Risk Adjustment Purpose and Challenges...

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Risk Adjustment Purpose and Challenges ExplainedFor Healthcare Professionals


Educa9onprovidedby:BrianBoyce,BSHS,CPC,CPC-I,CRC,CTPRPCEO,Proprietor&ManagingConsultant,ionHealthcare®

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CourseObjec,ves•  Understandthepurposeofthenewriskadjustmentpaymentmethodology.

•  Understanddifferenthowriskadjustmentpaymentsandforecas9ngareestablished

•  Recognizehowdocumenta9oncanaffectpaymentandforecas9ngefforts

•  UnderstandthedifferencebetweenICDcodingguidelinesastheypertaintoriskadjustmentmodels

•  LearnhowriskadjustmentmodelsdifferfromFeeForServiceandothertradi9onalmethods

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PublicHealth“Thescienceandartofpreven2ngdisease,prolonginglife,andpromo2ngphysicalhealthandefficiencythroughorganizedcommunityeffortsforthesanita2onoftheenvironment,thecontrolofcommunityinfec2ons,theeduca2onoftheindividualinprinciplesofpersonalhygiene,theorganiza2onofmedicalandnursingservicesfortheearlydiagnosisandpreven2vetreatmentofdisease,andthedevelopmentofthesocialmachinerywhichwillensuretoeveryindividualinthecommunityastandardoflivingadequateforthemaintenanceofhealth.”•  Adefini9onof“publichealth”byEdwardA.Winslow,a

theore9cianandleaderofAmericanpublichealthinthefirsthalfofthe20thcentury,1920.

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PublicHealthControversy•  PublicHealthcanbecontroversial

– Milkproducersresistedpasteuriza9on– Landlordsresistedbuildingcodes–  Individualfreedomsvs.improvingthecommunity’shealth(smoking,vapes,guns,etc.)

•  Thegovernmenthasaprimarypurposetopromotethegeneralwelfareofitspeople,andthisincludeshealthandsafety

•  Thegovernmentcannotguaranteethisforeveryindividual,butitsroleistomaximizethehealthandsafetyofall

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PayingforHealthcare•  The4mainmethodsofpayingforhealthcareservicesinclude:– Out-Of-PocketPayment–  IndividualPrivateInsurance– Employment-BasedGroupPrivateInsurance– Governmentfinancing

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FeeForServiceIssues•  FeeForService(FFS)paysprovidersaspecificamountofmoneyforaspecificservicerendered(byCPT®procedurecode)

•  FFSisthemostcommonlyusedmethodofreimbursement,butthisischangingwithriskadjustment

•  FFSpaymentsincreasebyincreasingthenumberofservices,tests,visits,procedures,andduplica9onofservices

(NoteCPT®isaregisteredtrademarkoftheAMA)

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FeeForServiceIssues•  FeeForService(FFS)createsfinancialincen9ves:

–  Toprovideserviceswhicharereimbursedathigherrates–  Toinventnewservicesthatarebilledathigherfeesthangold-standardandlesscostlyservices

–  Encouragesoveruseandmisuseofservices

•  FFScreatesaDISINCENTIVEto:–  Deliverservicesatalowerorfairerfeestructure–  Provideservicesthatarenotreimbursed(carecoordina9on,treatmentplanning,webande-visits,etc.

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FeeForServiceIssues•  Providersarereimbursedforwhatwasdone,withnoinsighttothequalityofcareprovided

•  ProviderscanbepaidMOREinreimbursementsforpoorqualitywhichcausesaddedfollowupvisits,oraddi9onaltreatments

•  Manypaymentreformmodelsarelookingatwaystoadjustpaymentforpa9entcarebasedonthepa9ent’sneed(bydiagnosiscode);andwhileincludingqualityofcaremeasures(a>en9onto,andmanagementofchroniccondi9ons)

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Capita,on•  Paymentofafixedamountofmoneythatispaidinadvance,usuallyonamonthlyrate,totheMCO(ManagedCareOrganiza9on)tocoverthedeliveryofallcareandhealthservices–  PMPM=permember,permonth

