74
Risk Adjustment, Quality Measures, & Care of Older Adults February 7, 2018 3 2/6/2018
Risk Adjustment, Quality
Measures, & Care of Older
Adults
February 7, 2018
3 2/6/2018
Upcoming HMSA Provider Trainings
Feb. 08, 2018 – Payment Transformation – 2018 Measurement Changes
Feb. 14, 2018 – QUEST Integration Basics Feb. 20, 2018 – New Provider Orientation
Feb. 28, 2018 – COREO – Part 2 “Set”
To register, please call 948-6820 (Oahu) or
1 (877) 304-4672 (toll-free Neighbor Islands) 2/6/2018 5
Today’s Presenters
Paula Murray
Educator, Provider Services
Lara Adelberger
STARS Clinical Coordinator
2/6/2018 6
Agenda
Risk Adjustment
What is RA, Why Do We Need it
What are HCCs & RAFs
Tips for Success
‒ Getting a Jump on Quality
• STARs: Medicare Advantage Quality
• Coding to Close Care Gaps
• Dual Special Needs
• Medication Management
Success in Performance
New Reporting Codes
Success Strategies
Payment Transformation
2/6/2018 7
Risk Adjustment
2/6/2018 8
Terminology
CMS - Centers for Medicare & Medicaid Services
HCC (Hierarchical Condition Categories) - Groupings of
specific ICD10 codes that roll up into a similar condition
category.
RxHCC - Some HCC codes adjust risk due to prescription
burden of disease
MA (Medicare Advantage) - A method of helping CMS
budget for the cost of caring for populations of patients
RA - Risk Adjustment
RAF (Risk Adjustment Factor) - A coefficient that adds
together reported ICD-10 codes & demographics to
create the risk profile of a Medicare member. 2/6/2018 9
What is Risk Adjustment?
Process CMS Uses to Reimburse Medicare
Advantage Plans Based on Members’ Health
Status
Ensures CMS Pays Plans Appropriately for
Members’ Predicted Health Costs Based on
Demographics & Health Status
2/6/2018 10
Why Risk Adjustment Needed?
Accurately Reflect Membership’s Health
Greater Disease Burden = Higher Risk
Adjustment Score
Healthier Patient = Lower Risk Adjustment Score
2/6/2018 11
Hierarchical Condition Categories
2/6/2018 12
69,000+ Total ICD-10 Codes
8,600 ICD-10s in
Risk Adjustment
79 HCCs
HCC Background
Introduced - 2004
Determine Capitated Payments
Allows Risk Adjusted Payments
Based on Complexity
12-Month Diagnostic Coding History Predicts
Financial Utilization
RAF Score Reflects Patient’s Complexity
RAF Score X Base Rate = PMPM Capitated
Reimbursement for Next Coverage Period
2/6/2018 13
What is an HCC Code?
Over 9,000 ICD-10 Codes Represent Costly, Chronic
Diseases Such As:
2/6/2018 14
Diabetes
Chronic Kidney Disease
Congestive Heart Failure
Chronic Obstructive Pulmonary Disease
Malignant Neoplasms
Some Acute Conditions (MI, CVA, Hip Fx)
Hierarchical Condition Categories
2/6/2018 15
Examples of Hierarchies
Source Description RAF
HCC 17 Diabetes with Acute Complications 0.368
HCC 18 Diabetes with Chronic Complications 0.368
HCC 19 Diabetes without Complication 0.118
Hierarchical
Condition Category
(HCC)
If the Disease Group is Listed in this column……Then drop the Disease
Group(s) listed in this column
11 Colorectal, Bladder, and Other Cancers 12
17 Diabetes with Acute Complications 18,19
18 Diabetes with Chronic Complications 19
27 End-Stage Liver Disease 28,29,80
2/6/2018 16
Examples of Hierarchies Source Description RAF
HCC 106Atherosclerosis of the Extremities with
Ulceration or Gangrene1.413
HCC 107 Vascular Disease with Complications 0.410
HCC 108 Vascular Disease 0.299
HCC 161 Chronic Ulcer of Skin, Except Pressure 0.536
HCC 189Amputation Status, Lower Limb/Amputation
Complications0.779
Hierarchical
Condition Category
(HCC)
If the Disease Group is Listed in this column……Then drop the Disease
Group(s) listed in this column
106Atherosclerosis of the Extremities with
Ulceration or Gangrene107,108,161,189
107 Vascular Disease with Complications 108
110 Cystic Fibrosis 111,112
111 Chronic Obstructive Pulmonary Disease 112
2/6/2018 17
What Affects Risk Scores?
