Risk Adjustment Overview

Hello and welcome to Risk Adjustment, Importance of Coding webinar.

Today we will discuss what risk adjustment is in the process, medical record retrieval encoding, provider coding education, hierarchical condition, categories and common errors and lastly best practices.

Now before we dive in, just a little disclaimer that us CQIL's are not certified coders, nor are we risk adjustments specialists.

We do not ever tell network providers how to code, because you all code according to the services you render and the documentation in the medical record must support any codes used.

The purpose of this presentation is to relay information to you in an effort to stress the importance of coding. If you have any questions related to the content.

There will be an email for the risk adjustment department provided at the conclusion.

Risk adjustment and the process.

What is risk adjustment? It is the process where health plans are equitably reimbursed based on the expected cost to care for their member population and the purpose of this system is to adequately cover the cost of care by providing covered benefits for enrollees, including those with complex conditions.

So essentially risk adjustment ensures that insurers receive appropriate revenue for the health care cost of the population they are insuring.

Providers have an important role to play in risk adjustment too according to the AAPC, which is the advancing the business of healthcare.

An engaged partnership between the provider, and the health plan is vital to bringing valuable benefits to enrollees. For instance, insurers may use premiums and risk adjustment payments to offer its members enrollment in exercise programs, case or disease management.

Transportation to medical appointments and any other services.

The health plan uses diagnosis codes that providers submit on claims to identify what types of programs are needed and more specifically, who needs them.

So for the providers risk adjustment simply means that the documentation should capture the patient's full health story including all of the conditions that may affect how they are managed and, or treated all current and coexisting diagnoses should be documented during every encounter and submitted to the highest level of specificity.

In addition, all relevant conditions must be captured on an annual basis year over year.

So, let's walk through the risk adjustment process.

A patient visits a health care provider either in person or virtually, the provider documents all relevant medical conditions in the patient's medical record and claims are submitted to support what was completed during the visit which will include the diagnosis codes as well as quality codes, the plan receives the codes and are able to predict risk scores for financial purposes.

The plan also submits claims to the regulatory bodies such as the Centers for Medicare and Medicaid services also known as CMS and the State. Now for the regulatory action based on applicable risk adjustment model risk scores and reimbursements are calculated. The plan data is reviewed and audit planning countered submissions are completed.

Risk adjustment coding. Medical record retrieval also known as MRR and coding ensures Horizon knows and understands the full health status of our members and allows Horizon to identify provider educational opportunities centered around improved coding and documentation.

The benefits of this include providing feedback to providers on any missed diagnosis codes that weren't included on claims and that is an under payment risks as well as unsupported diagnosis codes included on the claims, now that would be an overpayment risk.

This process may identify provider billing issues, such as EMR diagnosis code restrictions and another benefit is complete and accurate clinical diagnosis to drive comprehensive care and improve clinical outcomes.

Now, at some point in the future, there will be a shift focusing on documentation improvement and billing of diagnosis codes, which will reduce the need to retrieve such a high volume of medical records.

We are going to review a couple of helpful acronyms to help capture the full health status of a patient. It is very important that providers document the patient's full health history as previously mentioned.

The first acronym is MEAT, it is used to describe 4 factors that help providers with proper documentation to establish the presence of a diagnosis during an encounter.

M for manage or monitoring to include signs and symptoms, whether it's improving or worsening of the condition, E, for evaluate to include test results, medication effectiveness and response to treatment, A for assess

to include ordering tests, review records or counseling and lastly, T, for treated to include medications therapies, other treatments and procedures.

The next helpful for acronym to help capture the full health status of a patient.

The TAMPER approach involves reviewing the chart for acceptable documentation and evidence and also pulling it together to tell a comprehensive and accurate story about the patient for ongoing and future care.

Now, this acronym stands for T for treatment to include surgery, medication, therapy, procedure, counseling, education, DME ordered or given and labs ordered. A for assessment to include acknowledging, giving status level of condition.

M, for monitoring or medicate to include ordering referencing labs, other tests, prescribing medication.

P, for plan. Plan for management, or follow up of condition.

E, for evaluate to include examining as in a physical exam.

R for a referral, referral to specialists for treatment, or a consultation of a confirmed condition.

HCC stands for Hierarchical Condition Categories, and these are a set of medical codes that are linked to specific clinical diagnosis and each HCC represents multiple diagnoses with similar clinical complexity, and expected annual care costs.

So these diagnoses had been assigned a value for risk adjustment. HCC models rely on the reported ICD 10 codes to establish the patient's health status annually so thorough clinical documentation and complete diagnosis coding are crucial to accurate HCC reporting.

Risk adjustment coding common errors.

We will now review a few situations where an audit has shown inaccuracies in reporting, which leads to an incorrect HCC.

HCC 74, disorder of the immune mechanism.

Diagnosis codes, D84.9 which is immunodeficiency, unspecified or D89.9 disorder involving the immune mechanism. Unspecified.

These codes should not be reported for immunosuppression resulting from use of drugs to treat auto immune conditions such as rheumatoid arthritis, multiple sclerosis or inflammatory bowel disease.