•  Example:AgreedRateof800.00PMPM–  1,000members=800,000.00permonthforcareofallmembersOR

–  1,000members=9,600,000.00peryearforcareofallmembers

•  TheProblem?–Notallpa9entshavetheexactsamecosts…..Opentowasteofhealthcaredollars

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ModifiedCapita,on•  Keepcurrentes9matesofaveragecostsPMPM,but

a>empttonarrowactualneedorcosts•  Basedonknowndiagnoses•  Thepa9entwithmul9plechroniccondi9onsor

diagnoseswillcostmore(andweknowapproximatelyhowmuchexactly)thanthepa9entwithfewproblemsordiagnoses

•  Thisenablesfinancialforecas9ngforthenecessaryfundingtowardthecareofpa9entsinthepopula9ongroup

=RISKADJUSTMENT

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RiskAdjustment(RA)•  RiskAdjustmentisamethodofanalysisusingdiagnosesforfinancialforecas9ngthathasbeengrowinginpopularityinhealthcare

•  MedicaidplansbeganusingRiskAdjustmentmodelingin1996andhascon9nuedtoupdatethatmodel

•  MedicareAdvantagePlanshavebeenusingtheHCC/RiskAdjustmentmodelsince2004andisexpandingtheprogram

•  CommercialPlansarenowlookingatRiskAdjustmentasavaluablemethodtoiden9fyandplanforhighriskpa9ents

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Popula,on-basedMedicine•  Managingchroniccondi9onsacrossapopula9onofpeoplebytrea9ngallwithaspecificdiagnosiswiththesamegoldstandardsandpreventa9vecaremeasures

•  Healthcarelargelymanagescomplica9onsaretheyariseasopposedtoa>emp9ngtopreventthem

•  Riskadjustmentallowsforawarenessandac9onforthoseinneedofdiseasemanagement

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RA&AffordableCareAct(ACA)•  “TheAffordableCareActcallsforariskadjustmentprogram

thataimstoeliminateincen9vesforhealthinsuranceplanstoavoidpeoplewithpre-exis9ngcondi9onsorthosewhoareinpoorhealth.Riskadjustmentensuresthathealthinsuranceplanshaveaddi9onalmoneytoprovideservicestothepeoplewhoneedthemmostbyprovidingmorefundstoplansthatprovidecaretopeoplethatarelikelytohavehighhealthcosts.Insuranceplansthencompeteonthebasisofqualityandservice,andnotonthebasisofwhethertheycana>racthealthypeople”(Larsen,2011)

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AffordableCareAct(ACA)•  Healthinsurancecoverageisakeyfactorinmaking

healthcareaccessible•  In1980,25millionAmericanswereuninsured,andby

2009,itincreasedto51million(Bodenheimer/Grumbach,2012)

•  Whilemostpeopleobtainemployerplaninsurance,thosewhoseemployerswerenotofferinginsurance,orthosewhowereself-employed,orunemployedwereleqtofendfortheirownhealthcaresolu9ons

•  SmallincreasesinfamilyincomecoulddisqualifypeopleforMedicaidbenefits

•  Between2007-2008,29%oftheUSpopula9on(87Millionpeople)wentwithouthealthinsurance

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AffordableCareAct(ACA)•  TheACAestablishedseveralposi9vemovementsforuninsuredpa9ents.Thesepa9entspreviouslycosthugehealthcaredollarsthroughERandhospitaliza9onvisitsthathadtobewri>enoffbyhospitalsandotherorganiza9ons

•  Thereare4metalcategoriesforpa9entstochoosefrombasedonwhattheycanaffordandwhatplanstheythinktheyneed

•  TherearedifferentplanstypessuchasHMO,PPO,POS,andEPO

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AffordableCareAct(ACA)

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MetalLevel InsurancePays Pa,entPays

Catastrophic <60% >40%Catastrophicplansareavailabletothoseunder30yearsorthoseover30yearswithaqualifyinghardship.

