PPT-Coding for Risk Adjustment

Cynthia Trapp MSCHFP CMPE CPCO CPC CPCI AAPCFellow CCSP CHC New England MGMA Regional Conference Friday May 4 2018 Defining Risk Adjustment History of CMS Risk Adjustment Risk Adjustment Models. g gym memberships and exercise classes Medicare Advantage plan receives payment for each member from CMS Payment is based on member predicted health status and demographic characteristics Medicare Advantage plan regulated by CMS brPage 6br Introducti Colorado Division of Insurance. Risk Adjustment Question. Who should administer Risk Adjustment in Colorado?. Federal Government; or. State Government:. Use Federal Model (2012 Exchange Bill says to “strongly consider”). Socioeconomic Status;. Linking Cost and Quality Measures. HSCRC . Performance Measurement . Workgroup. May 28, 2014 . Tom Valuck, MD, JD. Presentation. . Overview. U. pdate . the . Performance Measurement Workgroup . Socioeconomic Status;. Linking Cost and Quality Measures. HSCRC . Performance Measurement . Workgroup. May 28, 2014 . Tom Valuck, MD, JD. Presentation. . Overview. U. pdate . the . Performance Measurement Workgroup . A Work Plan for State Officials. December 2, 2011. Ross Winkelman, FSA Mary Hegemann, FSA and Syed Mehmud, ASA. Contributions by Tom Leonard, James Woolman, Julie . Peper. , and Patrick Holland. Caveats. An Introduction and Discussion. MAPAM. March 16, 2017. Agenda. Risk Adjustment . How Risk Adjustment Works. Risk Adjustment Factor (RAF) Scoring Process. Comprehensive Annual Visits. Predictive Modeling & Quality of Care. Risk adjustment. Program establish by Centers for Medicare and Medicaid Services [CMS]. GOAL. : to allocate resources to those patients who most need them, based on each patient’s severity of illness. Risk-adjustment practices consider chronic diseases as predictors of future healthcare needs and expenses. Detailed documentation and compliant diagnosis coding are critical for proper risk adjustment.Risk Adjustment Documentation & Coding provides: • Risk adjustment parameters to improve documentation related to severity of illness and chronic diseases. • Code abstraction designed to improve diagnostic coding accuracy without causing financial harm to the practice or health facility. The impact of risk adjustment coding—also called hierarchical condition category (HCC) coding—on a practice should not be underestimated: • More than 75 million Americans are enrolled in risk-adjusted insurance plans. This population represents more than 20% of those insured in the United States. • Insurance risk pools under the Affordable Care Act include risk adjustment. • CMS has proposed expanding audits on risk adjustment coding. Meticulous diagnostic documentation and coding is key to accurate risk-adjustment reporting. This book will help align the industry though an objective compilation and presentation of risk adjustment documentation and coding issues, guidance, and federal resources.Features and Benefits • Five chapters delivering an overview of risk adjustment, common administrative errors, best practices, topical review of clinical documentation improvement and coding for risk adjustment alphabetized by HCC group, and guidance for development of internal risk adjustment coding policies. • Six appendices offering mappings, tabular information, and training tools for coders and physicians that include an alphanumeric mapping of ICD-10-CM codes to HCCs and RxHCCs and information about Health and Human Services HCCs versus Medicare Advantage HCCs. • Learning and design features: - Vocabulary terms highlighted within the text and conveniently defined at the bottom of the page. - “Advice/Alert Notes” that highlight important advice from the ICD-10-CM Guidelines for Coding and Reporting. - “Key Coding Concepts” that offer the advice published in ICD-10-CM Coding Clinic for ICD-10-CM and ICD-10-PCS. - “Sidebars” that detail measurements pertinent to risk adjustment seen in physician documentation, eg., cancer staging, disability status, or GFRs. - “Coding Tips” that guide coders to the right answers (using terminology and ICD-10-CM Index and Tabular entries) or provide cautionary notes about conflicts in the official ICD-10-CM guidance. - “Clinical Examples” that underscore key documentation issues for risk adjustment. - Clinical coding examples that provide snippets or full encounter notes and codes to illustrate key issues for the HCC or RxHCC. - “Documentation tips” highlight recommendations to physicians regarding what should be included in the medical record or how ICD-10-CM may classify specific terms. - “Examples” that explain difficult concepts and promote understanding of those concepts as they relate to a section. - “FYI” call outs that provide quick facts. • Extensive end-of-chapter “Evaluate Your Understanding” sections that include multiple-choice questions, true-or-false questions, and Internet-based exercises. • Downloadable slide presentations for each chapter that cover key content and concepts. • Exclusive content for academic educators: A test bank containing 100 questions and a mock risk-adjustment certification exam with 150 questions Capturing risk in medical documentation and coding successfully gives a complete and accurate picture of your patients’ health but it is also critical for ensuring proper reimbursement, managing cost, projecting future resource requirements and delivering high-quality care. Chronic diseases are not outliers, especially in older patients. 