RISK ADJUSTMENT – HCC CODING

Presented by: Debra Johnson-Phythian, CCS-P, CRC, CPMA

AHIMA ICD-10-CM/PCS Trainer

HIM Coding and Documentation Educator, Parkland Health and Hospital System

Debra.johnson-phythian@phhs.org 1

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Acronyms

• APM Advanced Alternative Payment Models

• HCC Hierarchical Condition Category

• MACRA Medicare Access & CHIP Reauthorization Act

• MIPS Merit-based Incentive Payment System

• QPP Quality Payment Program

• SGR Sustainable Growth Rate

Risk Adjustment and Hierarchical Condition Category (HCC) coding is a payment model mandated by the Centers for Medicare and Medicaid Services (CMS) in 1997. Implemented in 2003, this model identifies individuals with serious or chronic illness and assigns a risk factor score to the person based upon a combination of the individual’s health conditions and demographic details.

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The individual’s health conditions are identified

by diagnoses that are submitted by providers on

incoming claims.

HCC OverviewHCC takes into account several patient demographic and diagnosis factors that influence overall reimbursement

• Accurate coding is the primary means to ensure accurate payments for the health plan and the providers

• The more complex conditions of patients place them into a risk and severity adjusted category that supports a higher payment by Medicare to the MA plan.

• Who does HCC affect?

• HCC affects all providers under a risk adjustment reimbursement model.

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CMS requires documentation in the person’s medical record by a qualified health care provider to support the submitted diagnosis. Documentation must support the presence of the condition and indicate the provider’s assessment and/or plan for management of the condition.

This must occur at least once each calendar year in order for CMS to recognize the individual continues to have the condition.

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In the Risk Adjustment model there are more than

• 10,000+ ICD-10 codes that map to

• 79 HCC codes in the Risk Adjustment model

MACRA

Goodbye Sustainable Growth Rate (SGR) and Physician Quality Reporting System (PQRS).

Hello MACRA— the Medicare Access and CHIP Reauthorization Act, with its two roads to reimbursement. Each road, however, has its own speed bumps.

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MACRA

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MACRAYour facility or practice can pursue either the merit-based incentive payment system (MIPS) or the alternative payment model (APM). But time is running out to decide which reimbursement path you'll travel to be reimbursed for services provided to Medicare beneficiaries.

That's because reimbursement under either system will be effective in 2019. But data collection and reporting are effective now, started Jan. 1, 2017.

Here's the rub: Failure to select and report measures in 2017 may result in as much as 4 percent payment penalty in 2019. 8

MIPS

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• MIPS takes the place of the Physician Quality

Reporting System (PQRS), Meaningful Use, and the

Value-based Payment Modifier, all of which sunset

Dec. 31, 2018.

• MIPS also adds a new category called Improvement

Activities.

• Under MIPS, instead of each program having its

own penalty, CMS will score providers across all

categories to determine a downward, neutral, or

positive payment adjustment (up to -/+ 4 percent in

2019).

MIPS

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Those that fall into the MIPS payment track will be

scored based on their performance across four key

categories:

• Quality • Cost• Improvement Activities• Advancing Care Information

In 2019, the relative weights of each category will equal:

Quality: 60%; Cost: 0%, Improvement Activities: 15%, and

Advancing Care Information: 25%. However, over time the

Cost category will grow in weight.

PITFALL ALERT

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MIPS: Test for 2017

If you submit a minimum amount of 2017

data to Medicare (for example, one quality

measure or one improvement activity), you

can avoid a downward adjustment

(to avoid penalties)

Who will NOT participate in MIPS?

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5 Simple Rules

13Management: Chart, Patient panel, and Practice policies

Recapture Chronic Conditions: Document and capture all chronic

conditions annually. Best practice “during 1st half of the year”

“sooner than later”

Low Hanging Fruit: Be aware of the highest prevalent and/or

easily overlooked conditions in your specialty.

Identify new conditions: Consult, Radiology, Pathology reports

Be Specific: The more specified code the better the chances for it

to Risk. (example Major depression, unspecified F32.9 does not

but Major depression mild F32.0 does). Documentation retains

reimbursement by supporting claim submissions and correct code

assignments

1. Recapture chronic conditions

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• Conditions we know the patient has

• Conditions in the Problem list

• Conditions treated last year and are still

monitored and/or treated

• Classic chronic conditions that may improve

but still require reporting

• Diabetes

• CHF

2. Capture the low hanging Fruit

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Low

Hanging

Fruit

Atherosclerosis/

PVD

~ 38-41%

T2DM and it’s

Manifestations

~ 25-27%

Mood Disorders

~ 20%

3. Identify new conditions

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• New conditions that develop

• Acute CVA

• Late effects of CVA

• Existing conditions no one identified in the

past

• AAA incidental finding on radiology report

• Review the “body” of radiology reports, not just the

final diagnosis or interpretation

4. Be more specific

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• Assign correct codes for Severity

• Major Depression Disorder

• Mild, Moderate, Severe, in remission

• Diabetes

• With manifestations

• Control status

• CKD

• Stages

• Code remission status

• Depression, Alcohol, Drugs, Leukemia

Document thoroughly

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The Golden Rule …

"If it’s not

documented

by the

physician/provider,

it didn’t happen.”