Bronze 60% 40%Bronzeplanshavethelowestpremiums(monthlypa2entcost)butthehighestdeduc2blesandotheroutofpocketcosts.

Silver 70% 30%Silverplansofferthebestvalueforsavingonoutofpocketcosts.Thosewhoqualifyforcost-sharingreduc2onsbasedonincomecanhavealowerdeduc2bleandpayloweroutofpocketcosts.Bestforthosewhodon’texpecttouseregularmedicalservicesanddon’ttakeregularprescrip2ons.

Gold 80% 20%Goldplansareidealforthosewithmoreexpecteddoctorvisitsand/orprescrip2ons.

Pla,num 90% 10%Pla2numplanshavehighermonthlypremiums,butpaymoreforcostsofcare.Idealforthosewithregulardoctorvisitsand/orlotsofprescrip2ons.


AffordableCareAct(ACA)•  TheACAalsoestablishedthatthesecommerciallyofferedplansmustuseariskadjustmentmethodfores9ma9ngopera9ngcosts.

•  Thecostsofpopula9onhealthareacrossapa9entpopula9onbyHIOSID(uniqueissuerID)numberperstate.

•  HIOS(HealthInforma9onOversightSystem)isthefederalgovernment’sprimarydatacollec9onvehicleforhealthinsurance“Exchanges”Marketplaces.Onefunc9onofHIOSistocollectdatafromhealthplanissuersthatwanttobecomecer9fiedqualifiedhealthplan(QHP)issuers.

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PayForPerformance•  CMSdefinesPayforPerformance(P4P)as:

–  “Theuseofpaymentmethodsandotherincen9vestoencouragequalityimprovementandpa9ent-focused,high-valuecare.”

•  ChangesarealreadyunderwaywithHEDIS®measuresandhealthplansthatreviewotherspecificqualityofcaremeasures

•  Combiningreimbursementandfinancialplanningbasedonwhatproblemsthepa9enthaseachyearalongwithexpectedcareneedshelpstopinpointacloseraccuratepaymenttowardqualitycareofchroniccondi9ons

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MedicalManagement•  Improveoverallmemberhealthwhichwillthenreducecostsofcare(preventa9ve)

•  TrackHEDIS®qualitymeasures•  Trackdaysforinpa9entstays•  Createpoliciesfor“medicallynecessary”•  Telephonicandothermanagementofpa9entcases,oqeninareassuchas:– Cardiology,COPD,Cancer,Transplant,etc.

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Quality&U,liza,onManagement•  Reviewandinves9gatequalityini9a9vesandmonitorhealthoutcomes

•  Analyzecostpa>ernsandappropriateuseofresources

•  Meetscostprojec9onswhileensuringqualityofcaredelivered

•  Thesevaluesareassistedthroughriskadjustmentreviewofrecordstoensurequalityismetforspecificillnessesandtoprojectu9liza9onneedsbasedondiagnoses

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RiskAdjustment•  Enableschangestoaddressqualityofcareforchronicillnesses

•  Iden9fiesDiseaseManagementopportuni9es•  Iden9fiesQualityofCareopportuni9es•  Iden9fiesmarkersforU9liza9on

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DifferentPrograms,SameGoals•  WhetherRiskAdjustmentisbeingu9lizedforMedicaid,Medicare,orCommercialpa9ents,themainingredientsusedareDiagnosisCodes(ICDcodes)

•  Diagnosesarecollectedandtheirspecificitydrivesriskscoreorcategoriza9on

•  Theworse,ormoreseriousacondi9on,ordiagnosis,thehighertheriskscoring

•  RiskScoreseitheraffectincomingpaymentorthefuturefinancialforecas9ngforeachpa9ent

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RiskAdjustmentModels

MedicaidCDPSModel

CMSHCCModel

HHSHCCModel

HybridModels

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VariousModelsinRATherearevarioussystemsusingRiskAdjustmentbeyondHCCforMedicareHMOplans.Someoftheseinclude:

