STRATEGIC CODING IN THE ERA OF

MACRA:

Impact of Risk Scoring And Attribution

October 2017

Linda Gates-Striby

Lggates@ascension.org

Disclosures

• Linda Gates-Striby

• Nothing To Disclose

Increasing Our Focus

• The coding landscape in physician practices is changing quickly as healthcare

shifts towards “value-based care” and quality payment models.

• Coding specificity, accuracy, and compliance is having an increasing impact on

Medicare reimbursement in the years to come.

• We MUST pay greater attention to ICD-10 coding.

• Coders and Clinicians need to understand the specifics required of our “new

world” of value and ensure we are documenting and coding in the most

accurate and appropriate manner.

• Forward thinking practices and coders are already focusing on HCC/RAF and

many are beginning CDI type efforts in the outpt environment

MACRA Basics

Does Anyone Really Understand

MACRA?

ACC MACRA HUB

Registry Participation ACC’s PINNACLE Registry

or Diabetes Collaborative

Registry can help you fulfill

MIPS requirements for

Quality, Improvement

Activities and Advancing Care Information.

Free participation

Compatible with over 85 EHRs

Monthly performance and benchmarking reports

Should I Do Anything Different?

• MIPS and Risk Adjustment HCC coding is the system used for Risk Adjustment under MIPS.

• Diagnosis codes (ICD-10) are assigned a weight that measures patient acuity. Medicare expects that patients with higher HCC scores will consume more healthcare dollars and have worse outcomes.

• If 60% of the MIPS score for providers is going to come from risk adjusted quality and resource use scores, it is critically important to accurately reflect the acuity of our patient population.

• Doing so will help quality and cost scores to accurately reflect the excellent care provided by physicians.

• Your diagnosis coding is about to become much more important, both for immediate fee-for-service reimbursement and over the following

What Are The MIPS Elements?

PQRS Program

Value Based Modifier Program

Meaningful Use Program

Medicare Shared Savings

Program

Merit Based

Incentive Program

(MIPS)

2017 First Reporting

Year, effects 2019

Payments

MIPS Financial Impact

Page 9

MIPS Scoring

Page 10

A.K.A.

Meaningful

Use

HCC Impact on Sample Contracts

National Quality

Benchmarks

MSSP/ ACO Benchmark

Anthem MA (PMPM and

Savings)

Page 11

Simplified Version

• Using an actuarial tool to plug in a person’s current health conditions and apply data collected since approximately 2004 about those conditions.

• Now apply a forecasting perspective to estimate future financial implications, and more importantly, to predict future patient care management needs and plan for potential complications.

• The thought is to attempt to level the playing field and allow each individual’s health to be reflected as it truly is.

• We each carry a level of risk. The healthiest of us – those without any chronic health conditions, are at the lower end of the risk scale.

• With the addition of some conditions, the risk increases.

• Add even more conditions and the risk continues to rise – and so will that person’s health care needs & “resource use”

Diagnosis Coding – The New RVU?

• Consider that CMS and other payors generally use data that is

two years behind when they implement changes

• What we are submitting now is setting us up for payment

changes in the future in a number of ways – what we don’t know

for sure is exactly how many ways

• We need to be as specific as possible – and present a true and

accurate picture of our patient’s severity

• We need to be thinking about this at each encounter as we

never know for sure if we will see the patient again in the year

Why Should I Care?

• For CMS “MACRA” replaces the flawed SGR and is

scheduled to go into effect in 2019

• Claims submitted in 2017 will be used in the 2019

implementation

• Commercial payors such as Anthem, United, Aetna, Cigna, Humana and

others are also using claims data to determine their “Value” or “resource

use” scores for individual providers

Where Does Documentation & Coding Fit In?

• Builds the “language” to describe overall patient care

• Creates the connections of independent medical conditions

• Requires you to bring “uniqueness” and specificity to each patient encounter

• Rationalizes coverage for increasing complex patients

• Objectifies the claim “my patients are the sickest”

• Will provide the context to use “big data” to plan and execute Population Health – Predictive Analytics

How Does Risk Adjustment Impact You?

• Risk adjustment facilitates more accurate comparisons by accounting for

differences in patient case mix

• Risk adjustment plays a role in quality rankings by estimating an expected

performance on a quality or cost measure based on the case mix and

then comparing that estimate to the actual performance.

• The essential component of these measures is a ratio of actual-to-

expected performance, where the expected performance is reflective of

the clinical complexity

RAF - Risk Adjustment Factor

What Do We Mean By RAF?