For the reporting of immunodeficiency conditions, documentation must specify the type of immunosuppression such as primary, defined by an inherent absence or quantitative deficiency of cellular humoral or both components that provide immunity.

Secondary is acquired and defined by loss or qualitative deficiency in cellular or humoral immune components that occur as a result of a disease process, or its therapy.

The next HCC is 132, unstable angina and other acute ischemic heart disease, if coronary artery disease, I25.10 is documented in the medical record without any evidence of a clinical syndrome of angina, whether it be stable or unstable being addressed and atherosclerotic heart disease of native coronary artery with unstable angina pectoris, which is I2 5.110 cannot be reported. Medical record documentation for an acute coronary syndrome, which is I24.8 and or unstable angina, which is to I20.0 and other correlated conditions must specify a definitive diagnosis along with supportive evidence that may include the underlying disease and associated symptoms.

The next common error is HCC 142 specified arrhythmias.

To correctly report an arrhythmia condition, such as unspecified atrial fibrillation or Supraventricular tachycardia documentation must include a definitive diagnosis of the type of arrhythmia being addressed, we need to avoid contradictory documentation for which the final diagnosis does not support the evaluation. And the treating clinician in the medical record should be clear. Diagnosis codes I48.91 or I47.1 can be captured when the documentation contains the specific type of arrhythmia, and should always be reported at the highest level of disease specificity documented by the treating physician.

HCC 2 septicemia, sepsis, systemic inflammatory response syndrome or shock. Report diagnosis A41.9 of sepsis when documentation specifically addressed the quality of care, the patient is receiving and includes an underlying system infection, treatment of condition with medications and tests such as blood cultures ICD 10 CM guideline section I, states the term urosepsis is a non-specific term and does not have a code in ICD 10.

It is not to be considered synonymous with sepsis. If a provider uses the term urosepsis he or she should be questioned for clarification.

HCC 8 metastatic cancer.

If this is a valid patient diagnosis, the documentation should specifically indicate both the primary and the secondary malignant sites and include supportive evidence that the primary site has metastasized, even though it was removed and the secondary malignancy is active, we need to specify the histology and or behavior of the neoplasm. If known, as benign, primary malignant, secondary malignant, in situ or uncertain, as per the ICD guidelines, only multiple myeloma and leukemia conditions can be categorized as in remission. Other types of cancer are identified as active current or history of.

The next one is HCC42, Peritonitis/gastrointestinal perforation necrotizing enterocolitis. When reporting a peritonitis condition, determine its underlying cause and treatment as well as if the documentation includes pertinent information regarding body fluids. The treatment usually involves antibiotics, medication for pain, and drainage of fluid when necessary.

Gastrointestinal perforation is usually associated with Crohn's disease and malignancy. When reporting this, document the specific treatment and nature of the disease process that cause the perforation.

Next one is HCC 42 necrotizing enterocolitis. This is a serious condition that occurs with inflammation infection or ischemia lead to intestinal necrosis and while it is most commonly seen in premature infants, the condition can occur in term infants.

Infants outside of the newborn period as well as adults, when reporting this condition, the age of the patient needs to be determined and the specific treatment, it depends on the nature of the disease and should be documented.

Coders should carefully review the documentation for proper code abstraction and should know how to differentiate disease processes.

HCC 82 drug dependency. Code F13.20 when documentation clearly indicates dependency of current prescribed drug the patient is actively taking.

Documentation of drug dependence solely in the past medical history should not be linked to a current medication or drug, without dependence documented in the patient's assessment and plan within the medical record.

Proper documentation should include pattern of harmful usage, current state, and the relationship to any identified mental, behavioral or physical disorder. If documented drug use is not treated or noted as affecting the patient's health, do not code for drug dependency.

So this is the last example, we will review.

HCC 88 and 59 major depressive disorder and bipolar disorders. When documenting this a record must contain information regarding the episode, severity and state of remission.

The providers should document if depression is well controlled with medication or active therapy should note results of a depression screening and if suicide risk was access. When documenting bipolar disorder the providers should report whether the current episode is hypomanic, manic, depressed or mix. The severity, and state of remission.

Suggested best practices. Before we conclude, let's take a look at some best practices.

Every visit should be treated as if it's the only opportunity you have to capture a patient's health status in the year, regardless of the reason for the visit.

Fully document all applicable conditions for each patient you treat by, including the appropriate ICD 10 codes on every claim submission and document all current and co-existing diagnosis during every encounter and submit to the highest level of specificity, all relevant conditions must be captured on an annual basis year over year. In addition to submitting ICD 10 codes, ensure you also submit quality codes to help HEDIS gaps in care.

Adopt technologies, such as electronic health records or voice translation software to improve accuracy and efficiency.

Engage clinicians to accurately capture primary conditions and present comorbidities, particularly in more complex cases.

Involve coders in office staff to ensure the use of coding, best practices.

Standardized coding processes to minimize disruption in the billing work flow.

So, this concludes the presentation. If you have any questions please email the risk adjustment team at the email you see noted here.

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