Diagnosisbasedprograms:•  ChronicIllnessandDisabilityPaymentSystems(CDPS)-Medicaid•  HierarchicalCo-Exis9ngCondi9ons(HCC-C)–MedicarePartC•  HierarchicalCo-Exis9ngCondi9ons(HCC)–HHS(ACA/Commercial)•  DiagnosisRelatedGroups(DRG)–Inpa9ent•  AdjustedClinicalGroups(ACG)–Outpa9ent

Prescrip,onbasedprograms:•  MedicaidRx(UCSD)•  RxGroups(DxCG)•  HierarchialCo-Exisi9ngCondi9ons(HCC-D)–MedicarePartD

Someadd:Pa,entFunc,onalAbili,es(ADL’s)

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HistoryofCDPSModel•  Startedin1996totailorcurrentriskadjustmentmodelstobe>er

applytoMedicaidprograms.Developmentstartedusingclaimsfromdisabledbeneficiariesinforma9onfromtheDisabilityPaymentSystem(DPS)fromColorado,Michigan,Missouri,NewYork,andOhiobyRickKronickandassociates

•  Updatein2000toincludedisabledandTANF(TemporaryAssistanceforNeedyFamilies)beneficiariesfromCalifornia,Georgia,andTennessee.ThisupgradedprogramwasthenrenamedtheChronicIllnessandDisabilityPaymentSystem(CDPS)

•  In2001,ToddGilmerandassociatesdevelopedtheMedicaidRx(MRX)usingCDPSinforma9on.BasedoncombiningfromtheChronicDiseaseScore(CDS)developedbyVonKorffandassociatesandtheRxRiskmodelbyFishmanandassociates

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HistoryofCDPSModel•  In2008,CDPSandMRXmodelswereupdatedusingMedicaid

datafrom44statesin2001and2002.Anothermodelwasdevelopedemployingbothdiagnos9candpharmacydatacalledCDPS+Rx

•  DatawassuppliedbyCMSfromMedicaidAnaly9ceXtract(MAX)datasystem.MAXdataconsistsofpa9ent-leveldatafileswithinforma9ononMedicaideligibility,u9liza9onofservices,andpaymentsforservices

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Stage1GroupsinMajorCategories(CDPSModel):

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1)  Psychiatric2)  Skeletal3)  CentralNervousSystem4)  Pulmonary5)  Gastrointes9nal6)  Diabetes7)  Skin8)  Renal9)  SubstanceAbuse10)  Cancer

11) DevelopmentalDisability12) Genital13) Metabolic14)  Pregnancy15)  Eye16)  Cerebrovascular17)  AIDS/Infec9ousDisease18) Hematological


HierarchiesinCDPS

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CDPSCategoriesareHierarchicalwithinMajorCategories:Forexample:CardiovascularCategory:(4levels)

-CARVHincludes3Stage1groupsand7diagnoses-CARMincludes13Stage1groupsand53diagnoses-CARLincludes26Stage1groupsand314diagnoses-CARELincludes2Stage1groupsand35diagnoses

VH(weight2.037)=VeryHigh:Hearttransplants,valves,etc.M(weight0.805)=Medium:HeartaCacks,etc.

L(weight0.368)=Low:Heartdisease,etc.EL(weight0.130)=ExtraLow:Hypertension,etc.

*Creditonlyformostsevereform/diagnosisincategory.Eachhigherleveltakesallotherlowerdiagnosesintoconsidera9onalready.


