Hierarchical Coding Categories and Beneficiary Risk · • HCC 120 Seizure Disorders and...
Transcript of Hierarchical Coding Categories and Beneficiary Risk · • HCC 120 Seizure Disorders and...
Hierarchical Coding Categories and Beneficiary Risk
Lynette ByrnesUnited Rheumatology
Gloria Johnston, MBA, RN, RHITHealthAdvanta
Copyright © 2018 United Rheumatology
Agenda
Objectives• To introduce the audience
to HCCs
• To discuss the importance of capturing chronic conditions considered in the treatment of Rheumatology patients
• To review actions Rheumatology practices can take to improve performance under cost and other risk-based contracts
Content Slides
Why HCCs Matter to Physician Practices
3 - 7
HCC and Beneficiary Risk Overview 8 - 11
HCC Risk Adjustment Scoring 12- 20
Actions for Rheumatology Practices 21 - 25
Resources and Supplemental Information
28 - 33
Disclaimer
This presentation is intended to serve as an educational tool and
provide a general overview of the topics discussed. We strive for
accuracy but cannot be held responsible for any errors or
omissions in information as denoted on the slides.
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Why HCCs Matter to Physician Practices
3
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Why HCCs Matter to Physician Practices
Quality50%
Cost10%
ACI25%
CPIA15%
2018 • Cost represents 10% of the total MIPS score in 2018
• Cost is expected to increase to 30% in the coming years
• Cost is far more difficult to influence than the other MIPS categories
• Tolerance for costs is higher for sicker patients
• In 2018, up to 5 MIPS bonus points available for practices who take care of the sickest patients
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Why HCCs Matter to Physician Practices
• Cost represents 10% of the total MIPS score in 2018
• Cost is expected to increase to 30% in the coming years
• Cost is far more difficult to influence than the other MIPS categories
• Tolerance for costs is higher for sicker patients
• In 2018, up to 5 MIPS bonus points available for practices who take care of the sickest patients
Quality30%
Cost30%
ACI25%
CPIA15%
Possibly as early as 2019
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MIPS Cost Measures
• Measurement is the average cost to the Medicare program for attributed patients
• Patients are attributed based on plurality of ambulatory evaluation and management services EM
• Two-pass evaluation
▪ Primary care physicians, NPs and PAs
▪ Specialists
• Determined by claims
• Includes all Part B costs
• Compared to historical benchmark for scoring
• Cost impacts MIPS score if at least 20 patients are attributed
Per Capita Cost
• Measurement is total costs of inpatient admission episodes for certain high resource MSDRGs diagnoses, procedures
• Episodes are attributed to the provider who bills the highest Part B professional services during the triggered admission
• Attributed costs include 3 days prior to admission, the inpatient admission and 30 days post admission
• Cost impacts MIPS score if at least 35 episodes are attributed
• Rheumatology rarely exceeds minimum episode threshold
Medicare Spending Per Beneficiary Cost
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MIPS Cost Measures
• Measurement is the average cost to the Medicare program for attributed patients
• Patients are attributed based on plurality of ambulatory evaluation and management services EM
• Two-pass evaluation
▪ Primary care physicians, NPs and PAs
▪ Specialists
• Determined by claims
• Includes all Part B costs
• Compared to historical benchmark for scoring
• Cost impacts MIPS score if at least 20 patients are attributed
Per Capita Cost Per Capita Costs Countermeasures
• Ensure every patient has a PCP and sees that PCP once per year
• When appropriate, utilize incident to billing for mid-level providers
▪ Established patients
▪ Existing problem
▪ Established plan
▪ Physician in office at time of service
• Ensure that patient complexity is expressed on the claim to align beneficiary risk with each patient’s health status
• Tolerance for costs is higher for sicker patients
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Why HCC’s Matter to Physician Practices
• Risk adjustment is not a concept exclusive to Medicare
▪ Private payers use beneficiary risk in risk-based contracts
▪ Medicare Part C Plans Medicare Advantage are funded by Medicare based on beneficiary risk
▪ Medicaid uses HCC risk
• As payment models continue to evolve toward a system whereby providers will be paid for managing populations, risk stratification will be paramount
HCC and Beneficiary Risk Overview
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What is HCC?