Enrollee Health Status
Demographic Characteristics
Accurate Documentation
Coded HCCs
Health Status Determined Based On: Physicians Use diagnosis Codes to Document Health Status
Each HCC Model Category Relates to a “Relative Factor” or Health
Risk Score
2/6/2018 18
RAW RISK
SCORE
How Does Risk Adjustment Work?
Physicians Diagnose & Report Patients’ Conditions
Physicians Do Not Assign RAF Score
CMS Adjusts Payments Based on Expected Costs
Risk Scores Reset
Each Year
2/6/2018 19
Risk Adjustment Coding Example
No conditions coded Some conditions
coded
All chronic
conditions coded
76 year old female 0.442 76 year old female 0.442 76 year old female 0.442
Medicaid eligible 0.151 Medicaid eligible 0.151 Medicaid eligible 0.151
DM with
complications
X DM w/o
complications
0.118 DM with
complications
0.368
Vascular disease X Vascular disease X Vascular disease 0.299
CHF X CHF X CHF 0.368
Disease interaction
(DM+CHF)
X Disease interaction
(DM+CHF)
X Disease interaction
(DM+CHF)
0.182
Total RAF 0.593 Total RAF 0.711 Total RAF 1.810
2/6/2018 20
Why Is Risk Adjustment Important?
CMS - Make Appropriate Payments for Patients’
Expected Medical Costs
Coding Correctly Can Increase Payment
Documentation & Accurate Coding Critical
Allows Physicians & Payers to Manage Patients’
Health Care
Accurate Coding Helps Identify High-Risk
Patients
2/6/2018 21
Why HCC Risk Adjustment Important?
Improved Quality of Care Thru Disease Management
Programs
Accuracy in Member Health Status Profile
Appropriate Risk Premium From CMS
2/6/2018 22
How Risk Adjustment Affects You
2/6/2018 23
Providers Treat Patients on Plans
Funded Thru Risk Adjustment Models
Providers Document/Code Diagnoses
Accurately & To Highest Specificity
Documentation/Coding Establishes
Complexity & workload of Patient Panel
Documentation & Diagnoses Become
Basis for Funding & Reimbursement
Proper Coding = Proper Resources
Why Code Accurately?
2/6/2018 24
Accurate Timely Claims
Accurate Codes
Correct Paymen
t
Inaccurate Claims
Less Specific Codes
Less Paymen
t
Characteristics of HCC Model
Characteristics of CMS-HCC
Model
Prospective in Nature
Diagnostic Sources
HCCs/Multiple Chronic Diseases
Disease Interactions
Demographics
2/6/2018 25
How HCCs Affect an MA Plan
CMS Model is Cumulative
Multiple HCC Categories Assigned to Indicate
Multiple Chronic Conditions
Some Categories Supersede Other Categories
2/6/2018 26
RxHCCs
Cover Many Diagnoses Not Covered in HCC
Most HCC Diagnoses Are Also RxHCC Codes
All RxHCC Are NOT Also HCC
Complement Reimbursement for Managing Patients w/Illnesses Not As Complex or Costly as HCC Diagnoses, But Qualify Due to Increased Medication Costs 2/6/2018 27
What The Future Holds?
Healthcare Rapidly Changing
Affects More Than Just Medicare Patients
Documentation & Coding Increasingly
Drive Reimbursement & Quality Measures
Risk Adjustment Used For ACA & Medicaid
.
2/6/2018 28
How Do We Improve?
