As Medicare Advantage plans continue to grow in popularity, practices must familiarize themselves with the concept of...">

Know how risk adjustment could affect your practice

March 17th, 2015 - Lisa Eramo

As Medicare Advantage plans continue to grow in popularity, practices must familiarize themselves with the concept of risk adjustment, Brian Boyce, BSHS, CPC, CPC-I, of ionHealthcare, LLC told attendees at AAPC’s 22nd annual HEALTHCON conference in Nashville, TN earlier this month. Boyce, who provides online risk adjustment coding training through the AAPC, spoke about several risk adjustment methodologies, including one involving hierarchical co-existing conditions (HCC) on which Medicare Advantage plans base payment.
 
Other diagnosis-based risk adjustment models include chronic illness and disability payment systems (CDPS) for Medicaid, diagnosis-related groups (DRG) for inpatient hospitals, and adjusted clinical groups (ACG) for outpatient hospitals.
 
As with commercial HMOs, Medicare Advantage plans reimburse providers on a monthly basis that includes a ‘per member per month’ calculation. This calculation is based partially on the member’s age, gender, geography, and race, Boyce said. However, there is also a clinical adjustment made through the assignment of risk factors associated with certain diagnosis codes.
 
“We want to look at all current diagnosis that the patients have. Some of these diagnoses add value to patient profiles,” Boyce said. “The more severe or complex a diagnosis, the higher its risk score is going to be.”
 
Thorough documentation is key. “If we don’t account for all of the diagnosis codes that patients currently have, there will be a decrease in the monthly payment from Medicare to health plans and possibly from health plans to providers in the future,” Boyce said. “But it’s not just about payments. Some of these insurance plans are very ‘keyed into’ quality of care measures. They’re very interested in identifying all of the problems that patients have so they can be proactive in taking care of those problems.”
 
Boyce provided the following documentation tips:
 
·       Ensure that the treating licensed provider documents each diagnosis during a face-to-face visit. Also ensure that he or she signs this documentation personally and includes a date and credential with that signature.
·       Clearly state each diagnosis as a current problem on the specific date of service. If a diagnosis is not a current problem, state how that diagnosis affects medical decision-making for the current visit.
·       Document diagnoses that require ongoing evaluation.
 
Explain to physicians that the diagnoses they document communicate the seriousness of the medical decision-making (MDM) that they perform, Boyce told attendees. In risk adjustment models, CPT codes have little significance, he said. For example, even though a patient with current diabetes may present for a different problem (e.g., sore throat), physicians should document the diabetes because this information clearly plays a role in the MDM that the physician must perform when determining the type of drugs that he or she can prescribe.
Boyce said coders need to make physicians aware of the following:
 
·       Documentation is important. Physicians should document any and all conditions that the patient has. Note that there are many current diagnoses in risk adjustment models that may never be treated directly during a particular visit but that affect risk scores. Examples include old myocardial infarction, amputation, drug addiction, or family/personal history of a condition.
·       Coders cannot assume a link or cause and effect between two conditions (e.g., hypertension and congestive heart failure or diabetes and neuropathy) unless this information is explicitly documented. Documentation of this link allows coders to code to the highest degree of specificity.
·       Specify when a condition is chronic (e.g., chronic renal failure vs. renal insufficiency), as this information is important in terms of risk adjustment. Co-existing conditions include ongoing conditions, such as multiple sclerosis and Parkinson’s disease, he said.
·       Document the manifestation of the diabetes. This is important for ICD-10-CM coding assignment as well as risk adjustment.
·       Know that major depression plays a large role in risk adjustment. Specify major depression, when applicable. Note that ICD-9-CM code 311 (Depression, NOS) is intended for transient or temporary depressive events. Patients who are on long-term anti-depressant therapy are considered to have major depression, Boyce noted.
·       There are different rules for coding uncertain diagnoses in the inpatient vs. outpatient settings. In the inpatient setting, these diagnoses can be coded if they are still uncertain at the time of discharge. In the outpatient setting, coders cannot code conditions that are ‘suggestive of,’ ‘probable,’ ‘suspect,’ etc.
 
‘History of’ conditions are particularly tricky for coders, he said. ‘History of’ statements are confusing because physicians using this wording may mean either of the following:
 
·       Condition is historical only and no longer exists
·       Condition is a current ongoing problem that has been present for a long time
 
“Physicians should only list conditions in the past medical history when they truly are historical in nature and no longer being treated,” Boyce said. “Then have a separate section for current chronic conditions. Get in the habit of separating these two sections.”
 
Boyce reminded attendees that physicians sometimes incorrectly include a current diagnosis in the past medical history or a ‘history of’ condition in the chief complaint. He said coders should apply the TAMPER acronym (treatment, assessment, monitor/medicate, plan, evaluate, or referral) to each diagnosis listed in the past medical history to determine whether those diagnoses are actually current conditions. Coders must query if the information is ultimately unclear. Coders cannot code for conditions that were previously treated and no longer exist, he added.
 
Beware of patient-stated conditions when coding from the review of systems, Boyce reminded attendees. Conditions or diagnoses reported by the patient must be validated by the provider before they can be coded, he said.
 
The best way to ensure accurate risk adjustment is to dive deeply into the medical record documentation—including the assessment, exam, and review of systems—when coding diagnoses, Boyce said. Capturing all diagnoses is important for risk adjustment as well as predictive modeling. Insurers use coded data to closely monitor patient costs and outcomes, he added.  

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