• The HCC risk score reflects the overall health status of the patient and is influenced by demographic factors
• HCCs are derived from ICD codes submitted on Medicare claims
• Diagnoses from all contributing providers are included in the HCC risk score
• The HCC model is made up of 9,531 costly chronic disease ICD-10 codes organized into 189 HCC categories
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Top Chronic Conditions That Influence Beneficiary Risk
• Congestive heart failure
• Vascular disease
• Ischemic or unspecified stroke
• Ischemic heart disease
• Specified heart arrhythmia
• Angina
• Morbid obesity
• Rheumatoid arthritis
• Inflammatory connective tissue disease
• Cancer
• Diabetes
• Chronic obstructive pulmonary disease
• Major depressive and bipolar disorders
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What is HCC?
• HCCs are wiped clean each January
• Capture comorbidities for all new patients and once per year for established patients
Source: https://www.google.com/search?q=he%27s+cured+pig+cartoon&tbm=isch&source=iu&ictx=1&fir=CY3ehcOIFg8DjM%253A%252CMCyWt0RCwdIiCM%252C_&usg=__cbvWImKAuTCeINaiOzbjxt2MWKE%3D&sa=X&ved=0ahUKEwjvzIXQgrvaAhWE7IMKHeBaCrUQ9QEIKzAA#imgrc=a34zq2F888zLZM:
HCC Risk Adjustment Scoring
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HCC Risk Adjustment Score
HCC Risk Score
Disease Interactions
Diagnosis
Demographics
HCC Inputs
• Age
• Gender
• Duel enrollment in Medicaid
• Residency status –community vs institutional
• Diagnoses ICD-10 codes
▪ Disease-disease interactions
▪ Disease-disability interactions
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HCC Risk Adjustment Score
HCC 1.0
Average Risk Patient
HCC < 1.0
Healthier Patient
HCC > 1.0
Sicker Patient
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Beneficiary Risk Adjustment Factor (RAF) Example
Scenario A: 75 year old male
ICD-10 ICD-10 DESCRIPTION HCCHCC
Score
Demographic base factor --- 0.466
M06.09RA without Rheumatoid factor, multiple sites
40 0.423
E11.9Type 2 diabetes mellitus without complications
19 0.104
E66.9 Obesity, unspecified 0.000
I49.9Cardiac Arrhythmia, unspecified
0.000
Disease Interaction: 0
HCC Beneficiary RAF: 0.993
ICD-10 ICD-10 DESCRIPTION HCCHCC
Score
Demographic base factor --- 0.466
M06.09RA without Rheumatoid factor, multiple sites
40 0.423
E11.21Type 2 diabetes with diabetic nephropathy
18 0.318
E66.01 Morbid obesity 22 0.273
I48.2Atrial fibrillation, chronic
96 0.268
Disease Interaction: 0
HCC Beneficiary RAF: 1.748
Scenario B: 75 year old male
Note: Increased specificity does not always increase the score. See supplemental slides for additional information.
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Beneficiary Risk Profile
You can gain insight into your historic beneficiary risk profile by reviewing your QRUR
• Overall beneficiary risk compared to all patients nation-wide
• Attributed patient beneficiary risk percentile scores
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Sample Rheumatology QRUR Reports
Practice A: 10+ Provider Suburban Rheumatology Practice
Beneficiary Risk 56th Percentile
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Sample Rheumatology QRUR Reports
Practice B: Two Provider Rural Rheumatology Practice
Average Beneficiary Risk 69th Percentile
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• Retrieve beneficiary details from Table 3B of the QRUR
• Group patients into HCC percentile ranges
• Count patients by HCC percentile range then graph results
Creating an HCC Profile For Your Practice
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• It is important to do a baseline assessment of ICD coding to determine if current coding practices support accurate assignment of beneficiary risk
ICD Coding Analysis
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• It is important to do a baseline assessment of ICD coding to determine if current coding practices support accurate assignment of beneficiary risk
ICD Coding Analysis
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Rheum
Related ICD Count %
Yes 64,393 98.48%
No 996 1.52%
Actions for Rheumatology Practices to Support Appropriate Beneficiary Risk Assignment
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What Do I Need To Do?
