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.