• Used to access the clinical complexity of a patient and predict the burden of illness for individuals and populations

• Acts as a multiplier when calculating CMS payments in a year

• Factors into bidding and payment of MA plans

• Focuses on identification, management, and treatment of chronic conditions

• Provides a payer with additional resources to manage the health of a riskier population

Additional Resources

• More accurate coding leads to improved practice modeling and stratification of a population

Better Analytics

• Encourages regular outreach to patients who aren’t coming in regularly but may need follow-up

Encourages Regular

Management

How Are Payments Or Expected Costs

Calculated?

HCC – Hierarchical Condition Category 101

The Least You Need To Know

Model Is Here To

Stay In One Form

Or Another

Goes To A Blank

Slate Every

Calendar Year

Subject To Data

Validation

Sampling

The HCC & RAF Connection 79 to 3,000

The CMS model is

accumulative – a patient

can have more than one

HCC category assigned to

them. Some categories

override others and there is

a hierarchy of categories.

The HCC must be captured

using claims data every 12

months.

The HCC must be documented and supported in the medical record and this can be subject to a “data validation” review

The plan must submit the “one best medical record” that supports the patient’s HCC scoring if identified for validation.

The HCC model has

been the basis for

reimbursement to

MAO plans since 2004.

Due to it’s proven

success in predicting

resource use it is now

being used to

determine much more

and by more payors.

Patients with multiple HCCs in a single category will be scored at the highest level

*Additional risk is scored when certain conditions coexist

When multiple conditions are present in the same patient a higher score will be used . i.e. CHF & COPD or CHF and CRF

Sample Encounter And The Accumulative Impact

HPI

•Mickey comes in for a follow up of his CHF.

He also has DM and CRF stage IV.

A/P

1.Chronic Systolic HF – Currently Stable, to

continue current dose of Lasix

2.Type II DM and Stage IV CKD – Stable,

scheduled to see nephrologist in 2 weeks

Sample Patient - Mickey M

Financial Metrics

All 3 conditions result in an extra $816 per month + $9,792

Reporting CHF only would provide an extra

$312 per month

+$3,744

Add’l for 12

months

HCC/RAF Scoring

This pt has 3 HCC categories, all three

codes risk adjust and would represent an

accumulative “scoring”. This Pt’s RAF

Score would be .960

If the anticipated monthly cost was $850

this now becomes $850 x .960 = $1,666

What If Mickey Also Had A Skin Ulcer? HCC Condition RAF

Score

HCC

157

Pressure ulcer of skin

with necrosis through to

muscle tendon or bone

2.551

HCC

158

Pressure ulcer of skin

with full thickness skin

loss

1.371

HCC

161

Chronic ulcer of skin

except pressure

.549

HCC

162

Severe skin burn or

condition

.422

A patient with HCC 157 will be spending $2,168 more each month (2.551 X $850)

A patient with HCC 158 will spend $1,165 more per month (1.371 X $850)

A patient with HCC 161 will spend only $466 more per month (.549 X $850) and

A patient with HCC 162 will spend only $358 more per month (.422 X $850).

What Does Coding Correctly Mean?

Documentation & Coding

Humana Offer

“Don’t Miss” Chronic Conditions

• DM & complications

• CHF

• COPD

• A Fib

• Morbid Obesity

• HTN & complications (HTN alone does not have a RAF score)

• Major Depression

• PVD

• Malnutrition

Use ICD-10 Appropriately I.E. as specific as possible

Provider’s role is to accurately capture the conditions that are treated, managed, or impact care

Coded conditions must be documented – i.e. “MEAT” – manage, evaluate, assessment, treatment plan

Accurate coding and documentation is critical to risk scoring and our future

What Does And Does Not Risk Adjust Does

• CKD stage IV & V

• Morbid Severe Obesity

• Angina, Unstable Angina

• Complete AV Block

• ASCVD with intermittent claudication

Seeing a pattern?

Does Not

• CKD Stage I, II, and III

• Obesity Unspecified

• Chest Pain

• AV Block 1st or 2nd degree

• ASCVD unspecified

Don’t code to a greater

degree than you

document!

“MEAT”

Documentation & Coding Guidelines

Access all

conditions that

coexist that day

are treated,

managed, & affect

patient care

Consider, document

and report the

disease as

accurately as

possible – use

specificity codes

Ensure you are

addressing and

reporting/coding

these conditions at

least once per

calendar year

Per ICD-10 Official Guidelines for coding and reporting “Code

all documented conditions that coexist at the time of the

encounter/visit, and require or affect patient care treatment or

management.”