• Document and code comorbidities
▪ All new patients
▪ Established patients once per calendar year
• Be specific when documenting and coding for comorbidities
• Review your current QRUR report to see how you performed historically on cost measures
▪ Cost performance
▪ Beneficiary risk percentile
• Conduct a baseline ICD coding analysis
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• It is appropriate to capture and code for a comorbidity when it is
necessary to consider the comorbidity in treating the patient
▪ Disease state
▪ Medications used to manage the comorbid condition
▪ Disease-disease interactions
▪ Impact of planned treatment on the treatment or outcome of the
comorbidity
• Documentation of the comorbidity must reside within the assessment and
plan section of the note in order for the ICD to be assigned
• Do not assign ICDs solely based on past medical history or the problem list
• Be careful about copy/paste/carry-forward for comorbidities. Your
comment pertaining to the comorbidity must reflect current status
Documenting and Coding Comorbidities
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• These examples, if documented in the Assessment and Plan
section of the note , support reporting the comorbidity:
▪ Hypertension – BP 138/82 today. Well controlled on Atenolol 100mg daily.
▪ Hypertension – BP 168/92 today on Atenolol 100mg daily. Return to PCP for BP check.
▪ Chronic Afib – Asymptomatic today, on Warfarin. Managed by Cardiologist.
▪ Morbid obesity – BMI 41.2 today. Referred to PCP for BMI management.
▪ Diabetic neuropathy legs and feet – Managed by PCP, on Lyrica and Metformin.
Documenting and Coding Comorbidities
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• Here are examples of insufficient documentation to report comorbidities on the claim:
• Past medical history: CHF since 2001
• Vitals: BMI 41.1
• Assessment: Diabetes [no further discussion in the note]
Documenting and Coding Comorbidities
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Questions?
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Thank You
Gloria Johnston, MBA, RN, RHITChief Health Information Officer
O: 888-507-2988 x102C: 919-723-7938
Lynette Byrnes Chair Administrator Committee
VP RCM Management & Practice Workflows
C: 631.334.6296E: [email protected]
Supplemental Slides
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Resources
Resource Link
CMS Cost Measures https://www.cms.gov/Medicare/Quality-Payment-Program/Resource-Library/2018-Resources.html
Cost Performance Category Fact Sheet https://www.cms.gov/Medicare/Quality-Payment-Program/Resource-Library/2018-Cost-Performance-Category-Fact-Sheet.pdf
CMS QPP Site https://qpp.cms.gov
Healthcare Update eNewsletters http://healthcareenewsletters.com/articles/20180402.html
Hierarchical condition categories(HCCs) and the shift to value-basedReimbursement [3M whitepaper]
http://multimedia.3m.com/mws/media/1340264O/hccs-and-shift-to-value-based-reimbursement-white-paper.pdf
2017 RAF Score Reference https://www.cms.gov/Medicare/Health-Plans/MedicareAdvtgSpecRateStats/Downloads/Announcement2017.pdf
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Glossary
• Beneficiary Risk – Valuation assigned to each Medicare patient which is reflective of their health status
• HCC – Hierarchical Condition Category
• MIPS – Merit-based Incentive Payment System
• RAF – Risk Adjustment Factor
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RAF Score Reference
33 Source: http://multimedia.3m.com/mws/media/1340264O/hccs-and-shift-to-value-based-reimbursement-white-paper.pdf
• Example from 2017 RAF Score Reference
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Diagnosis Specificity and HCCs
34 Source: http://multimedia.3m.com/mws/media/1340264O/hccs-and-shift-to-value-based-reimbursement-white-paper.pdf
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• HCC 2 Septicemia, Sepsis, Systemic Inflammatory Response Syndrome/Shock
• HCC 42 Peritonitis/Gastrointestinal Perforation/Necrotizing Enterocolitis
• HCC 120 Seizure Disorders and Convulsions
• HCC 122 Non-Traumatic Coma, Brain Compression/Anoxic Damage
• HCC 125 Respirator Dependence/Tracheostomy Status
• HCC 126 Respiratory Arrest
• HCC 127 Cardio-Respiratory Failure and Shock, Including Respiratory Distress Syndromes
• HCC 156 Pulmonary Embolism and Deep Vein Thrombosis
Disease-Disease Interaction HCC’s
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