RiskAdjustmentisSpreading•  RiskAdjustmentisamethodofanalysisusingdiagnosesforfinancialforecas9ngthathasbeengrowinginpopularityinhealthcare

•  MedicaidplansbeganusingRiskAdjustmentmodelingin1996andhascon9nuedtoupdatethatmodel

•  MedicareAdvantagePlanshavebeenusingtheHCC/RiskAdjustmentmodelsince2004andcon9nuetomodifytheprogramyearly

•  CommercialPlansarenowrequiredtohaveRiskAdjustmentasamethodtoiden9fyandplanforpa9entsundertheACA(HHSHCCModel)

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DocumentedDiagnoses•  Riskadjustmentispurelyconcentrateduponwhatpa9entshaveascurrentcondi9onsinsteadofwhatwas“done”orperformed”onthepa9ent

•  Codersmustunderstandthatcollec9ngallcurrentdiagnoseswillaffectpaymentsaswellasforecas9ng

•  Diagnosesuncollectedwillbeleqwithnodollarstomanagethosecondi9ons

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SignificancetoProviders•  Providershavefamiliarityno9ngtheseriousnessandseverityofthepa9entstheytreatthroughtheuseofE/Mprocedurecodes

•  HigherlevelE/Mcodesiden9fyseriousencounters,u9lizingmoremedicaldecisionmaking,andarereimbursedatahigherrate

•  InRiskAdjustmentscenarios,theseprocedurecodeshavenosignificance

•  Instead,specificdiagnosiscodescommunicatetheseriousnessofmedicaldecisionmaking

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SignificancetoProviders•  UsingspecificICDDiagnosisCodeswillhelpconveythetrueseriousnessofthecondi9onsbeingaddressedineachvisit

•  Documen9ngthesecarefullyinvolvestwomainfocalpoints:① Iden9fyingtheDiagnosisasaCurrentorOngoing

problemasopposedtoaPMH(PastMedicalHistory)orpreviouscondi9on

② ChoosingthemostspecificDiagnosisCodewhilealsobeingsuredocumenta9onsupportsit

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WhyItMa\ers•  ForMedicareAdvantagePlans

① RiskAdjustment(RA)iden9fiespa9entswhomayneeddiseasemanagementinterven9onsand

② RAestablishesthefinancialallotmentallowedfromCMStowardtheannualcareofeachpa9ent;withmoredollarsallocatedforthosewithhigherriskscores

•  ForMedicaidandCommercialPlans① RiskAdjustment(RA)iden9fiespa9entswhomayneed

diseasemanagementinterven9onsand② RAestablishesthe“overallstateofthepopula9on”by

aggrega9ngdiagnoses;whichassistsinfinancialforecas9ngforfuturemedicalneed

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RiskAdjustmentPayment•  PaymentsinriskadjustmentmodelstaketheideaofanHMOPMPM,andapplythemonthlyvaluetowardknowncurrentdiagnosesbeingmanaged

•  Paymentcanincreaseifallcurrentdiagnosesaresubmi>edproperlyandcandecreaseifdiagnosesarewithheld

•  Eachdiagnosismustbefoundascurrentinatleastoneface-tofacevisitbyanapprovedprovidertobecountedinthemodel

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HowICDCodesLinktoHCCValue•  MostoftheICDdiagnosiscodeswhichareinthemodelsare

chroniccondi9ons•  MedicaidCDPSandHHSHCCModelsrecognizemorecodes•  RiskAdjustmentisbasedonadjus9ngthees9matedriskofeach

pa9entbasedonknowndiagnoses•  PartCHCC(HCC-C)arethosediagnoseswhicharecostlyto

managefromamedicalperspec9ve•  PartDHCC(HCC-D)arethosediagnoseswhicharecostlyto

managefromaprescrip9ondrugperspec9ve•  Somediagnosesarebothtoughmedicallyaswellascostlyfor

prescrip9ondrugmanagementandthereforecarryvalueinbothmodels

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CMSHCCPaymentExample NoCondi,onsCoded(DemographicsOnly)

SomeCondi,onsCoded(ClaimsDataOnly)

AllCondi,onsCoded(ChartReviewbyCer,fied

Coder)76yearoldfemale .468 76yearoldfemale .468 76yearoldfemale .468

MedicaidEligible .177 MedicaidEligible .177 MedicaidEligible .177

DMNotCoded DM(nomanifesta9ons)