Stay up to date on best practices and HCCs
Report a complete picture of RAF scores
HCC streamlines the process of creating clean claims
and allows for efficient reimbursement
2/6/2018 29
HMSA and Risk Adjustment
2/6/2018 30
HMSA & Risk Adjustment - Retrospective
Review • Ensure Accuracy of Chart Reviews
Analyze • Report Chart Review Findings to Providers
Educate • Provide Training & Education on RA Basics
Improve • Conduct Performance Management Reviews
Align • Improve & Maximize RA Scores of MA Plans
2/6/2018 31
HMSA and Risk Adjustment -
Prospective
2/6/2018 32
Formula For Success
2/6/2018 33
Best Practice: See Each Patient Every
Year
Factors Affecting Patient’s Diagnostic Picture
Not seeing PCP
annually
Patient Seen Infrequently for Other
Problems, w/out Updating &
Documenting Chronic Conditions
Patient w/Chronic Conditions Not
Monitored = Chronic
Conditions Not Treated
2/6/2018 34
Documentation
2/6/2018 35
Diagnosis Specificity
Care Plan
Accuracy
Additional Strategies
CMS Acceptable Signature
Documentation Tips
“h/o”, “s/p” - Indicative to Coders Past Condition
& Cannot Code as Active Disease
Must Indicate Treatment Plan - Each Diagnosis
Describe Relationships Between Diseases &
Manifestations Use Linking Terms: “due to”,
“secondary to”
2/6/2018 36
Linking Words
Creates Relationship Between Diseases &
Manifestations
Assures Coders Cause & Effect Between Disease
& Manifestation
Appropriate Terms: Due To
Secondary To
Use Associative Suffix “ic”, “ive”
Example: Diabetic Ulcer / Hypertensive Heart Disease
2/6/2018 37
Documentation Specificity
Diabetes
Type 1
Type 2
Complications
Insulin Use
Bronchitis
- Acute - Chronic - Unspecified
-Obstructive - Asthmatic
Hepatitis
Type:
A, B, or C
- Acute - Chronic - Unspecified
Wounds / Ulcers
-Trauma - Underlying Etiology
- Location - Stage
2/6/2018 38
Don’t Forget Z-Codes
• Lower Extremities
• (AKA, BKA, Foot, Toes)
Amputations
• Dialysis, Fitting Adjustment Catheter, Presence of Dialysis Catheter
Renal Dialysis
• Bone Marrow, Heart, Kidney, Lung, Liver, Pancreas
Organ Transplant
2/6/2018 39
Don’t Forget Z-Codes
• Morbidly Obese, BMI >40
• Must Document Height & Weight BMI
• Asymptomatic
• HIV Status HIV
• Gastrostomy, Ileostomy, Urostomy, Tracheostomy, Cystostomy
Artificial Openings
2/6/2018 40
Coding & Documentation
Improvement Minimize Non-Specific Code Use
Documentation/Diagnosis Codes Reflect Accurate Acuity of
Patient’s Condition Known & Present During Encounter
Unspecified Codes May Be Appropriate - Some Cases
Use Unspecified When Documentation Does Not Reflect
Higher Specificity Level
Documentation Improvement & Coding Proficiency Go
Hand-In-Hand
2/6/2018 41
Plan Now For Future
Fee-For-Service Reimbursement Emphasized
CPT & HCPCS Codes for Professional Claims
Instead of Diagnosis Codes
Focus Accurate ICD-10 Coding & Documentation
Accurately Reflect How Patients Categorized by
Payers & How Future Reimbursements are
Determined
2/6/2018 42
Tips & Tricks
Improve ICD-10 Code Use
Learn Current ICD-10 Guidelines & Conventions
Code From Medical Record Documentation
Perform Documentation Reviews
Monitor Coder Productivity & Quality
2/6/2018 43
Documentation Strategy
All Encounters Must Contain: Patient Name & DOB on Every Page
Date of Service
Provider Signature + Credentials
Compliant Signatures Authenticated Electronic Signatures OR
Original Signatures
Typed or Stamped Signatures Not Acceptable
Highest Specificity - “Benign Hypertension” vs “HTN”
All Diagnoses Must Include Assessment & Treatment
Plan - Lists Not Sufficient!
2/6/2018 44
MEAT in Your Documentation
45
Signs, Symptoms, Disease Progression / Regression
Test Results, Treatment / Medication Effectiveness
Testing, Discussion, Records Review, Counseling
Medications, Therapies, Other Modalities
HCC Coding Success Tips
Capture HCCs Once Every 12 Months
Ensure Diagnosis Code(s) Billed Match
Documentation
Be Mindful of M.E.A.T.