Capturing Comorbidities Is Essential

• In our Fee-for-Service model we have gotten used to making sure a diagnosis justifies medical necessity for the CPT codes on a claim.

• Many practices stop short of documenting and capturing comorbidities that show complicated medical decision making, treatment plans, and more accurately reflect the condition of the patient.

• These comorbidities have not been required for proper reimbursement, and many practices say that they do not always code comorbidities

• In contrast – the majority of practices indicate that their physicians do a good job of documenting these comorbidities in the note.

• The change may not be one of documentation, but more of a coding change that is needed. Practices who want to more accurately reflect patient acuity need to do a better job of coding comorbidities

Documentation Guidelines • Chronic condition ______ is stable will continue with current treatment

regime

• Chronic condition ______ now requires the following changes in

management….

• Chronic condition ______ is being managed by specialist______ and

the patient is scheduled for follow up on _______

29

More is More?

Statements such as this will support your consideration on that

visit, and adding the code to your claim.

This could also support a “risk” element in your medical decision

making **

Top Conditions That Are Represented in

HCC Categories and RAF Scores • Diabetes with complications

• Morbid obesity

• Multiple cancers

• Cirrhosis & end stage liver disease

• Protein-calorie malnutrition

• Rheumatoid Arthritis

• Drug and Alcohol dependence

• Major depressive, Bipolar, & paranoid disorders

• Quadriplegia & paraplegia

• CHF

• Acute MI

• Unstable angina & acute Ischemic disease

• Atrial flutter and fib

• Vascular disease with complications

• COPD

• CKD – stage 4, 5, dialysis status

• Parkinson’s

• Cerebral palsy

• Hemiplegia/hemiparesis

Sample Code Reports

The Coding Path To Readiness ? • Continue to educate and

reinforce with providers the importance of accurately coding the patient’s condition(s)

• Identify providers with high use of unspecified codes and low use of typical chronic conditions

• Share individual provider RAF scoring patterns

• Begin to monitor high cost of care numbers per provider and rule out underlying coding issues

• Build accurate HCC profiles on assigned patients

• Get patients in for their annual wellness visits (PCP) • Reaffirm old dxs

• Establish appropriate new dxs

• Clarify & code disease interactions & relationships

• Specify the unspecified as soon as you know

Areas To Review

• Show current state of disease process for accurate reporting: • Acute, chronic, compensated, decompensated, exacerbated

• If ruled out/resolved, state it

• Cause of condition should be reported, if known

• Show relationship in diagnoses to other disease process through linking conditions’, providing linking terms between diagnoses, such as: • With

• Due to

• Caused by

• Secondary to

Helpful White Paper

More Resources • HCC University – excellent resource with lists of all HCC

categories and weight of each code available for download

• CMS MACRA webinar series (https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/Value-Based-Programs/MACRA-MIPS-and-APMs/Quality-Payment-Program-Events.html)

• MGMA MACRA Resource Center (http://www.mgma.com/government-affairs/issues-overview/medicare-payment-policies/macra)

CMS Attribution Of Beneficiaries

• The Value-Based Payment Modifier (Value Modifier) Program evaluates the performance of solo practitioners and groups, as identified by their Medicare Taxpayer Identification Number (TIN), on the quality and cost of care they provide to their Medicare Fee-for-Service (FFS) beneficiaries. The Centers for Medicare & Medicaid Services (CMS) disseminates this information to TINs in confidential Quality and Resource Use Reports (QRURs). For each TIN subject to the Value Modifier, CMS also uses these data to calculate a Value Modifier that adjusts the TIN’s physicians’ Medicare Physician Fee Schedule payments upward, downward, or not at all, based on the TIN’s performance.

• In assessing performance on several of the quality and cost measures included in the QRUR and Value Modifier, CMS uses a two-step attribution process to associate beneficiaries with TINs during the year performance is assessed. The attribution methodology determines which beneficiaries are included in the calculation of each TIN’s quality and cost performance and payment adjustment under the Value Modifier.

If You Have Seen One Form of Attribution…..

CMS Attribution Basics

Attribution Depends on Who Provides “Plurality of Primary Care Services”

Medicare uses a two-step process for determining which patients are tied to a provider

and who will constitute the spending-per-beneficiary and claims-based-quality-measure

denominators.

Medicare is now aligning the methods used in ACO patient attribution with the VBPM

patient attribution – This is intended to create consistency between Medicare’s Value-

Based Payment initiatives.

