Alice B Torrez MHA CPC Educator Coding and Documentation Health Information Management University of New Mexico Hospital 2 View of Risk Adjustment Are my patients sicker These numbers are not right ID: 930822
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Slide1
CMS-Hierarchical Condition Codes and Risk Adjustment
Alice B. Torrez MHA, CPCEducator Coding and DocumentationHealth Information ManagementUniversity of New Mexico Hospital
Slide22
Slide3View of Risk Adjustment
Are my patients
sicker?
These numbers are not right…
Provider
Payer
I documented the services…
What are HCCs?
Why can’t they document correctly?
Was that really a stroke in the office?
Diabetes does not cure itself
Diagnosis needs greater specificity
3
Proving medical necessity through increased specificity in documentation
Slide4HCC SourcesHospital
InpatientException: Skilled nursing facilities and hospice facilities are considered non-covered facilities, so their diagnoses cannot influence HCC
calculations
H
ospital Outpatient
Exception
: Freestanding ambulatory surgery centers (ACS), home health, and
freestanding dialysis centers
are
not
acceptable sources for diagnoses
M.E.A.T. - clinical documentation Physician S
ettingsThis includes data collected from non-network as well as network physicians obtained in a face-to-face visitException for face-to-face: Pathology services (professional component only)
4
Slide5CMS Hierarchical Condition Categories
Purpose/objectiveTo compensate health insurance plans (Medicare Advantage) for enrollees’ health level of riskRisk adjustment applied to quality outcome measures
Prospective in nature
Reviews health status in a base year to predict costs in the next year
Documentation translated into the appropriate ICD-10-CM diagnosis code
HCC, MCC, CC – how do they relate?
5
Slide6Documentation Best Practice
Acuity of Disease – Mild, Moderate, Severe,
Acute, Chronic
Type and Cause of
the condition
As Indicated by “______” -
Supports Medical Necessity
Infectious Agent –
C
ausal Organism
Linking –
“Due to” “Secondary to” “Related to”
Anatomical Site or Region
Laterality –
Right, Left, BilateralEpisode of Care –
Initial, Subsequent, SequelaeDrug, Tobacco, ETOH –
Use, Abuse, or DependenceUnderlying Conditions
Disease Manifestations
27
Slide7Hierarchical Condition CategoriesMedicare Risk Adjustment Factor (RAF) payment model introduced by Centers for Medicare and Medicaid (CMS) in
2004ICD-9 affected 3,6000 codesICD-10-CM > 9,000 codesThe goal is to pay Medicare Advantage Plans and Prescription Drug Plans
accurately and fairly based on SOI/Complexity of care needed ($)
Demographics
Health status
The Risk Adjustment model measures the disease burden
Provider Documentation
7
Slide8Diagnosis Code ValueIn RAF diagnosis codes carry a risk adjustment value, dx are weighted much like DRGs
Similar to the concept of RVU assigned to CPT codesThe more severe or complex a diagnosis, the higher its value
If two or more diagnosis are documented from the same category, the diagnosis that is more severe or complex will trump any others
8
Slide9Individual Risk Score Each member (Medicare Beneficiary) is assigned a Risk Adjustment Factor (RAF)Based on the specificity of the chronic condition
& based on the number of HCCs documentedThe highest scores reflect: The most complicated patients
Highest patient severity of illness
Highest consumption of resources
9
Slide10Measuring Risk-Estimating CostsDemographicsAge
SexDisabilityLiving circumstancesDual eligibility Status (MC/Mcaid)HistoryClaims data (Parts A &B)
Reported illnesses
Reported diagnoses
=
Hierarchical Condition
Categories
10
Slide11CMS Hierarchical Condition CategoriesLimited to
Diagnoses More than 9,000 codes - map
to
79 HCC (9000+ codes)
Mainly
chronic diseases that statistically support