Use Linking Statements or Document Causal
Relationships for Manifestation Codes
Review Specialist Documentation
2/6/2018 46
Questions?
2/6/2018 47
Stars:
Coding for Quality
CMS asks:
“How Good is Your MA Plan?
Inform beneficiaries as they choose a plan
Encourage evidence-based practices
Improve health & well-being
Stars: What gets scored?
Preventative Screenings
Chronic Disease Care
Medication Management
Care Coordination
Dual Eligible Member
Care
Why code for quality metrics?
Reduce HEDIS medical record collections
Increase quality scores and payments for Payment
Transformation
Increase cost of care payments for Payment Transformation
and MACRA
Get credit for the work you do
CODE TO CLOSE CARE GAPS
Care for Older Adults: Dual Special Need
Once per calendar year
Four part assessment:
Medication Review
Functional Status Assessment
Pain Assessment
Advance Care Planning
COA form available with coding
and checklist assessments
• Complete the assessments • Add completed form to your
medical record • File a claim
Medication Reconciliation Post
Discharge
Hospital Discharge
30 day window –
Medication Reconciliation
Document in chart:
Discharge medications were reviewed and reconciled with pre-admit medications. Document on claim
(CPT II code 1111F) Forms available on provider portal
CODE FOR BURDEN OF
ILLNESS
Rheumatoid Arthritis
Z87.30: Patient reported or personal history of RA, History of
RA in remission
refused
error in DX
in remission
anti-inflammatory
No Data
Non Formulary Drug
RA Patients not on a DMARD
DMARD
Hospital Readmissions
Admission
30 days
Readmission
Risk scores and accurate
coding affect risk-
adjusted measures
Populations with a
higher burden of illness
have higher expected
admissions (and
readmissions)
Potentially Preventable Complications
Hospitalizations related to:
Diabetes
Diabetes-related
amputations
COPD
Asthma
Hypertension
Heart Failure
Bacterial pneumonia
Urinary Tract Infection
Cellulitis
Pressure ulcer
Metric is scored on observed
hospitalizations vs. expected
Code to highest level of specificity
Take Home Thoughts
Use CPT II codes to report quality care
Code burden of illness to the highest specificity
Need a guide to helpful codes for quality measures?
Quick Reference Guide “Coding for Medicare Star
Ratings”
https://hmsa.com/portal/provider/zav_pel.aa.MED.100.htm
Payment Transformation coding guide
In Performance Measures
Important Reminders
Reporting Measures
All Codes on Claims Submitted to HMSA, Are
Captured for Numerator Credit in Cozeva -
Whether Claim Line “Approved” or “Denied”
Some CPT Codes Used May Trigger Member
Co-Payments
Please Consider Coding Options
That Minimize Impact on Your
Patients
62
Benefits Reminders
Some Performance Measures Recognized as
Affordable Care Act (ACA) Preventive Services
Have No Member Co-Payment When Specific
Combination of Procedure Code & Diagnosis
Code is Billed
Check HHIN to Determine if Member Has a
Commercial HMSA ACA-Compliant Plan
63
HHIN
2/6/2018 64
Aging Into Measures
Calendar-Year View: Displays All Members For
Measure if Qualifying Age as of December 31st
Example:
Adolescents Immunizations Required By 13th
Birthday (Meningococcal & Tdap)
Cozeva Populates Measure Registry w/All
Members Born 2004 as Denominator (Patients 12 at Beginning of Year & 13 at Year End)
PCP Receives Numerator Credit For Required
Shots Given By 13th Birthday 65
Success Strategies: Pediatrics
Children Measure
Newborn Through Age 15
Months
Well-Child Visits In The First 15 Months
By Age 2 Birthday Childhood Immunizations By Age 2
By Age 1 Birthday
By Age 2 Birthday
By Age 3 Birthday
Developmental Screening in First 3 Years of
