Hierarchical Coding Categories and Beneficiary Risk · • HCC 120 Seizure Disorders and...

Hierarchical Coding Categories and Beneficiary Risk

Lynette ByrnesUnited Rheumatology

Gloria Johnston, MBA, RN, RHITHealthAdvanta

Copyright © 2018 United Rheumatology

Agenda

Objectives• To introduce the audience

to HCCs

• To discuss the importance of capturing chronic conditions considered in the treatment of Rheumatology patients

• To review actions Rheumatology practices can take to improve performance under cost and other risk-based contracts

Content Slides

Why HCCs Matter to Physician Practices

3 - 7

HCC and Beneficiary Risk Overview 8 - 11

HCC Risk Adjustment Scoring 12- 20

Actions for Rheumatology Practices 21 - 25

Resources and Supplemental Information

28 - 33

Disclaimer

This presentation is intended to serve as an educational tool and

provide a general overview of the topics discussed. We strive for

accuracy but cannot be held responsible for any errors or

omissions in information as denoted on the slides.

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Copyright © 2018 United Rheumatology4


Quality50%

Cost10%

ACI25%

CPIA15%

2018 • Cost represents 10% of the total MIPS score in 2018

• Cost is expected to increase to 30% in the coming years

• Cost is far more difficult to influence than the other MIPS categories

• Tolerance for costs is higher for sicker patients

• In 2018, up to 5 MIPS bonus points available for practices who take care of the sickest patients



• Cost represents 10% of the total MIPS score in 2018

• Cost is expected to increase to 30% in the coming years

• Cost is far more difficult to influence than the other MIPS categories


• In 2018, up to 5 MIPS bonus points available for practices who take care of the sickest patients

Quality30%

Cost30%

ACI25%

CPIA15%

Possibly as early as 2019


MIPS Cost Measures

• Measurement is the average cost to the Medicare program for attributed patients

• Patients are attributed based on plurality of ambulatory evaluation and management services EM

• Two-pass evaluation

▪ Primary care physicians, NPs and PAs

▪ Specialists

• Determined by claims

• Includes all Part B costs

• Compared to historical benchmark for scoring

• Cost impacts MIPS score if at least 20 patients are attributed

Per Capita Cost

• Measurement is total costs of inpatient admission episodes for certain high resource MSDRGs diagnoses, procedures

• Episodes are attributed to the provider who bills the highest Part B professional services during the triggered admission

• Attributed costs include 3 days prior to admission, the inpatient admission and 30 days post admission

• Cost impacts MIPS score if at least 35 episodes are attributed

• Rheumatology rarely exceeds minimum episode threshold

Medicare Spending Per Beneficiary Cost


MIPS Cost Measures

• Measurement is the average cost to the Medicare program for attributed patients

• Patients are attributed based on plurality of ambulatory evaluation and management services EM

• Two-pass evaluation

▪ Primary care physicians, NPs and PAs

▪ Specialists

• Determined by claims

• Includes all Part B costs

• Compared to historical benchmark for scoring

• Cost impacts MIPS score if at least 20 patients are attributed

Per Capita Cost Per Capita Costs Countermeasures

• Ensure every patient has a PCP and sees that PCP once per year

• When appropriate, utilize incident to billing for mid-level providers

▪ Established patients

▪ Existing problem

▪ Established plan

▪ Physician in office at time of service

• Ensure that patient complexity is expressed on the claim to align beneficiary risk with each patient’s health status



Why HCC’s Matter to Physician Practices

• Risk adjustment is not a concept exclusive to Medicare

▪ Private payers use beneficiary risk in risk-based contracts

▪ Medicare Part C Plans Medicare Advantage are funded by Medicare based on beneficiary risk

▪ Medicaid uses HCC risk

• As payment models continue to evolve toward a system whereby providers will be paid for managing populations, risk stratification will be paramount

HCC and Beneficiary Risk Overview

9


What is HCC?

• The HCC risk score reflects the overall health status of the patient and is influenced by demographic factors

• HCCs are derived from ICD codes submitted on Medicare claims

• Diagnoses from all contributing providers are included in the HCC risk score

• The HCC model is made up of 9,531 costly chronic disease ICD-10 codes organized into 189 HCC categories


Top Chronic Conditions That Influence Beneficiary Risk

• Congestive heart failure

• Vascular disease

• Ischemic or unspecified stroke

• Ischemic heart disease

• Specified heart arrhythmia

• Angina

• Morbid obesity

• Rheumatoid arthritis

• Inflammatory connective tissue disease

• Cancer

• Diabetes

• Chronic obstructive pulmonary disease

• Major depressive and bipolar disorders


What is HCC?