.118 DMwithVascularManifesta9ons

.368

VascularDisease notcoded

VascularDisease withoutcomplica9on

.299 VascularDisease withcomplica9on

.41

CHFnotcoded CHFnotcoded CHFcoded .368

Nointerac9on Nointerac9on +DiseaseInterac9onbonusRAF(DM+CHF)

.182

Pa9entTotalRAF .645 Pa9entTotalRAF 1.062 Pa9entTotalRAF 1.973

PMPMPaymentforCare

$452 PMPMPaymentforCare

$743 PMPMPaymentforCare

$1,381

YearlyReserveforCare

$5,418 YearlyReserveforCare

$8,921 YearlyReserveforCare

$16,573


FinancialForecas,ng•  HHSandMedicaidmodelsmaynothaveanimmediate“affectedmonthlypayment,”howevercollec9onofdiagnosiscodeswillaffectforecas9ng

•  Plansa>empttoes9matenecessaryrecoursesandplanaccordinglyforfutureyears

•  Themorethatisknownaboutpa9entsdiagnosestoday,themorespecificforecas9ngmaybecome

•  Ifdiagnosesarewithheld,thentherewillnotbeenoughmoneysetasideto“earmarked”inan9cipa9ontotreattheseillnessesandtheirpossiblecomplica9ons

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CodeForAllDiagnoses•  SomecodersmayconfuseE/Mguidelinesfordiagnosisrepor9ngasitpertainstotheselec9onoftheE/Mlevelofservicecodes

•  WhenchoosingalevelofserviceforE/M,diagnosiscodesshouldonlybecountedtowardthelevelofservicewhentheyaredocumentedhowtheywereevaluatedoraddressed

•  Thisisen9relyrelatedtoselec9onoflevelofserviceforE/Mpurposes,anddoesnotchangethefactthatICDcodingguidelinesinstructcoderstoincludeallcomorbidi9esforeachencounter

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ICD-9GuidelinesICD-9-CM:SecQonIV.DiagnosQcCodingandReporQngGuidelinesforOutpaQentServices:H.ICD-9-CMcodeforthediagnosis,condiQon,problem,orotherreasonforencounter/visit

ListfirsttheICD-9-CMcodeforthediagnosis,condi2on,problem,orotherreasonforencounter/visitshowninthemedicalrecordtobechieflyresponsiblefortheservicesprovided.ListaddiQonalcodesthatdescribeanycoexisQngcondiQons.Insomecasesthefirst-listeddiagnosismaybeasymptomwhenadiagnosishasnotbeenestablished(confirmed)bythephysician.(ICD-9-CM,2013)

K.CodealldocumentedcondiQonsthatcoexist

CodealldocumentedcondiQonsthatcoexistattheQmeoftheencounter/visitandrequireoraffectpaQentcaretreatmentormanagement.Donotcodecondi2onsthatwerepreviouslytreatedandnolongerexist.However,historycodes(V10-V19)maybeusedasecondarycodesifthehistoricalcondi2onorfamilyhistoryhasanimpactoncurrentcare

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ICD-10GuidelinesICD-10-CM:SecQonIV.DiagnosQcCodingandReporQngGuidelinesforOutpaQentServicesG.ICD-10-CMcodeforthediagnosis,condiQon,problem,orotherreasonforencounter/visitListfirsttheICD-10-CMcodeforthediagnosis,condi2on,problem,orotherreasonforencounter/visitshowninthemedicalrecordtobechieflyresponsiblefortheservicesprovided.ListaddiQonalcodesthatdescribeanycoexisQngcondiQons.Insomecasesthefirst-listeddiagnosismaybeasymptomwhenadiagnosishasnotbeenestablished(confirmed)bythephysician.(ICD-10-CM,2013Dra\)J.CodealldocumentedcondiQonsthatcoexistCodealldocumentedcondiQonsthatcoexistattheQmeoftheencounter/visitandrequireoraffectpaQentcaretreatmentormanagement.Donotcodecondi2onsthatwerepreviouslytreatedandnolongerexist.However,historycodes(categoriesZ80-Z87)maybeusedassecondarycodesifthehistoricalcondi2onorfamilyhistoryhasanimpactoncurrentcareorinfluencestreatment