80% percent of older adults have at least one chronic condition. If you have any Medicare patients with chronic conditions and if you are participating in Merit-based Incentive Payment Systems (MIPS), the AMA’s Risk Adjustment, Documentation and Coding 2e (RA, 2e) will help you capture the care rendered so the severity of your patients’ illnesses is adequately captured to reflect your utilization. If you omit risk-adjusting diagnoses because a specialist is managing the care of your patient’s chronic condition, you are hurting your MIPS efficiency rating. Most chronic conditions will impact the overall health of the patient therefore, they are appropriate to capture for your documentation.In a value and outcome-based health care environment, lack of specificity in ICD-10-CM coding and documentation has ripple effects for a practice and its patients, like – loss of important data and financial returns and increased patient risk. Continuity of care and a complete picture of a patient’s overall health are key to quality care. Connecting diagnosis with comorbidities (causes) with ICD-10-CM codes (such as hypertension with heart disease or diabetes and hyperlipidemia with diabetes, etc.) for patients with chronic conditions helps improve care and documentation. RA, 2e, covers this in detail and can help you document your patient’s health and wellbeing, and help you get the right reimbursement, especially for your high-risk patients.  Use Risk Adjustment Documentation & Coding, 2nd Edition, to: Improve documentation in general and in relation to severity of illness and chronic diseases with risk adjustment parameters. Code more accurately with expert guidelines and recommendations.Connect diagnosis with comorbidities (cause) with the checklists in the teaching/training tools for the 10 most common chronic diseases.The impact of risk-adjustment coding (hierarchical condition category (HCC) coding) on a practice is significant because: More than 75 million Americans are enrolled in risk-adjusted insurance plans. This population represents more than 20% of those insured in the United States. Insurance risk pools under the Affordable Care Act include risk adjustment. CMS, which disbursed more than $900 million in MIPS bonuses for 2020, is tightening requirements for these bonuses, and has also proposed expanding audits on risk-adjustment coding.FEATURES AND BENEFITSFive chapters delivering an overview of risk adjustment, common administrative errors, best practices and guidance for development of internal risk-adjustment coding policies, which are organized by diagnoses topic (diabetes, dementia, ischemic heart, etc). Each topic has separate guidance for documentation and for coding.10 ICD-10-CM teaching/training tools for the top-10 most-common chronic diseases to help with documentation and coding.10 ICD-10-CM coding aid for quick reference and code selection for the top-10 most-common chronic diseases. Two appendices offering mappings and tabular information of ICD-10-CM codes that risk-adjust to CMS-HCCs (used for MIPS) and RxHCCs. Learning and design features: Vocabulary terms highlighted within the text and defined at the bottom of the page. Advice/Alert Notes?that highlight important coding and documentation advice from federal regulatory sources. Sidebars?that provide derivative story and additional information, such as: Coding Tips?that guide physicians and coders with practical advice from sources like AHA\'s Coding Clinic and cautionary notes about conflicts and exceptions.Clinical Examples?that underscore key documentation issues for risk adjustment. Clinical Coding Examples?that provide snippets or full encounter notes and codes to illustrate risk-adjustment coding and documentation concepts. Documentation tips?that highlight recommendations to physicians regarding what should be included in the medical record or how ICD-10-CM may classify specific terms. Examples?that explain difficult concepts and promote understanding of those concepts as they relate to a section FYI?call outs that provide quick facts. Abstract & Code It!?exercises that test diagnosis abstraction and coding skills (exclusive to Chapter 4). Assessment tools for instructors and independent learners:Extensive end-of-chapter Evaluate Your Understanding sections that include multiple-choice questions, true-or false questions, and audit- and Internet-based exercises. Two downloadable course tests and slide presentations for each chapter. Exclusive content for academic educators: A test bank containing 100 questions and a mock risk-adjustment certification exam with 150 questions.  