• HCCs are wiped clean each January

• Capture comorbidities for all new patients and once per year for established patients

Source: https://www.google.com/search?q=he%27s+cured+pig+cartoon&tbm=isch&source=iu&ictx=1&fir=CY3ehcOIFg8DjM%253A%252CMCyWt0RCwdIiCM%252C_&usg=__cbvWImKAuTCeINaiOzbjxt2MWKE%3D&sa=X&ved=0ahUKEwjvzIXQgrvaAhWE7IMKHeBaCrUQ9QEIKzAA#imgrc=a34zq2F888zLZM:

HCC Risk Adjustment Scoring

13


HCC Risk Adjustment Score

HCC Risk Score

Disease Interactions

Diagnosis

Demographics

HCC Inputs

• Age

• Gender

• Duel enrollment in Medicaid

• Residency status –community vs institutional

• Diagnoses ICD-10 codes

▪ Disease-disease interactions

▪ Disease-disability interactions


HCC Risk Adjustment Score

HCC 1.0

Average Risk Patient

HCC < 1.0

Healthier Patient

HCC > 1.0

Sicker Patient


Beneficiary Risk Adjustment Factor (RAF) Example

Scenario A: 75 year old male

ICD-10 ICD-10 DESCRIPTION HCCHCC

Score

Demographic base factor --- 0.466

M06.09RA without Rheumatoid factor, multiple sites

40 0.423

E11.9Type 2 diabetes mellitus without complications

19 0.104

E66.9 Obesity, unspecified 0.000

I49.9Cardiac Arrhythmia, unspecified

0.000

Disease Interaction: 0

HCC Beneficiary RAF: 0.993

ICD-10 ICD-10 DESCRIPTION HCCHCC

Score

Demographic base factor --- 0.466

M06.09RA without Rheumatoid factor, multiple sites

40 0.423

E11.21Type 2 diabetes with diabetic nephropathy

18 0.318

E66.01 Morbid obesity 22 0.273

I48.2Atrial fibrillation, chronic

96 0.268

Disease Interaction: 0

HCC Beneficiary RAF: 1.748

Scenario B: 75 year old male

Note: Increased specificity does not always increase the score. See supplemental slides for additional information.


Beneficiary Risk Profile

You can gain insight into your historic beneficiary risk profile by reviewing your QRUR

• Overall beneficiary risk compared to all patients nation-wide

• Attributed patient beneficiary risk percentile scores


Sample Rheumatology QRUR Reports

Practice A: 10+ Provider Suburban Rheumatology Practice

Beneficiary Risk 56th Percentile


Sample Rheumatology QRUR Reports

Practice B: Two Provider Rural Rheumatology Practice

Average Beneficiary Risk 69th Percentile


• Retrieve beneficiary details from Table 3B of the QRUR

• Group patients into HCC percentile ranges

• Count patients by HCC percentile range then graph results

Creating an HCC Profile For Your Practice

20


• It is important to do a baseline assessment of ICD coding to determine if current coding practices support accurate assignment of beneficiary risk

ICD Coding Analysis

21


• It is important to do a baseline assessment of ICD coding to determine if current coding practices support accurate assignment of beneficiary risk

ICD Coding Analysis

22

Rheum

Related ICD Count %

Yes 64,393 98.48%

No 996 1.52%

Actions for Rheumatology Practices to Support Appropriate Beneficiary Risk Assignment

23


What Do I Need To Do?