increased
costs
related
to care HCCs reflect hierarchies among related disease categories
11
Slide12Common Missing or Incomplete Diagnoses
Diabetes (manifestation, related to…)Depression (major, recurrent, episodic, in remission)Renal failure (manifestations), stage 4, stage 5
MI (old)
Angina pectoris (decubitus, prinzmetal-with documented spasm)
Cancers coded as “history of” rather than active
Drug or alcohol dependence
Malnutrition (mild, moderate, severe, protein calorie)
Atrial fibrillation (chronic, paroxysmal, persistent, typical, atypical)
Amputations (current, acquired, history of)
12
Slide13CMS Chronic Conditions (79)13
HCC1 = HIV/AIDS
HCC82 = Respirator Dependence/Tracheostomy
HCC2 = Septicemia, Sepsis, Systemic Inflammatory Response Syndrome/Shock
HCC83 =
Respiratory
Arrest
HCC6 = Opportunistic Infections
HCC84 = Cardio-Respiratory Failure and Shock
HCC8 =
Metastatic Cancer and Acute Leukemia
HCC85 = Congestive Heart Failure
HCC9 = Lung and Other Severe Cancers
HCC86 = Acute Myocardial Infarction
HCC10 = Lymphoma and Other Cancers
HCC87 = Unstable Angina and Other Acute Ischemic Heart Disease
HCC11 = Colorectal, Bladder, and Other Cancers
HCC88 = Angina Pectoris
HCC12 = Breast, Prostate, and Other Cancers and Tumors
HCC96 = Specified Heart Arrhythmias
HCC17 = Diabetes with Acute Complications
HCC99 = Cerebral Hemorrhage
HCC18 = Diabetes with Chronic Complications
HCC100 = Ischemic or Unspecified Stroke
HCC19 = Diabetes without Complication
HCC103 = Hemiplegia/Hemiparesis
HCC21 = Protein-Calorie Malnutrition
HCC104 = Monoplegia, Other Paralytic Syndromes
HCC22 = Morbid Obesity
HCC106 = Atherosclerosis of the Extremities with Ulceration or Gangrene
HCC23 = Other Significant Endocrine and Metabolic DisordersHCC107 = Vascular Disease with Complications
HCC27 = End-Stage Liver Disease
HCC108 = Vascular Disease
HCC28 = Cirrhosis of Liver
HCC110 = Cystic Fibrosis
HCC29 = Chronic Hepatitis
HCC111 = Chronic Obstructive Pulmonary Disease
HCC33 = Intestinal Obstruction/Perforation
HCC112 = Fibrosis of Lung and Other Chronic Lung Disorders
HCC34 = Chronic Pancreatitis
HCC114 = Aspiration and Specified Bacterial Pneumonias
HCC35 = Inflammatory Bowel Disease
HCC115 = Pneumococcal Pneumonia, Empyema, Lung Abscess
HCC39 = Bone/Joint/Muscle Infections/Necrosis
HCC122 = Proliferative Diabetic Retinopathy and Vitreous Hemorrhage
Slide14CMS Chronic Conditions (79)14
HCC40 = Rheumatoid Arthritis and Inflammatory Connective Tissue Disease
HCC124 = Exudative Macular Degeneration
HCC46 = Severe Hematological Disorders
HCC134 = Dialysis Status
HCC47 = Disorders of Immunity
HCC135 = Acute Renal Failure
HCC48 = Coagulation Defects and Other Specified Hematological Disorders
HCC136 = Chronic Kidney Disease, Stage 5
HCC54 = Drug/Alcohol Psychosis
HCC137 = Chronic Kidney Disease, Severe (Stage 4)
HCC55 = Drug/Alcohol Dependence
HCC157 = Pressure Ulcer of Skin with Necrosis Through to Muscle, Tendon, or Bone
HCC57 = Schizophrenia
HCC158 = Pressure Ulcer of Skin with Full Thickness Skin Loss
HCC58 = Major Depressive, Bipolar, and Paranoid Disorders
HCC161 = Chronic Ulcer of Skin, Except Pressure
HCC70 = Quadriplegia
HCC162 = Severe Skin Burn or Condition
HCC71 = Paraplegia
HCC166 = Severe Head Injury
HCC72 = Spinal Cord Disorders/Injuries
HCC167 = Major Head Injury
HCC73 = Amyotrophic Lateral Sclerosis and Other Motor Neuron Disease
HCC169 = Vertebral Fractures without Spinal Cord Injury
HCC74 = Cerebral Palsy
HCC170 = Hip Fracture/Dislocation
HCC75 = Myasthenia Gravis/Myoneural Disorders, Inflammatory and Toxic Neuropathy
HCC173 = Traumatic Amputations and Complications
HCC76 = Muscular Dystrophy
HCC176 = Complications of Specified Implanted Device or Graft
HCC77 = Multiple Sclerosis
HCC186 = Major Organ Transplant or Replacement Status