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GeneralRAGuidelines•  Theseprogramsoperateonsimilarrulesandguidelinestoinclude:–  Specificdiagnosesmustbedocumentedinaface-to-facevisitbythetrea9nglicensedprovider(showingcreden9als:MD,DO,PA,NP,OT,CRNA,MSW,andsimilarmaster’slevelproviders)andthedocumenta9onmustbesignedbythetrea9ngprovidertobeaccepted

–  DiagnosesmustbeclearlystatedontheDOS(DateOfService)asacurrentproblemifaudited

–  Diagnosesmustbedocumentedeachyear,ongoingaseachyearisevaluatedwithouthistoricalcontextinfluence

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GeneralDiagnosisCodingRules•  Codeallcurrentdiagnosesthatwereapartofthemedical

decisionmakingofthevisit•  Signsandsymptomsshouldneverbecodedwhenthereasons

forthesymptomsareiden9fied.Forexample,onewouldnotcode“shortnessofbreath”whenadiagnosisofasthmaisknown,nor“heartburn”whenadiagnosisofGERDisknown

•  Olddiagnoseswhichhavebeentreatedannolongerexistshouldnotbecodedunlessthereisa“historyof”codethatcommunicatestheoldcondi9on(mostofthesedonotriskadjust,butmaybevaluabletodiseasemanagementandsuspectlogic)

•  Persistentdiagnosessuchasamputa9ons,OldMI,ostomy,quadriplegia,etc.shouldbere-documentedatleastyearly

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DiagnosisSpecificity•  Documenta9onofdiagnosesmustbespecific•  ThisisparamountnotonlyforRiskAdjustmentprograms,butalsoforICD-10implementa9onefforts

•  Comorbidi9es;Causeandeffectrela9onshipsofdiagnoses;Loca9on;andOthermodifyingfactorsshouldbeclearlydocumented

•  Examplesofcommonlyunder-diagnosedcondi9onsarediabetesandhypertension

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TheWord“Chronic”•  Diagnosisspecificityisofparamountimportanceandinmanydiagnoses,useoftheword“chronic”canchangethechosendiagnosiscode(anditssubsequentriskvalue)

•  Examplesinclude(butarenotlimitedto):– ChronicRenalInsufficiencyvs.Renalinsufficiency– ChronicHepa99sBvs.Hepa99sB– ChronicBronchi9svs.Bronchi9s– Chroniccorpulmonalevs.corpulmonale

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PastMedicalHistory(PMH)•  ThedifferentwaysprovidersdocumentPMHorhistoricaldiagnosesischallengingforcodersandauditorsreviewingmedicalrecords

•  SomeprovidersusePMHasatruelistofolddiagnoses,whileothersusethisasacombinedlistofhistoricalandcurrentproblems

•  Thisdocumenta9ondisparityisalsooqenseeninthechiefcomplaintorHPI(HistoryofPresentIllness)

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Documenta,onMa\ers•  Lackofdocumenta9onmayleavediagnosiscodeswhicharecurrenttomemissedfromtheriskadjustmentequa9on

•  Thesemisseddiagnosiscodesarenotreimbursedorforecasted

•  Themisseddiagnosesalsoaffectpa9entcarebypoten9allyleavingpa9entsoutofdiseasemanagementprogramsofferedbythehealthplanswhentheyarenotawareofthediagnoses

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Documenta,onTips•  Avoidhomegrownabbrevia9ons•  Documentallcauseandeffectrela9onships•  Includeallcurrentdiagnosesaspartofthecurrent

medicaldecisionmakingandcarrythemtothefinalassessmentoftheencounter

•  Eachnoteneedsadate,signature,&creden9al(MD,DO,NP,PA,etc.)

