Risk Capture & HCC Coding- Cardiovascular Disease - PowerPoint Presentation

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Risk Capture & HCC Coding- Cardiovascular Disease

Momen Wahidi, MD, MBA

Dev Sangvai, MD, MBA

The Shift to Value-Based Care

Market is increasingly shifting toward population health (value-based) contracts

In order to be eligible for incentive payments and avoid penalties, providers must meet

“risk-adjusted” cost benchmarks

set by payers

Commercial payers and Medicare base these cost benchmarks by assessing the

complexity of each provider’s patient population

Value-Based Contracts at DUHS

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Commercial

Coventry CareLink

Cigna

BCBSNC

Medicare Shared Savings Program

Medicare

Medicare Advantage

Aetna

Humana

BCBS-Experience Health

Medicaid

NPCC

Employee Plan

Duke Select

The HCC Model: How CMS Assigns Risk

The

Hierarchical Condition Categories (HCC) Model is a prospective model that uses

medical diagnoses and demographic

data to calculate a risk adjustment factor (RAF) for

every

fee-for service (FFS) and Medicare Advantage (MA) beneficiaryThe model provides for higher payments for sicker beneficiaries Adjustments account for common comorbid conditions that predict higher risk, and thus higher costs (e.g., CHF, COPD, DM, CKD, …)

DXGs to Condition Categories (CC)

DXGs are aggregated into Condition Categories

ICD-10 codes map to Diagnostic Groups (DXG)

Each ICD-10 code maps to exactly one Diagnostic Group (DXG) that are homogenous clinically and in costs

HCCs to CMS-HCCs

Result: 70 CMS HCCs

CCs to Hierarchical Condition Categories (HCC)

CCs are grouped hierarchically based upon severity

CMS-Hierarchical

Condition Categories (CMS-HCCs)

n=70

Diagnostic Groups

(DXGs)

n=68,000+

Condition Categories (CCs)

n=189

Hierarchical Condition

Categories (HCCs)

n=189

ICD-10 Codes

Risk-Adjustment Factor (RAF)

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The HCC Model: How CMS Assigns Risk

A Little More About RAFs (Risk Adjustment Factors)

Each patient’s RAF score includes:

Baseline demographic elements (e.g., age, sex, eligibility status) Incremental increases based on HCC diagnoses submitted on claims from face-to-face encounters with qualified practitioners

The RAF score is based upon a formula that sums the incremental contributions from conditions that increase the patient’s risk of generating increased expenses

RAFs are normalized to “1” (>1 = relatively unhealthy, <1 = relatively healthy)

RAFs are multiplied by a published denominator to determine the predicted annual expenditure per beneficiary

IMPORTANT: Each year, on January 1, a patient’s slate is wiped clean and the patient becomes

“healthy” again—the right diagnosis codes must be reported annually in order to maintain a patient’s risk score!

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A Little More About RAFs (Risk Adjustment Factors)

Sample patient:

77 year old male with CHF, DM without complications, and COPD

Result:

Expected annual expenditure is $12,887 and CMS-HCC risk score is 1.656

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*Figures are for demonstration purposes only and do not necessarily reflect current values

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How RAFs Are Calculated- An Example

Role of the Provider

ICD-10-CM is the official diagnosis code set for risk adjustment paymentThe provider’s role is to fully capture and document all conditions that are treated, managed, or that affect patient care at each visit,

at least once a year

.

This means:

Coding all conditions that coexist at the time of the encounter that affect patient care

Coding each patient to the highest level of specificityEnsuring all diagnoses are appropriately documented/substantiated in the patient’s medical record6Role of the Provider

Isn’t this just a primary care issue?

No, this is a team sport and all providers are impacted by this performanceMedicare:MACRA went into effect on 1/1/2017 DUHS participates in an ACO and, therefore, we are in the APM (Advanced Alternative Payment Models) track of MACRA

Our performance in the ACO (cost benchmarking) affects reimbursement rates on Medicare patientsPrivate payers:We are in a value-based risk contract with BCBS-NC (Blue Premier) and every provider is affected

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How Can We Help the Providers Optimize HCC Coding?

DHTS has employed a MC tool that identifies HCC codes that have not been coded for a patient being seen in our clinics.

When this tool identifies a patient with HCC codes that have not been billed yet in a calendar yearIt presents the provider with options during the clinic encounter.

Add a visit diagnosis

Add diagnosis to problem list

Resolve problem

Do no addressIf provider does not choose one of these options, she not be able to close the encounter

How Can We Help the Providers Optimize HCC Coding?