HCC78 = Parkinson's and Huntington's Diseases
HCC188 = Artificial Openings for Feeding or Elimination
HCC79 = Seizure Disorders and Convulsions
HCC189 = Amputation Status, Lower Limb/Amputation Complications
HCC80 = Coma, Brain Compression/Anoxic Damage
https://www.cms.gov/Medicare/Health-Plans/MedicareAdvtgSpecRateStats/Risk-Adjustors-Items/Risk2014.html?DLPage=1&DLEntries=10&DLSort=0&DLSortDir=descending
Slide1515
Slide16The Process16
Care is delivered to the member
At
a
face-to-face encounter
Care and diagnosis are documented
In the chart/progress note
ICD-10-CM codes are submitted
based on f-t-f encounter/clinical findings
HCC code data is submitted to CMS
CMS calculates MA Risk Adjustment Score
Plan & providers can deliver better care and better & reimbursement is RAF is accurate
CMS determines
cost of care based on RAF and provides capitation revenue to MA Plan
Slide17How the Hierarchies Function
CategoryIncluded HCCs
Community, Non-Dual, Aged Factor
Diabetes
HCC 17 Diabetes with acute
complications
0.6022
HCC 18 Diabetes with
chronic complications
0.3542
HCC 19 Diabetes w/o complications
0.3153
17
Slide18Which Patient Demonstrates Higher Risk?Patient A
85 year old, femaleLives in her homeNon-smoker, no alcohol, participates in Zumba 2x week, and attends church activitiesDiagnoses:Osteoporosis
Hypothyroidism
Dislocated right hip from Zumba class
Medications
Multivitamins, calcium
Levothyroxine
Patient B
77 year old, male
Lives in his home
H/O ETOH dependence, 50+ years smoker, sedentary lifestyleDiagnoses: Chronic respiratory failureCKD stage 3
Liver cirrhosisCOPDDiabetic foot ulcer, right heelMedications
Too many to list18
Slide19Disease InteractionsSome diseases “interact” with each other, causing an increase in care management and a corresponding additional risk factor.
As an example:Congestive Heart Failure combined with DiabetesWhen these two diagnoses are reported on the same patient, an additional risk factor is recorded.
2017 Ratebook Risk Factors
CHF HCC 85 .323
Diabetes, chronic complications HCC 18 .318
Disease Interaction of CHF and Diabetes
.
154
19
Slide20RAF Score Same Pt. 2017, 201820
$2,016.00 per month$24,192.00 annually
$1,170.40 per month
$14,044.80 Annually
Slide21High Level Example of a CMS Payment to a Plan
No Diagnoses Reported
Some Diagnoses Reported
All Diagnoses Reported
68 year old male
.300
68 year old male
.300
68 year old male
.300
Dual eligible
.192
Dual eligible
.192
Dual eligible.192Type 2 DM, not documentedType 2 DM, no complications
.097Type 2 DM with other skin ulcer.346
Congestive Heart Failure, not documented
Congestive Heart Failure, not documentedCongestive Heart Failure, coded
.355
Disease interaction (DM+CHF)
.205
Risk Adjustment Factor
.492.589
1.398
PMPM base payment$814
PMPM base payment
$814
PMPM base payment
$814PMPM for this patient
$401
PMPM for this patient$479
PMPM for this patient$1,138
Annual payment
$4,806
Annual
payment
$5,753
Annual payment
$13,656
21
PMPM = per member per month
Slide22Risk Adjustment Opportunities – Greater Specificity is Needed in DocumentationNeoplasms:
Lack of specificityStatus of conditionResolved/inactiveActiveType of CancerLocation: organPrimary and /or metastatic
Lymphoma, other
Acuity of Cancer
Acute/chronic
In remission
22
Slide23HCC 9 - DetailLung & Other Severe Cancers
Malignant NeoplasmUpper GI tractLiver and intrahepatic bile ductsGallbladder
Biliary tract
Pancreas
Trachea
Bronchus and lung
Pleura
Mesothelioma
Pleura
Peritoneum
Pericardia
Other & unspecified
Multiple Myeloma
Leukemia (non-acute)Myeloid Sarcoma
23
Slide2424
Slide25HCC 21 Protein Calorie Malnutrition
The Term Malnutrition carries no HCC WeightDocument signs, symptoms, cause, and typeNutritional marasmus
Marasmic kwashiorkor
(Not usually likely in U.S.)