Life, Annual
Age 3 to 17 CSHCN Screener, Every 3 Years
Age 3 to 17 Weight Assessment & Counseling for
Nutrition and Physical Activity
Age 3, 4, 5 & 6 Well-Child Visit Annually
Birth to Age 20, Per State
EPSDT Schedule
(QUEST Integration)
EPSDT Form Submission
66
Success Strategies: Pediatrics
Children Measures
Ages 12 to 21 Adolescent Well-Care Visit
Ages 12 to 17 Screening - Symptoms of Clinical
Depression & Anxiety [Patient Health
Questionnaire-2, -4, -9, -Adolescents]
By Age 13 Birthday Immunization for Adolescents
All Patients (Each Visit) Patient Experience Survey
All Patients Check Well-Being All Panel Patients At
Least Once a Year [Annual Patient Survey
Administered to Sample of Patients]
67
Success Strategies: Adults
Adults Measures
Ages 18 & Older Flu Vaccine
Ages 18 & Older Tobacco Cessation & Follow-Up
Ages 18 & Older Screening - Symptoms of Clinical
Depression & Anxiety
Ages 18 & Older RealAge Assessment Completed
Ages 18 to 74 Body Mass Index Assessment
Ages 18 to 75 All 4 Diabetes Measures
Ages 18 to 85 Controlling Blood Pressure
Women Ages 24 to 64 Cervical Cancer Screening
Women Ages 52 to 74 Breast Cancer Screening
Ages 51 to 75 Colorectal Cancer Screening
68
Success Strategies: Adults
Adults Measures
Ages 65 & Older Advance Care Planning
Ages 65 & Older Review of Chronic Conditions
All Patients Check Well-Being of All Panel
Patients at Least Once a Year
[Annual Patient Survey Administered
to Sample of Patients]
69
Success Strategies –Office Workflows
Pre-visit Planning:
Review Schedule of Future Visits
Check Cozeva - Open Care Gaps
‒ Flag Gaps - Face Sheet,
Encounter Forms, Superbill,
EMR Alerts, etc.
‒ Medicare Patients w/RCCs: Print
Patient’s RCC List From Cozeva
‒ Reports From Specialists That
Need to Be Addressed (e.g.
Colorectal, Breast, Cervical
Screenings, etc.)
Success Strategies – Office Workflows
Patient Check-In/In-take:
Clinical Depression & Anxiety Screener PHQ 4
(Age 18 & Older)
Patient Assessment/Chief Complaints/Vitals
(HT, WT, BMI, BP, TEMP, etc)
If BP Reading is Too High (Above 139/89), Repeat BP
Document Appropriate Codes for BMI & BP
Tobacco Screening (Age 18 & Over)
Ask About Smoking Status
Document Medical Record & Use Appropriate Smoking
Status Codes
Success Strategies – Office Workflows
Patient Check-In/Intake (con’t)
Care Gaps (Breast Screening, Cervical Screening, Colorectal
Screening, & Diabetes Care)
If Patient Completed Any Screenings & No Results in
File, Have Patient Sign Release of Information Form to
Request Records
Flu Vaccine (Age 18 & Over) *Seasonal
Advance Care Planning (Age 65 & Older)
May Vary Per Office - Some Physicians Prefer to
Review w/Patient Themselves.
POLST Information & Documents: http://kokuamau.org/
Success Strategies – Office Workflow
Patient Roomed w/Physician:
Medicare Patients w/RCC
Documentation of M.E.A.T.
Each Attested Condition Code Highest Level Specificity
If Disconfirming, Enter Disconfirm Text in Cozeva
Advance Care Planning (Age 65 & Older)
Document Discussion & Code Appropriately
Adolescent Well Care Visit (Age12-21)
Medical Record Evidence Required For All Following: Health & Development History (Physical & Mental)
Physical Exam
Health Education/Anticipatory Guidance
Success Strategies – Office Workflow
Patient Check-Out:
Schedule Next Visit, Tests, Procedures, if
Applicable - Provide Patient w/the Information
Assist Patient w/Referrals/Specialist Appointments
Collect Co-Pay/Co-Insurance/Deductible
Resources https://hmsa.com/portal/provider/zav_pel.aa.MED.650.htm
2/6/2018 75
76
Questions will be Taken Through the
Chat Function
Thank You for Your Attendance!
Please Fax us Your Evaluation Form
Q&A
77