Capturing risk in medical documentation and coding successfully gives a complete and accurate picture of your patients’ health but it is also critical for ensuring proper reimbursement, managing cost, projecting future resource requirements and delivering high-quality care. Chronic diseases are not outliers, especially in older patients. 80% percent of older adults have at least one chronic condition. If you have any Medicare patients with chronic conditions and if you are participating in Merit-based Incentive Payment Systems (MIPS), the AMA’s Risk Adjustment, Documentation and Coding 2e (RA, 2e) will help you capture the care rendered so the severity of your patients’ illnesses is adequately captured to reflect your utilization. If you omit risk-adjusting diagnoses because a specialist is managing the care of your patient’s chronic condition, you are hurting your MIPS efficiency rating. Most chronic conditions will impact the overall health of the patient therefore, they are appropriate to capture for your documentation.In a value and outcome-based health care environment, lack of specificity in ICD-10-CM coding and documentation has ripple effects for a practice and its patients, like – loss of important data and financial returns and increased patient risk. Continuity of care and a complete picture of a patient’s overall health are key to quality care. Connecting diagnosis with comorbidities (causes) with ICD-10-CM codes (such as hypertension with heart disease or diabetes and hyperlipidemia with diabetes, etc.) for patients with chronic conditions helps improve care and documentation. RA, 2e, covers this in detail and can help you document your patient’s health and wellbeing, and help you get the right reimbursement, especially for your high-risk patients.  Use Risk Adjustment Documentation & Coding, 2nd Edition, to: Improve documentation in general and in relation to severity of illness and chronic diseases with risk adjustment parameters. Code more accurately with expert guidelines and recommendations.Connect diagnosis with comorbidities (cause) with the checklists in the teaching/training tools for the 10 most common chronic diseases.The impact of risk-adjustment coding (hierarchical condition category (HCC) coding) on a practice is significant because: More than 75 million Americans are enrolled in risk-adjusted insurance plans. This population represents more than 20% of those insured in the United States. Insurance risk pools under the Affordable Care Act include risk adjustment. CMS, which disbursed more than $900 million in MIPS bonuses for 2020, is tightening requirements for these bonuses, and has also proposed expanding audits on risk-adjustment coding.FEATURES AND BENEFITSFive chapters delivering an overview of risk adjustment, common administrative errors, best practices and guidance for development of internal risk-adjustment coding policies, which are organized by diagnoses topic (diabetes, dementia, ischemic heart, etc). Each topic has separate guidance for documentation and for coding.10 ICD-10-CM teaching/training tools for the top-10 most-common chronic diseases to help with documentation and coding.10 ICD-10-CM coding aid for quick reference and code selection for the top-10 most-common chronic diseases. Two appendices offering mappings and tabular information of ICD-10-CM codes that risk-adjust to CMS-HCCs (used for MIPS) and RxHCCs. Learning and design features: Vocabulary terms highlighted within the text and defined at the bottom of the page. Advice/Alert Notes?that highlight important coding and documentation advice from federal regulatory sources. Sidebars?that provide derivative story and additional information, such as: Coding Tips?that guide physicians and coders with practical advice from sources like AHA\'s Coding Clinic and cautionary notes about conflicts and exceptions.Clinical Examples?that underscore key documentation issues for risk adjustment. Clinical Coding Examples?that provide snippets or full encounter notes and codes to illustrate risk-adjustment coding and documentation concepts. Documentation tips?that highlight recommendations to physicians regarding what should be included in the medical record or how ICD-10-CM may classify specific terms. Examples?that explain difficult concepts and promote understanding of those concepts as they relate to a section FYI?call outs that provide quick facts. Abstract & Code It!?exercises that test diagnosis abstraction and coding skills (exclusive to Chapter 4). Assessment tools for instructors and independent learners:Extensive end-of-chapter Evaluate Your Understanding sections that include multiple-choice questions, true-or false questions, and audit- and Internet-based exercises. Two downloadable course tests and slide presentations for each chapter. Exclusive content for academic educators: A test bank containing 100 questions and a mock risk-adjustment certification exam with 150 questions.  