In healthcare compliance and in coding, there is no deviation from

this principle. We can’t code it if it isn’t documented, and thus we

can’t bill for it.

5. Management

Chart organization

Problem List (EMR may have a feature for HCC)

Medication List

Claim submission

Outside reports

Member Roster

See all new patients as soon as possible

See all patients at least once a year

Use Acute visits

Discharge summaries

Consults19

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PROBLEM LIST:

Problem Description Onset Date Chronic

Atherosclerosis of aorta 04/14/2014 Y

Single major depressive episode, in full

remission

04/23/2015 Y

Chronic kidney disease stage 3 09/04/2014 Y

Essential hypertension 02/01/2013 Y

Pure hypercholesterolemia 02/01/2013 Y

Coronary bypass graft finding 02/01/2013 Y

Primary malignant neoplasm of colon 02/01/2013 Y

Hyperplasia of prostate 02/01/2013 Y

Problem List (not yet mapped to SNOMED-CT®):

Problem Description Onset Date Notes

Rotator cuff rupture, complete 02/01/2013

Diabetes Mellitus Type 2,

Uncomplicated

04/23/2015

History of Colon CA

Z85.038(active or history of)

CAD with CABG? with

Angina?

New guidelines of

“With”

H

H

H

HDiabetic CKD

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Medication Reviewed

Adherence Medication Name Sig Desc Elsewhere Status

taking as directed Anusol-HC 2.5 % rectal cream apply by topical route 3 times every day

to the affected area(s)

N Verified

taking as directed aspirin 81 mg tablet,delayed

release

take 1 tablet by oral route every day N Verified

taking as directed Coreg Oral Tablet 12.5 MG TAKE ONE TABLET BY MOUTH ONE TIME

DAILY WITH FOOD

N Verified

taking as directed FreeStyle Lancets 28 gauge test blood sugars four times daily N Verified

taking as directed FreeStyle Lite Strips test blood sugars fours times daily as

directed

N Verified

taking as directed Lipitor 20 mg tablet TAKE ONE TABLET BY MOUTH ONE TIME

DAILY

N Verified

taking as directed loratadine 10 mg tablet take 1 tablet by oral route every day N Verified

taking as directed nitroglycerin 0.4 mg

sublingual tablet

place 1 tablet by sublingual route at the

1st sign of attack; may repeat every 5 min

until relief; if pain persists after 3 tablets

in 15 min, prompt medical attention is

recommended

N Verified

taking as directed triamcinolone acetonide 0.1

% topical cream

apply by topical route 2 times every day

a thin layer to the affected area(s)

N Verified

taking as directed Vitamin B-12 100 mcg tablet take 1 tablet by Oral route every day N Verified

Angina?

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# Detail Type Description

1. Assessment Type 2 diabetes mellitus without complications (E11.9).

Patient Plan We will see what the lab work shows today.

Plan Orders Hemoglobin A1C to be performed today and Microalb/Creat Ratio, Rndm U to be

performed today.

2. Assessment Atherosclerosis of aorta (I70.0), chronic.

Patient Plan Noted on previous x-rays. He also has PVD, but no sign of claudication. We will continue

to monitor.

3. Assessment Pure hypercholesterolemia (E78.0).

Plan Orders CPK to be performed today, Lipid Profile to be performed today and CMP to be

performed today.

4. Assessment Screening for other and unspecified deficiency anemia (Z13.0).

Patient Plan He appears anemic today, so we will check some labwork.

Plan Orders CBC to be performed today.

Assessment/PlanCC: This 86 year old male presents for hyperlipidemia.

History of Present Illness:1. hyperlipidemia

Risk factors include age over 50. There are no associated symptoms.

Chronic conditions addressed today: Diagnosis Description Code Status HPI Comments

Atherosclerosis of aorta I70.0

Screening Tools

Other Screenings:

Date Instrument Score Severity/Interpretation MDD Classification

02/02/2016 Patient Health Questionnaire (PHQ-2) 0

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This is what

was

captured for

this visit by

Provider

Condition ICD-10 HCC RAF Financial

Demographic 0.400

DM II uncomplicated E11.9 019 0.188

Atherosclerosis of Aorta I70.0 108 0.299

Totals 0.887 $

Condition ICD-10 HCC RAF Financial

Demographic 0.400

DM II uncomplicated E11.9 019 0.188

Atherosclerosis of Aorta I70.0 108 0.299 0.887

MDD, single in full remission F32.5 058 0.330

DM II with complication (CKD-3) E11.22 018 0.368

CAD w/angina (or)Angina unspecified

I25.709I20.9 088 0.141

PVDDM II with PVD

I73.9E11.51 108 0.000

Totals 1.538 $ > double

This is what

was possible

for capture

this visit by

Provider

Frequently overlooked conditions

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• Thrombocytopenia• D69.6

• Other Thrombocytopenia Purpura“Senile Purpura”• D69.2

• Remission status• Substance in remission/ Leukemia in remission

• Ostomies

• Para-thyroidism• Hyper or Hypo/ secondary (CKD patient may have this)

