risk adjustment purpose and challenges...
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©ionHealthcare,LLCAllrightsreserved.Foreduca9on&discussionpurposes.Permi>eduseviacontractualagreement/purchase.!
Risk Adjustment Purpose and Challenges ExplainedFor Healthcare Professionals
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Educa9onprovidedby:BrianBoyce,BSHS,CPC,CPC-I,CRC,CTPRPCEO,Proprietor&ManagingConsultant,ionHealthcare®
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Nopartofthispresenta9onmaybereproducedortransmi>edinanyformorbyanymeans(graphically,electronically,ormechanically,includingphotocopying,recording,ortaping)withouttheexpressedwri>enpermissionofionHealthcare,LLC.
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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.
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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
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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.
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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
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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/Brian.Boyce@ionHC.com
www.ionHealthcare.com
MedicalRecordAuditandReview-PhysicianPrac9ceOp9miza9on-LeadershipMentoringHealthcareEduca9onandNetworkingforPa9entsandProfessionals-RiskAdjustment
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