Opioid Use Disorder is defined by the DSM-5 as a “problematic pattern of opioid use…”
KEY TOPICS INCLUDE:
Vast changes are coming to Medicare risk adjustment in 2022 and beyond. Is your team ready?
What are the potential impacts to your revenue without RAPS?
Discuss the importance of managing HCCs year over year. What resources are available from CMS to help?
What are the components of a risk score and how is it calculated? What is the impact of the payment count?
Review NEW HCCs and see what documentation is needed to validate payment.
Simple steps for optimizing risk adjustment operations and associated revenue.
Take a deep dive into the grey areas and red flags of HCC coding and clinical documentation. See what your team should and should not be coding.
WHO SHOULD ATTEND?
EACH ATTENDEE WILL RECEIVE:
HOW DO I REGISTER?
Register here for Friday, February 19, 2021
Register here for Friday, March 26, 2021
Register here for Friday, April 23, 2021
Register here for Friday, May 28, 2021
WHAT IS THE COST?
Tickets - $49
Bring the Whole Team and SAVE 10% on 3 or more tickets!!
WHERE CAN I LEARN MORE?
Visit ERM365 (www.erm365.org/events) to learn more.
APPROVED by the AAPC for 5 CEUs
Medicare Advantage (MA) is one of the fastest-growing and most complex health plan lines of business representing significant growth opportunities for payers. Launching and/or managing a successful MA market requires careful, strategic planning to meet requirements, ensure compliance, and maximize the program benefits for your organization.
Success in this market will depend on success in each of the following essential areas:
This course will touch on all four essential areas of MRA Operations.
Learn more or Register here
Review the Agenda below:
Risk Adjustment Operations
CMS-HCC Risk Models
Calculating Risk Scores and Payments
Optimizing RA Operations
Join us on-demand for this event recorded 11/11/2020. The presentation is an introduction to risk adjustment and HCC coding for coders, physicians and other healthcare professionals.
Approved by the AAPC for 2 CEUs - only $14.99
Join us on-demand for this event recorded on 11/13/2020. This course is an advanced course on risk adjustment and HCC coding for coders, physicians and other healthcare professionals.
Approved by the AAFP and AMA for 5 CMEs and the AAPC for 7 hours CEUs – only $49.00
It has taken CMS more than 50 years, but the agency has finally proposed a regulatory definition for determining whether an item or service is "reasonable and necessary" for Medicare coverage purposes. Medicare Program; Medicare Coverage of Innovative Technology (MCIT) and Definition of "Reasonable and Necessary," 85 Fed. Reg. 54327 (Proposed Rule, September 1, 2020). This move comes in response to the President's October 3, 2019 Executive Order 13890 directing the Secretary of HHS to ensure that Medicare beneficiaries have access to new cures and technologies that improve health outcomes. While CMS simultaneously seeks to establish a Medicare coverage pathway for medical devices designated as breakthrough by the FDA in this proposed rule, the proposed regulatory definition, including a possible consideration of whether an item or service is covered in the commercial insurance market, marks some progress toward clarifying when Medicare coverage is available. Comments to the proposed rule must be received by November 2, 2020.
The 2021 ICD-10-CM files below contain information on the ICD-10-CM updates for FY 2021. These 2021 ICD-10-CM codes are to be used for discharges occurring from October 1, 2020 through September 30, 2021 and for patient encounters occurring from October 1, 2020 through September 30, 2021.
Overview of Changes
The final update includes hundreds of new ICD-10-CM codes including (but not limited to):
This audit involved individuals eligible for Medicare who were covered under traditional Medicare in one year but chose to enroll in Medicare Advantage (MA) the following year (transferred enrollees). The Centers for Medicare & Medicaid Services (CMS) maps certain diagnosis codes into Hierarchical Condition Categories (HCCs). For transferred enrollees who, while covered under traditional Medicare, receive a diagnosis that maps to an HCC, CMS makes higher payments to MA organizations for the following year.
Through data mining and discussions with medical professionals, we have identified several diagnosis codes that were at high risk of being miscoded and resulting in inaccurate payments. For this audit, we focused only on selected acute stroke diagnosis codes (which map to the Ischemic or Unspecified Stroke HCC) that were reported on one physician's claim without being reported on a corresponding inpatient claim.
Our objective was to determine whether selected acute stroke diagnosis codes submitted by physicians under traditional Medicare that CMS later used to make payments to MA organizations on behalf of transferred enrollees complied with Federal requirements.
We reviewed 582 of 8,437 transferred enrollees (that we selected with a stratified random sample) who received one instance of a high-risk acute stroke diagnosis code during 2014 or 2015. We had reviews performed to determine whether the medical records supported the submitted diagnosis codes. We relied on these reviews as the basis for our conclusions.
Almost all of the selected acute stroke diagnosis codes that physicians submitted to CMS under traditional Medicare and that CMS later used to make payments to MA organizations for 2015 or 2016 on behalf of the 582 transferred enrollees did not comply with Federal requirements. For 580 of the transferred enrollees, the medical records did not support the acute stroke diagnosis codes. Thus, the Ischemic or Unspecified Stroke HCCs were not validated.
These errors originated from physicians submitting incorrect acute stroke diagnosis codes on claims billed under traditional Medicare. However, these errors were unnoticed and caused inaccurate payments in MA because CMS did not have policies and procedures to (1) identify beneficiaries who transferred from traditional Medicare to MA, and (2) evaluate whether the acute stroke diagnosis codes submitted under traditional Medicare on their behalf complied with Federal requirements. As a result, we estimated that CMS made inaccurate payments of just over $14.4 million to MA organizations.
We recommend that CMS (1) educate physicians on how to correctly submit acute stroke diagnosis codes and how these diagnosis codes may impact the MA program, and (2) develop and implement policies and procedures to identify beneficiaries transferring from traditional Medicare to MA and evaluate whether the acute stroke diagnosis codes submitted under traditional Medicare comply with Federal requirements.
CMS concurred with our recommendations and described actions that it had taken or planned to take to address them. Specifically, CMS stated that it would continue to educate physicians on how to correctly submit acute stroke diagnosis codes, including updated information on how these codes may impact the MA program. CMS also stated that although our findings account for less than 0.5 percent of all transferred enrollees, it would review its existing policies and procedures to evaluate whether any further clarification is needed with regards to acute stroke diagnoses.
Filed under: Centers for Medicare and Medicaid Services
Billions in estimated risk-adjusted payments supported solely though HRA’s raise concerns about the completeness of payment data, validity of diagnoses on HRA’s and quality of care coordination for beneficiaries.
OIG findings highlight concerns about the extent to which MAOs are using HRAs to improve care and health outcomes, as intended, and about the sufficiency of the oversight by the Centers for Medicare & Medicaid Services (CMS).
From an analysis of 2016 MA encounter data, the OIG found that:
Diagnoses that MAOs reported only on HRAs, and on no other encounter records, resulted in an estimated $2.6 billion in risk-adjusted payments for 2017.
In-home HRAs generated 80 percent of these estimated payments. Most in-home HRAs were conducted by companies that partner with or are hired by MAOs to conduct these assessments—and therefore are not likely conducted by the beneficiary’s own primary care provider.
Twenty MAOs generated millions in payments from in-home HRAs for beneficiaries for whom there was not a single record of any other service being provided in 2016.