As a specialist, you will only see codes related to your specialty (e.g. oncology will see codes related to cancer, anemia, etc…)

An earlier version of the tool has been live for primary care since 2017The same tool went live for specialists in 2018

DCI providers have been able to see the tool but have not had a hard stop at the end of the visit to address the suggested diagnoses

Conditions Categories Presented to Cardiology and Cardiothoracic Surgery

Congestive Heart Failure

Cardio-respiratory

failure and shock

Unstable angina and other acute ischemic heart disease

Angina pectoris

Specified heart arrhythmiaVascular diseaseCOPD

Respirator Dependence/ Tracheostomy Status

Complications of Specified Implanted Device or Graft

Major Organ Transplant or Replacement Status

Add Visit Diagnosis

if appropriate-Note this diagnosis is already on Problem List.For diagnoses not on the Problem List, if accurate and appropriate, Add to Problem List

if appropriate.If the Problem is no longer applicable,

Resolve Problem

will remove it from the Problem List right from the BPA.

The BPA shows all HCC designated encounter diagnoses from the last 18 months. If not accurate or not appropriate to add to Problem List, clicking

N/A to Patient will prevent them from showing in the BPA again (ever).BPA Options

Conditions Specific Documentation Opportunities

Ambulatory Documentation and Coding Initiative

Ambulatory Documentation and Coding Operations (ADCO) Team –Helps support clinics and providers through real time education and feedback

Paula Allard, Director Coding Operations

Brittainy McKinney, Manager ADCO

Kimberly Telesco, ADCO Educator

Bobette Haley, ADCO Educator

ADCI Clinical Leadership Team-Dr. John Paat and Dr. Momen Wahidi, PDCDr. John Anderson, DPCPopulation Health Management Office (PHMO)PDC and DUHS ComplianceMany More….13

Ambulatory Documentation and Coding Initiative

Ambulatory Documentation and Coding Initiative

HCC 96 - Specified Heart Arrhythmias

I44.2 Complete atrioventricular blockI47.- Paroxysmal TachycardiaI48.- Atrial Fibrillation and FlutterI49.2 Junctional premature depolarization

I49.5 Sick Sinus Syndrome

Arrhythmias should be coded unless permanently corrected without ongoing pharmacological or mechanistic intervention

Avoid use of acronyms and abbreviations (e.g. AF is sometimes used for atrial fibrillation, but could also mean atrial flutter)

HCC 96 - Specified Heart Arrhythmias

Atrial Fibrillation

When documenting Atrial Fibrillation, be sure to specify:-Type

: Paroxysmal, persistent, chronic or permanent.-Status: Stable, worsening, controlled with medication etc.

Clearly link any medication specifically being used in the treatment of atrial fibrillation

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Concise

treatment plan for atrial fibrillation Example: “Continue amiodarone for atrial fibrillation and follow-up in 3 months”ICD-10 CodeDefinition

I48.0 Paroxysmal

Intermittent, self-

terminating Afib. Terminates spontaneously or with intervention within 7 days.

I48.11 Longstanding Persistent

Afib that has lasted for more than 12 months

I48.19 Other Persistent

Afib that fails

to resolve within 7 days. Often require pharmacologic or electrical cardioversion.

I48.20 Chronic

Less specified version of longstanding, persistent, or permanent Afib

I48.21 Permanent

Persistent or longstanding persistent Afib in which cardioversion is not indicated

I48.91 Unspecified

Physician doesn’t know or doesn’t state type (common new onset Afib)

Atrial Fibrillation

When documenting vascular disease, be sure to specify:

-Site or location affected

-Underlying cause

-Comorbidities (e.g. Diabetes)

-Nicotine use

- Presence of an ulcer or gangrene allows a higher-weighted HCC to be assigned.

Aortic atherosclerosis (I70.0) – incidental finding on radiology reports (e.g. chest CT) and should be addressed by provider if deemed clinically significantAortic aneurysm (I71.4) – Often surveilled with serial abdominal ultrasounds.

HCC 106-108 – Vascular Disease

HCC 106-108 – Vascular Disease

HCC 87-88 - Angina Pectoris

When documenting for Angina be sure to specify:-Type: Stable, unstable, is there presence of a spasm, Prinzmetal etc.

-Treatment Plan: Medications, response to treatment even if condition is stable, prevention efforts etc.Documentation Tips:

Angina that is controlled on medication should be documented and coded (e.g., “Angina stable on Isordil”).

Angina that is resolved with PTCA or CABG and NO pharmacologic Rx prescribed should NOT be documented and coded.

ICD 10 Code examples:

I20.0 Unstable AnginaI20.1 Angina with documented spasmI20.8 Other forms of Angina Pectoris (angina equivalent, stable angina)I20.9 Angina pectoris, unspecified (angina syndrome, Cardiac angina, ischemic chest pain)I25 codes specifying atherosclerosis of coronary arteries (native and graft) with angina pectoris (specified as with spasm, other, and unspecified)

HCC 87-88 - Angina Pectoris

MI and CVA coding in clinic

Accuracy of conditions:

CVA-

Current/active code ONLY if the patient is ACTIVELY having a CVA in the clinic. If they are coming in for a follow up, use the appropriate code. (History of CVA, late effect of CVA, etc.)

MI-

Active code ONLY if the patient had MI within past 4 weeks. After 4 weeks, you code healed/old MI code.Subspecialty narrow focus:Example: EP providers documenting and billing the arrhythmia but not addressing CHF or HTNOpportunities in Cardiovascular Disease