (cont.)

• Inpatient CDI typically not attuned to chronicity (HCC)‐based risk models

• Many (42%) of HCC‐impacted conditions/codes are not CCs or MCCs

• Encoders can flag them as “HCC”—but many don’t know importance

• They often don’t drive DRG assignment—so they are overlooked

• Even if captured—small percent of patients hospitalized in any given year


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• Outpatient: Pre‐review possible

• Outpatient: Post‐encounter changes difficult, concurrent review nearly impossible

• Querying

– Inpatient: Common

– Outpatient: Challenging

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• Querying difficult to accomplish

– Multitudes of providers, some of whom may not see inpatients so are unfamiliar with the concept of a “query” and their importance

– Some providers are part time or contracted

– Enforcing “after the fact” documentation modification may be difficult since not frequently (if ever) done

– Thousands of encounters = large daily accounts receivable


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• Querying difficult to accomplish – No single disease capture can move the needle significantly; not all conditions are created “equal”

• CKD Stage 3 (example, RF .289 → annual ~$2705) vs. Metastatic Cancer (example, RF 2.689 → $25,169)

• Diabetes without Complication (example, RF .105 → annual ~$982) vs. with Complication (example, RF .302 → annual ~$2827)

– The condition may have already been captured during the calendar year

– Patients with chronic disease likely to come back—opportunity to proactively address with next visit (especially early in the year)

– Likely to auto‐release encounters—how to justify holding up an encounter for a reply?

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Building a Program

• A CDI program includes a myriad of people, processes, and technology that must work together to ensure success. Organizations need a well‐rounded individual who can effectively articulate all the pieces: documentation requirements, code assignment, coding guidelines, and quality reporting.

Technology

Process

People

Source: https://www.ahima.org/topics/cdi


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The Role of CDI – Outpatient/Provider‐Focused Settings

• Most common background of CDI specialists

– Clinicians – many are from the field of nursing

• Benefits = strong clinical background helps them identify gaps in clinical evidence and documentation

– Health information management (HIM)

• Benefits = strong background in code assignment, coding guidelines, compliant documentation rules, and accreditation standards affecting timely documentation

CDI is about a skill set, not merely credentials or prior

background

Blended models

work best

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Challenges: Data, Metrics, and Performance

• Information regarding performance at the payer level/ACO significantly lags

– Impact of work not immediately known like inpatient CDI efforts

– Your performance is relative to how well you do compared to others

– Payer information about quality, resource utilization, and risk scores often summarized annually or biannually

– Taking action off of this data is too late

• You have to develop interim proxies that correlate to assess program progress and effectiveness


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Outpatient CDI – Financial Impact

• Payer

• Population # of members within payer for a payment year (retrospective, concurrent)

• Per member per month (PMPM)

• Reviews per/hour

• Revenue = PMPM X % reviewsSource: Courtesy of Essentia Health

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Analytics

• Tracking

Source: Courtesy of Essentia Health

Source: Courtesy of Essentia Health


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Summary

• The task of identifying HCC conditions can be challenging due to the small number (~13%)

• Risk adjustment utilizing HCCs shifts the focus from encounter‐based reimbursement to identifying overall health status during a payment year

• OP CDI efforts will require more FTEs, metrics, and performance standards due to the significant increase in number of encounters

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Thank you. Questions?

[email protected]

In order to receive your continuing education certificate(s) for this program, you must complete the online evaluation. The link can be found in the continuing education section of the program guide.


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