Beginning in 2017 CMS is also

reviewing APPs such an NP, PA, CNS in

the equation for “Plurality of Services”

Team Based Care

Medicare’s 2 Step Approach

Step 1

Step 2

Step 1: Beneficiaries are assigned to the primary care provider (whether physician,

NP, PA, or CNS) who provided the “plurality of primary care services” to the patient,

as measured by allowed charges – i.e. E/M visits .

But what if they were not seeing a PCP?

Step 2: Beneficiaries are assigned to the practice whose non-primary care

providers (i.e. specialists) provided the “plurality of primary care services”

to the patient, as measured by allowed charges – again – E/M visits

But wait… there’s more: “Primary Care Services” may include services that

a specialist provides, but which are unrelated to the conditions and events

that Medicare is tracking.

Specific Patient Names

Are Available

Take The Time To Do Deeper Dive What About The PCP Provider?

Is There A PCP Provider?

You don’t have to

guess - review your

QRUR report- it lists all

of the patient’s

Shows your total

patient cost – and from

where

Were these episodes

you controlled?

Are there other provider

costs that are hurting

your score?

This can be an eye

opening experience!

The data is based on Medicare

claim data

If there are providers not in your

network – this may be one of the

only ways you will see their costs

You may see the patient has

providers they are seeing that you

were never made aware of

The ACC has provided extensive web

sessions on how to use your QRUR reports

One thing specialists can do is consider

confirming that the patient has a PCP

If they have a PCP – make sure they are seeing

them at least once per calendar year

Finding out a patient with COPD for example

is assigned to you can actually signify a gap in

care – and no one may be managing that

condition.

A quick review may not only avoid attribution

errors – but could lead to better patient

outcomes all around around

Who Are You Accountable For?

Metrics Are Patient Centered

One way to help with appropriate attribution is is to ensure the PCP provider is conducting and billing for the Medicare Annual Wellness visit

This can help ensure that the patient stays connected to the PCP both clinically and through the attribution process

This also provides an opportunity to ensure that chronic conditions are addressed and hopefully coded and billed once per calendar year (HCC & RAF Scoring

This also provides an opportunity to ensure that chronic conditions are addressed and hopefully coded and billed once per calendar year (HCC & RAF Scoring)

In a P4P world it doesn’t always matter if you are the specialist or the PCP - you need to know what care your patients are receiving. You simply can’t stop with providing the best possible care in your field and sending patients out the door.

If You Remember Nothing Else….. • The claims we are submitting in 2017 will be used in

the 2019 implementation • How many patients have you already seen this year that you might

not see again before year end? – Did you code to the specificity you should have?

– Did you report the chronic conditions you evaluated that impacted your decisions?

2017 Claims Can Determine Your Fate

Don’t Get Caught Off Guard

PINNACLE and

Diabetes Collaborative

Registries

2017 Ohio-ACC Annual Meeting

PINNACLE: Largest outpatient CV registry in the U.S.

Founded in 2008 with more than 9,000 providers submitting data

from 3000 office

locations

* Data as of August 2017

Over 50 million records from 12 million unique patient lives to-

date

ACC2017 ACC2017

Diabetes Collaborative Registry Footprint to date

Confidential. Not for Distribution. (c)2017

7232 contracted providers from 2531 practice locations

across 47 states in the United States

As of August 2017 N = 1,278 sites with signed contracts * many are practices with multiple geographic locations

Registry Participation ACC’s PINNACLE Registry

or Diabetes Collaborative

Registry can help you fulfill

MIPS requirements for

Quality, Improvement

Activities and Advancing Care Information.

Free participation

Compatible with over 85 EHRs

Monthly performance and benchmarking reports

QCDR Participation

• As a QCDR, the registries submit data for the MIPS Quality category,

which accounts for 60 percent of the overall MIPS score.

• You can also earn bonus points for reporting additional

outcome and high priority measures!

• It’s easy to use and simplifies MIPS reporting. Data is captured

seamlessly through the electronic health record, and the ACC

transmits it to CMS for you.

• Avoid penalties for non-participation in MIPS by making reporting

easy and convenient.

Merit-based Incentive Payment System (MIPS) Reporting • Quality (60% score)

– 19 measures available

– ACC will submit on behalf or providers with consent

• Improvement Activities (15% of score) – 7 Registry Favorites

– Self-attestation tool via dashboard

• Advancing Care Information (25% of score) – Self-attestation tool via dashboard

Successful Reporting • Approved by CMS as QCDR for program years 2017, 2016, 2015

and 2014

• 2016 PQRS • Reported for over 2200 providers including:

• 26 Group Practices

• 16 measures available