In an era of accelerating medical costs and flat payments
from CMS, accurately reflecting the health status of your members through
proper HCC (Hierarchical Condition Category) management is the only way for
your Medicare Advantage plan to remain financially viable. The secret to successful long-term risk
adjustment for your Medicare Advantage plan is to properly educate your
providers as to the value of complete and accurate coding of every member,
every year. Historically, providers have coded for payment, which simply
doesn't work well in the new world of 100 percent risk-based plan compensation,
where complete and accurate coding of every patient on an annual basis is
imperative.
Compliant Coding = Compliant Documentation
The quality
of the documentation is vital to nearly every aspect of health care, and
accurate chart documentation and diagnosis reporting determines reimbursement
for the CMS Medicare Advantage Plans under the Risk Adjustment Program. However, CMS validation findings indicate
that coded conditions are not supported in approximately 30 percent of the
records reviewed.
Risk adjustment data validation is the process of verifying
that diagnosis codes submitted for payment by the MA organization are supported
by medical record documentation for an enrollee. You should assume that—sooner
or later—CMS will audit your medical records, and potentially your program.
Explaining the role of clinical documentation and its impact
on CMS-HCC will enable everyone to have a good understanding of the big
picture.
Important points you should make include:
- Well-documented
medical records facilitate communication, coordination, and continuity of
care, and promote the efficiency and effectiveness of treatment.
- Accurate
coding is the key to prompt reimbursement, practice profiling, and
contract negotiations. It is important for both financial and compliance
reasons.
- Chronic
conditions are important to show not only resource utilization, but also
severity of illness for statistical purposes.
- Specificity
is important for further research into treatment effectiveness for chronic
conditions.
- Showing
medical necessity means you are justifying your treatment choice and help
support E/M levels.
Evaluate you Program and Process
There may be opportunities within your current process to
capture a more appropriate CMS-HCC code. For instance, consider this list of
the top Ten Coding Errors for Risk Adjustment published by the AAPC:
- The
records must contain a legible signature including a credential.
- EMR
records must be authenticated, such as “electronically signed by,”
followed by the providers name and credential
- Highest
degree of specificity refers to assigning the most precise ICD-9-CM code
that fully explains the narrative description in the medical chart of the
symptom or diagnosis.
- Discrepancy
between the diagnoses codes being billed versus the actual written
description in the medical record. If the record indicates depression, NOS
(311), but the diagnosis code written on the encounter document is major
depression (296.20) these codes do not match; in addition, they map to a
different HCC category. The diagnosis code and the description should
mirror one another
- Documentation
does not indicate that the diagnoses are being monitored, evaluated, assessed/addressed,
or treated (MEAT).
- Status
of Cancer is unclear, treatment is not documented
- Chronic
conditions such as hepatitis or renal insufficiency not documented as
chronic.
- Specificity:
unspecified Arrhythmia coded rather than the specific type of arrhythmia.
- Chronic
conditions or status codes not documented in the medical record at least
one per year.
- Missing
linkage or causal relationship for diabetic complication/Failure to report
mandatory manifestation code.
Regardless of where you find shortcomings, you’ll want to
consider options to improve clinical documentation.
Develop a compliance
plan and/or a coding integrity plan.
Limit retrospective reviews and implement proactive policies
with ongoing monitoring and feedback.
Many plans use analytics to detect members who might have
missing diagnosis codes based on the analysis of pharmacy, claims, and DME
data. Analytics are a good tool to point you in the right direction, but they
are not a solution alone. Even if the
analytics identify the patient is missing a diagnosis, and the medical record
indicates the patient has the condition, often the doctor has not documented
the condition in the appropriate manner (MEAT, etc.) which, from a coding guideline perspective, means that code cannot be
submitted.
Prospective chart reviews reduce the chances of submitting
invalid or non-specific diagnose codes to CMS, and also reduce providers’
compliance risk. Having a review program in place also allows you to identify
problem areas quickly, and identify opportunities for provider education and
interaction.
The medical record
should tell a complete story. Coders need to understand what the physician
is thinking and know when the provider isn’t documenting the complete
information to assign the most specific diagnosis code. Ensure that all
opportunities for documentation improvement are identified.
ICD 10 and Risk Adjustment
2014 is sure to bring a unique set of challenges to the Risk
Adjustment Arena.
Currently, there is a
30% shortage of certified coders in the US, and that is expected to jump by 57%
with the implementation of ICD-10
What is the potential impact of this transition? Consider
these 7 potential risks:
·
ICD-10 requires changes at the core of
healthcare business, especially how patient care is documented (Compliance will
require far more effort than learning a new code),
·
Inadequate allocation of training and education resources
will have a more significant impact with ICD-10 than it ever did with ICD-9,
·
Reimbursement losses due to ineffective,
physician clinical documentation will be magnified,
·
Without sustained physician leadership and sponsorship,
the possibility for negative political impacts related to poor physician
clinical documentation will increase,
·
Training physicians can be a challenging effort,
·
Fraud and
abuse is now more aggressively pursued so that poor clinical documentation can
pose a higher risk than previously experienced, and
·
Less than appropriate clinical documentation
results in a lack of compliance within medical staff by-laws specific to
Medicare patients, and is applicable to both out-patient and in-patient
settings.
RETURN ON INVESTMENT CDI Education
Consider the following ROI example from “Cracking the Code”
A Physician Clinical
Documentation Improvement Program is a self-funded initiative.
While each healthcare organization must balance funding
numerous concurrent or planned initiatives, a program for Physician Clinical
Documentation Improvement is one of a few initiatives that can be self-funded
based on the increased revenue that consistently is generated from improved
documentation. Why is this true? The
cost of a program will initially yield an ROI of a ratio of 1 to 5 or 1 to 4.
Example based on
actual returns after a Physician Clinical Documentation
Improvement program has been enacted:
Small Hospital (100 beds): Investment in program (external
resource) = $25,000
Increase in Revenue = $ 125,000
RETURN ON INVESTMENT – CODING + CDI + Lean Practice Management
Education Empowers. It empowers physicians, NP’s and PA’s,
Receptionist, Nurses, Coders, Medical Records Clerks, Patients and Care Takers.
ERM’s unique Rapid
Practice Innovation program routinely returns 300%+, but the greatest gift
of all is the desire for something better. In as little as a week, we have
successfully “revived” dying practices.
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