• Malnutrition• Even mild (E44.1)

Frequently overlooked conditions

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• Cachexia• R64 bedridden or recently discharged patients

• Amputations• Z89.4 – Z89.5 Lower limbs (even a toe)

• Crohn's disease• K50.90

• Impaction – ileus• K56.7 Ileus

• K56.41 Impaction

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Summary• EHR

• Accurate problems list

• HCC indicators

• 5 simple rules

• Patient Management

• See every patient a minimum of once a calendar year

• See highly weighted patients during the ½ of the year.

• Claims

• Know how many diagnosis codes can be submitted per claim

• Know how to expand a claim

• MACRA/ MIPS

• Don’t wait

If you don’t have – get one

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HIM and CDI Prepare for Value-based Reimbursement (VBR)

•Making the move to a value-based reimbursement model requires health information management (HIM) and clinical documentation improvement (CDI) professionals to become committed to becoming lifelong learners and educate themselves on every aspect of VBR. There is a tremendous amount to learn, so if you have not already gotten into your own research and education, here are a few action items for you to consider in 2017:

• Learn everything you can about the PPACA, value-based reimbursement, population health, the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA), the Merit-Based Incentive Payment System (MIPS), hierarchical condition categories (HCCs), the Program for Evaluating Payment Patterns Electronic Report (PEPPER), and quality metrics/core measures.

• Make sure you are at the table: know the strategy and roadmap of your organization, and identify projects and tasks to champion.

• Take a deep dive into analytics. Now is the time to demonstrate your expertise. Who better knows the data that is being analyzed to address and measure financial and quality performance for each patient population?

• Create best practices in care coordination, as you will be expanding to reach in-utilization management, CDI, coding, and information management to include ambulatory inpatient post-acute care.

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HIM and CDI Prepare for Value-based Reimbursement (VBR)•

• Get to know your colleagues who manage your payer contracts. You cannot provide adequate CDI or coding expertise and/or quality performance tracking if you do not know the terms in your contracts. Hospitals must operate in the FFS world while attempting to anticipate value-based penalties or incentive bonuses.

• Be the resource for regulatory and payer compliance. Reporting requirements for quality measures are rapidly changing and increasing for every payer. What was once tracking for 30-day readmissions for a small population is now expanded to include many other clinical conditions and payers, and extended to 90-day readmissions. Expect more!

• Partner with your quality department colleagues. Many of today’s value-based incentives and penalties are driven by quality measures. Think of the dynamic team when HIM, CDI, and quality are working together, focused on the quality metrics.

• Champion a renewed effort for an information governance framework in your organization. Given the vital nature of data accuracy, you must be the leader is searching for the “source of truth” of the data used as information in value-based reimbursement.

• Work with your internal IT planning team to create a new integrated financial and clinical platform for a common view of the patient experience and associated information across care settings.

• Understand the role and demands on the physician and build education programs and technology enablement to facilitate physician engagement with all of your “asks.”

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????•

• How many FTE needed

• Consider:

• Mid-level providers

• Medical Assistants

• Special dedicated staff members

• What departments need to be included

• Consider:

• IT/Reporting

• Finance

• Billing/Coding

• Providers and staff

• Education team

• EHR suppliers

WHAT IS YOUR PROVIDER PAYMENT MODEL??????

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Advancing Risk Through Physician Reimbursement

RISK ADJUSTMENT – HCC CODING

www.cms.gov

http://www.curemd.com/PDF/macra-for-dummies.pdf

http://optimityadvisors.com/insights/blog/macra-101-condensed-guide-macra-mips-and-apms

https://www.cms.gov/medicare/quality-initiatives-patient-assessment-instruments/value-based-programs/macra-mips-and-apms/macra-mips-and-apms.html

https://www.cms.gov/Medicare/Health-Plans/MedicareAdvtgSpecRateStats/Risk-Adjustors-Items/Risk2017.html?DLPage=1&DLEntries=10&DLSort=0&DLSortDir=descending

https://www.icd10monitor.com/risk-adjustment-excitement-and-anxiety

Bonnie S. Cassidy, MPA, RHIA, FAHIMA, FHIMSS

https://qpp.cms.gov/mips/improvement-activities

https://www.advisory.com/research/physician-practice-roundtable/members/expert-insights/2016/nine-faqs-on-provider-payment-under-macra

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RISK ADJUSTMENT – HCC CODING

Debra.johnson-phythian@phhs.org32