The Risk Adjustment Coding and HCC Guide brings together hard-to-find information about risk adjustment (RA) coding and hierarchical condition categories (HCCs) in a new comprehensive resource that explains this complex reimbursement methodology. Now your organization will have a guide that provides both the big picture and the fine detail needed to document, code, and report essential information so that accurate risk levels are assigned and appropriate reimbursement received. Risk-adjustment practices consider chronic diseases as predictors of future healthcare needs and expenses. Detailed documentation and compliant diagnosis coding are critical for proper risk adjustment.Risk Adjustment Documentation & Coding provides: • Risk adjustment parameters to improve documentation related to severity of illness and chronic diseases. • Code abstraction designed to improve diagnostic coding accuracy without causing financial harm to the practice or health facility. The impact of risk adjustment coding—also called hierarchical condition category (HCC) coding—on a practice should not be underestimated: • More than 75 million Americans are enrolled in risk-adjusted insurance plans. This population represents more than 20% of those insured in the United States. • Insurance risk pools under the Affordable Care Act include risk adjustment. • CMS has proposed expanding audits on risk adjustment coding. Meticulous diagnostic documentation and coding is key to accurate risk-adjustment reporting. This book will help align the industry though an objective compilation and presentation of risk adjustment documentation and coding issues, guidance, and federal resources.Features and Benefits • Five chapters delivering an overview of risk adjustment, common administrative errors, best practices, topical review of clinical documentation improvement and coding for risk adjustment alphabetized by HCC group, and guidance for development of internal risk adjustment coding policies. • Six appendices offering mappings, tabular information, and training tools for coders and physicians that include an alphanumeric mapping of ICD-10-CM codes to HCCs and RxHCCs and information about Health and Human Services HCCs versus Medicare Advantage HCCs. • Learning and design features: - Vocabulary terms highlighted within the text and conveniently defined at the bottom of the page. - “Advice/Alert Notes” that highlight important advice from the ICD-10-CM Guidelines for Coding and Reporting. - “Key Coding Concepts” that offer the advice published in ICD-10-CM Coding Clinic for ICD-10-CM and ICD-10-PCS. - “Sidebars” that detail measurements pertinent to risk adjustment seen in physician documentation, eg., cancer staging, disability status, or GFRs. - “Coding Tips” that guide coders to the right answers (using terminology and ICD-10-CM Index and Tabular entries) or provide cautionary notes about conflicts in the official ICD-10-CM guidance. - “Clinical Examples” that underscore key documentation issues for risk adjustment. - Clinical coding examples that provide snippets or full encounter notes and codes to illustrate key issues for the HCC or RxHCC. - “Documentation tips” highlight recommendations to physicians regarding what should be included in the medical record or how ICD-10-CM may classify specific terms. - “Examples” that explain difficult concepts and promote understanding of those concepts as they relate to a section. - “FYI” call outs that provide quick facts. • Extensive end-of-chapter “Evaluate Your Understanding” sections that include multiple-choice questions, true-or-false questions, and Internet-based exercises. • Downloadable slide presentations for each chapter that cover key content and concepts. • Exclusive content for academic educators: A test bank containing 100 questions and a mock risk-adjustment certification exam with 150 questions Does . your . plan’s strategy violate the False Claims Act?. Phillips & Cohen LLP. www.phillipsandcohen.com. 2. Overview of Risk Adjustment Fraud. Risk adjustment fraud is essentially “upcoding” for diagnosis codes. Linking Cost and Quality Measures. HSCRC . Performance Measurement . Workgroup. May 28, 2014 . Tom Valuck, MD, JD. Presentation. . Overview. U. pdate . the . Performance Measurement Workgroup . on NQF .