Unspecified severe PCM
Mild
PCM
Moderate
PCM
Under development
following PCM
Sequelae
of PCMCachexia or wasting syndrome
25
Slide26Inclusion TermsUnder Development following PCMNutritional short stature
Nutritional stuntingPhysical retardation due to malnutritionUnspecified PCMMalnutrition NOSProtein-calorie imbalance, NOS
26
Slide27Malnutrition TipsWhen documenting malnutrition be sure under the general appearance section of the ROS the patient is not described as “within normal limits” or “well appearing”
Be sure the documentation is clearly treating malnutrition and not preventing malnutritionIn elderly persons, an indicative sign of malnutrition is delayed healing and an increased presence of decubitus ulcers of stage III or higher
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Slide28Malnutrition
Diseases that contribute to malnutritionCystic fibrosisChronic renal failure
Childhood malignancies
Congenital disease
Neuromuscular
diseases
Other
Contributors
Malignancy, chemotherapy
GI disorders
GastritisObstructionCrohn’s diseaseMalabsorbtionDiverticulitis
Other Contributors
S/P major bowel surgeryProlonged NPO status beyond 72 hoursSevere sepsis, alcoholismESRDSuppressed appetiteDysphasia
DepressionImmunocompromised (leukopenic state) & anemiaHyper-metabolic state (COPD, sepsis, Cancer…)CVA patient
28
Slide29Psychiatric Conditions HCC 57
SchizophreniaParanoidCatatonicUndifferentiated
Residual
Schizophreniform disorders
Other
29
Slide30Psychiatric Conditions HCC 58Major depressionBipolar
Paranoid DisordersDelusional disordersManic episodeWith and without psychotic symptomsFull or partial remissionBipolarDepressed, manic, or mixed
With or without psychotic feature
Full or partial remission
30
Slide31Psychiatric Conditions Major Depressive Disorder –
Single EpisodeSignificant weight loss (- ± 5% body weight within a monthInsomnia or hypersomniaPsychomotor agitation
Fatigue or energy loss nearly every day
Feelings of worthlessness, inappropriate guild
Diminished ability to concentrate or focus
Recurrent thoughts of death/suicide
Major Depressive Disorder –
Recurrent
The course of illness tends to vary
Bouts of depression separated by years between episodes in which there are no symptoms
Individuals may have more occurrences as they age
Specify:
Mild, moderate, severe
With or without psychosisPartial/full remission31
Slide32The Annual Wellnes Visit
Is an opportune time to assess all past medical conditionInitial Preventive Physical Exam (IPPE)Annual Wellness Visit (AWV)
The provider reviews past medical history to compile a list of all chronic health condition (tagging from a previous document?)
Add all acute problems that require continued management
Assessment and management of each health problem is documented in the medical record
Specificity
Link underlying disease, manifestations responsible for a
32
Slide33M.E.A.T.33
M.E.A.T. can be found in any section of the physician/out patient recordUse coding judgment to determine acceptable sources of support within each document
M
onitor (e.g., ordered lab s or diagnostic radiology)
E
valuat
(e.g., review lab or x-ray results, physical examination)
A
ddress/assess (e.g., condition described as “stable” or “improving
T
reat (e.g., patient referred to see a specialist, prescribe or refill meds, or decision for surgery
Slide34Medical Record DocumentationAll chronic conditions must be assessed and reported annually
CHF, Diabetes, COPDCo-existing acute conditionsProtein calorie malnutritionActive status conditionsAmputation, HIV, dialysis
Pertinent past conditions
OLD MI and other underlying medical problems
Medications that may indicate other conditions are controlled
Meds for hypertension
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Slide35Medical Record DocumentationSpecific rather than general informationMajor depression rather than depression, if applicableCausality
Diabetic neuropathy, not diabetes and neuropathyHighest level of specificityDiabetes Type 2 with renal manifestationInclude signs/symptomsAbnormal test resultsOther reason for the visitSupport documentation of conditions
Stable, controlled, uncontrolled, poorly controlled, improving, worsening
35
Slide36Medical Record Documentation“
History of” - the patient no longer has the conditionFrequent documentation error regarding use of “History Of” Documenting a
past condition
as active
Documenting
“history of”
when a condition is still active;
Exception: It is appropriate to document “history of” when documenting some status conditions (i.e. amputation)
Examples:
36
Incorrect Documentation
Correct Documentation
H/O CHF, Pt. is on Lasix
Compensated CHF, stable on LasixH/O Angina, pt. is on nitroquick
Angina, stable on nitroH/O COPD, pt. is on AdvairCOPD controlled with Advair
Slide37Documentation Tips37
Language Samples
Examples of Acceptable Language
Diabetes type 2, stable, well controlled on meds
COPD, stable on Advair
Assessment
Plan
Stable
Improved
Tolerating Meds
DeterioratingAsymptomaticUncontrolled
AsymptomaticMonitorD/C MedsContinue current MedsRefuses treatmentReferExercise
Control diet
Slide38CMS Risk Adjustment Data Validation AuditsWhat are CMS Risk Adjustment Data Validation (RADV) Audits?