• Document and code comorbidities

▪ All new patients

▪ Established patients once per calendar year

• Be specific when documenting and coding for comorbidities

• Review your current QRUR report to see how you performed historically on cost measures

▪ Cost performance

▪ Beneficiary risk percentile

• Conduct a baseline ICD coding analysis


• It is appropriate to capture and code for a comorbidity when it is

necessary to consider the comorbidity in treating the patient

▪ Disease state

▪ Medications used to manage the comorbid condition

▪ Disease-disease interactions

▪ Impact of planned treatment on the treatment or outcome of the

comorbidity

• Documentation of the comorbidity must reside within the assessment and

plan section of the note in order for the ICD to be assigned

• Do not assign ICDs solely based on past medical history or the problem list

• Be careful about copy/paste/carry-forward for comorbidities. Your

comment pertaining to the comorbidity must reflect current status

Documenting and Coding Comorbidities

25


• These examples, if documented in the Assessment and Plan

section of the note , support reporting the comorbidity:

▪ Hypertension – BP 138/82 today. Well controlled on Atenolol 100mg daily.

▪ Hypertension – BP 168/92 today on Atenolol 100mg daily. Return to PCP for BP check.

▪ Chronic Afib – Asymptomatic today, on Warfarin. Managed by Cardiologist.

▪ Morbid obesity – BMI 41.2 today. Referred to PCP for BMI management.

▪ Diabetic neuropathy legs and feet – Managed by PCP, on Lyrica and Metformin.


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• Here are examples of insufficient documentation to report comorbidities on the claim:

• Past medical history: CHF since 2001

• Vitals: BMI 41.1

• Assessment: Diabetes [no further discussion in the note]


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Questions?

28

Thank You

Gloria Johnston, MBA, RN, RHITChief Health Information Officer

O: 888-507-2988 x102C: 919-723-7938

E: [email protected]

Lynette Byrnes Chair Administrator Committee

VP RCM Management & Practice Workflows

C: 631.334.6296E: [email protected]

Supplemental Slides


Resources

Resource Link

CMS Cost Measures https://www.cms.gov/Medicare/Quality-Payment-Program/Resource-Library/2018-Resources.html

Cost Performance Category Fact Sheet https://www.cms.gov/Medicare/Quality-Payment-Program/Resource-Library/2018-Cost-Performance-Category-Fact-Sheet.pdf

CMS QPP Site https://qpp.cms.gov

Healthcare Update eNewsletters http://healthcareenewsletters.com/articles/20180402.html

Hierarchical condition categories(HCCs) and the shift to value-basedReimbursement [3M whitepaper]

http://multimedia.3m.com/mws/media/1340264O/hccs-and-shift-to-value-based-reimbursement-white-paper.pdf

2017 RAF Score Reference https://www.cms.gov/Medicare/Health-Plans/MedicareAdvtgSpecRateStats/Downloads/Announcement2017.pdf

https://www.cms.gov/Medicare/Quality-Payment-Program/Resource-Library/2018-Resources.html

https://www.cms.gov/Medicare/Quality-Payment-Program/Resource-Library/2018-Cost-Performance-Category-Fact-Sheet.pdf

https://qpp.cms.gov/

http://healthcareenewsletters.com/articles/20180402.html

http://multimedia.3m.com/mws/media/1340264O/hccs-and-shift-to-value-based-reimbursement-white-paper.pdf

https://www.cms.gov/Medicare/Health-Plans/MedicareAdvtgSpecRateStats/Downloads/Announcement2017.pdf


Glossary

• Beneficiary Risk – Valuation assigned to each Medicare patient which is reflective of their health status

• HCC – Hierarchical Condition Category

• MIPS – Merit-based Incentive Payment System

• RAF – Risk Adjustment Factor


RAF Score Reference

33 Source: http://multimedia.3m.com/mws/media/1340264O/hccs-and-shift-to-value-based-reimbursement-white-paper.pdf

• Example from 2017 RAF Score Reference


Diagnosis Specificity and HCCs

34 Source: http://multimedia.3m.com/mws/media/1340264O/hccs-and-shift-to-value-based-reimbursement-white-paper.pdf


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

• HCC 42 Peritonitis/Gastrointestinal Perforation/Necrotizing Enterocolitis

• HCC 120 Seizure Disorders and Convulsions

• HCC 122 Non-Traumatic Coma, Brain Compression/Anoxic Damage

• HCC 125 Respirator Dependence/Tracheostomy Status

• HCC 126 Respiratory Arrest

• HCC 127 Cardio-Respiratory Failure and Shock, Including Respiratory Distress Syndromes

• HCC 156 Pulmonary Embolism and Deep Vein Thrombosis

Disease-Disease Interaction HCC’s

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Hierarchical Coding Categories and Beneficiary Risk · • HCC 120 Seizure Disorders and...

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