•  Documenthistoryofhearta>ack,anyamputa9ons,hypoxia,statuscodes,ostomy,etc.,whenfactual

•  Onlydocumentdiagnosesas“historyof”or“PMH”whentheynolongerexistorareacurrentcondi9on

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Conflic,ngDocumenta,on•  Providerssome9mesdocumentconflic9ngstatements,

forexample:–  Normalpedalpulsesleqandright&BKA3yearsago–  AcutePancrea99sinPastMedicalHistory&inAssessment–  AcuteRenalFailure&CKDStageIIinAssessment–  HyperthyroidisminROS&HypothyroidisminAssessment–  BreastCancerinPastHistory&RefillofFemarainAssessment–  ProstateCancerinAssessment&RadicalProstatectomyinPMHwithnocurrenttreatment

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ChangesinModels•  Modelschangeyearlyandtheuniversalsuppor9ngfactorwillbeproviderdocumenta9on

•  Pressureulcerschangedtoonlyhavevaluein2014iftheyarestage3orhigher,wheretheypreviouslyalwayscounted-thusdocumenta9onofstagingoftheseulcersbecameparamount

•  OldMIwasdroppedasaPartCandcarriesPartDvalueonly

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ChangesinModels•  ManylungdiseasethatpreviouslyhadnoCvaluenow

carryPartCvalue•  Manynephri9scodesthathadPartCvalueweredropped

toPartDvalueonly•  CKDcodescorrela9ngtoStages4,5,and6(ESRD)carry

PartCvalue&PartDvalue,butallotherCKD(Stages1-3)onlycarrypartDvalue.

•  HypoxemiaandasphyxiaweredroppedaltogetherwithnoCorDvalue

•  Chronicpancrea99scon9nuedtocarryCvalue,butmanyotherpancrea99scodesonlycarryPartDvalue

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Cer,fiedCodersRole1.  Findlegibleface-tofaceencounterswithchroniccondi9ons

documentedandsignedbyanacceptableprovider2.  IncludeallChronicCondi9onsthatarepartoftheMedical

DecisionMakingProcessincludinganychroniccondi9onthatisundercurrenttreatmentwhetheritisthemainreasonforthevisitornot

3.  PastMedicalHistory,ReviewOfSystems,Exam,Assessment&Planareallpor9onsoftherecordthatmayhavevaluablecondi9onsdocumented

4.  Anyrecordwithinthecalendaryearworksfortheen9reyear,soifyoudonotfindanacceptablefirstrecord,keeplookingthroughouttheset

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Documenta,onforRA&ICD-10•  Manydocumenta9oneffortsforriskadjustmentsimultaneouslyassistforcodinginICD-10-CM

•  Makingstridestoimprovedocumenta9onthroughspecificityandclarityhelpsiden9fyvaluable9mespentbyprovidersand

•  Iden9fiespa9entsinneedofdiseasemanagementprograms

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3SmallStepstoTakeNow1.  Begintodocumentlaterality,specifying“leq”or“right”

wheneverapplicable2.  Begintodocumentmanifesta9onsclearly

I.  Thingswhichare“clinicallyintui9ve”arenotallowedtobeassumedbycoders

II.  Complica9ons&manifesta9onsneedtobedocumented3.  Begintoseparatediagnoseswhicharetrulyhistoricalas

opposedtothosewhicharecurrentI.  CurrentdiagnosescarryvalueaspartofMedicalDecision

MakingII.  PMH(PastMedicalHistory)Listsshouldonlycontain

diagnoseswhichhavebeentreatedandnolongerexist

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Ques,ons/Feedback

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Contact

BrianBoyce,BSHS,CPC,CPC-I,CRC,CTPRPCEO,Proprietor,andManagingConsultant2112W.LaburnumAvenue,Suite109Richmond,VA23227www.linkedin.com/in/boycebrian/[email protected]

www.ionHealthcare.com

MedicalRecordAuditandReview-PhysicianPrac9ceOp9miza9on-LeadershipMentoringHealthcareEduca9onandNetworkingforPa9entsandProfessionals-RiskAdjustment

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