Applicable to Medicare Advantage PlansCMS annual audits that ensure the integrity and accuracy of risk-adjusted payment
An audit that verifies diagnosis codes submitted by MA plans are appropriately supported by medical record documentation
MA plans may be selected for RADV Audits annually, and if selected:
Plans must submit medical records to validate reported diagnoses
38
Slide3939
Slide40Last but Not Least…40
MCC, CC, & HCC
Slide4141
MCC/CC (bold = MCC)HCC
SOI
ICD-10
Acute coronary insufficiency/occlusion
Y
2
I248, 1240
Acute coronary syndrome (ACS)
Y
2
I249
Acute Kidney Injury (AKI)Y3
N179Acute Tubular NecrosisY
4N170Anemia, acute blood loss2D62Angina, unstable
Y2I200Atelectasis (collapsed
lung)1J9811
Atrial fibrillation, persistentY
2I481Atrial
flutterY
2I4892Anxiety, alcohol induced
Y1
F10180Bacteremia
3R7881
Bleeding, GI2
K922Brain compression/herniation
Y4G935
Brain death
4G9382Cachexia (cachectic)Y
2R64Cardiac arrest (dc’d alive)
Y4I469CKD Stage 4/5Y
2N184/5Coma
Y
4
R4020
COPD, acute exacerbation
Y
2
J441
Deep vein
thrombosis
(needs greater specificity: acute, chronic embolism and thrombosis of inferior, superior vena cava, or other thoracic veins)
3
I8291
Depression, major, mild, moderate, recurrent
Y
2
F320,
F321, F339
Slide4242
MCC/CC (bold = MCC)HCC
SOI
ICD-10
Diabetes, hyperosmolar (Type II)
Y
4
E1100
Diabetes with ketoacidosis (Type
II)
Y
3
E11641Encephalopathy, metabolic
3G9341
Encephalopathy, toxic3G92ESRDY
2N186Heart failure, diastolic (heart failure, unspecified, is also an HCC)
Y2I5030
Heart failure: leftY
21501
Heart failure, systolicY
2I5020
Heart failure, systolic, acute
Y3
I5021Malnutrition: mild
Y2
E441Malnutrition: moderate
Y3E440, E46
Malnutrition: severeY
4E41, E43Obesity, hypoventilation syndrome, or morbid obesity due to excessive calories (BMI is an HCC also)
Y2E662
Pancreatitis, chronicY2K861
ParaplegiaY
2
G8220
Quadriplegia
Y
3
G8250
Schizophrenia, simple, paranoid, residual
Y
2
F2089
Transplant
status, kidney
Y
2
Z940
Transplant status, heart, lung, or liver
Y
3
Z941/2/4
Slide43Questions
43
Slide44ReferencesThe ABCs of the Initial Preventive Physical Examination:
https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/downloads/MPS_QRI_IPPE001a.pdfThe ABCs of Annual Wellness Visits: https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/downloads/AWV_chart_ICN905706.pdf
How to Properly Document Wellness Visits and physicials:
http://medicaleconomics.modernmedicine.com/medical-economics/content/tags/coding/how-properly-document-wellness-visits-and-physicals
https://www.cms.gov/Medicare/Prevention/PrevntionGenInfo/medicare-preventive-services/MPS-QuickReferenceChart-1.html
Physicians Practice: When a reventive visit uncovers a new patient complaint:
http://www.physicianspractice.com/blog/when-preventive-visit-uncovers-new-patient-complaint
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Slide45Alice Torrez, MHA, CPCEducator of Coding & Documentation
abtorrez@salud.unm.edu272-389145