Saturday, February 20, 2021

Opioid Use Disorder

 


Opioid Use Disorder is defined by the DSM-5 as a “problematic pattern of opioid use…”

  • A code of F11.20, opioid dependence, should not be assigned for patients taking pain medication as prescribed.
  • Instead a code of Z79.891, long term use of opiates, should be assigned.

Coders should always be mindful of ICD-10 Guidelines and Coding Clinic Guidance when assigning codes for substance use disorder.

2021 ICD-10 Guidelines (pages 43-44)

Chapter 5: Mental, Behavioral and Neurodevelopmental disorders (F01 – F99)

b. Mental and behavioral disorders due to psychoactive substance use

3. Psychoactive Substance Use, Unspecified
As with all other unspecified diagnoses, the codes for unspecified psychoactive substance use (F10.9-, F11.9-, F12.9-, F13.9-, F14.9-, F15.9-, F16.9-, F18.9-, F19.9-) should only be assigned based on provider documentation and when they meet the definition of a reportable diagnosis (see Section III, Reporting Additional Diagnoses). These codes are to be used only when the psychoactive substance use is associated with a physical disorder included in chapter 5 (such as sexual dysfunction and sleep disorder), or a mental or behavioral disorder, and such a relationship is documented by the provider.

AHA Coding Clinic Guidance

Question:
Medical record documentation indicates the patient is taking opioids prescribed by their physician for treatment of chronic pain. Does Guideline I.C.5.b.3. mean that codes cannot be assigned for the opioid use unless there is documentation of an associated physical, mental or behavioral disorder?

Answer:
A code for the use of prescription opiates would not be reported because there is no associated physical, mental or behavioral disorder.

Reference: AHA Coding Clinic 2018 2nd Quarter, pages 11 and 12

Learn more or download a copy of DSM-5 Criteria here https://erm365.org/opioid-use-disorder/


Saturday, February 13, 2021

Looking for an MRA Coding Tool?

2021 CMS-HCC Coding Tool Example


We have received several requests from physicians, coders and administrators for an “MRA Cheat Sheet”.

Many have asked for something that is a single page or similar in format to a “charge slip”. 

So, I wanted to share a simple example of one that could be used for primary care providers. 





Visit www.ERM365.org for more risk adjustment tools and information!


Sunday, January 24, 2021

Advanced Risk Adjustment and HCC Coding for Value Based Payments



Due to extremely high demand, new dates have been added for the 2021 workshops!


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?

  • Physicians and Other Providers
  • Coders, CDI Specialists and Auditors
  • Nurses, Medical Assistants and Scribes
  • Medical Directors and CIOs
  • MA, Medicaid and Commercial Plans
  • ACO, MSO and IPA Teams
  • Hospitals and Academic Centers
  • Community Health, RHCs and FQHCs
  • Health Alliance Members


EACH ATTENDEE WILL RECEIVE:

  • Color Presentation
  • CME / CEU / CE Certificate (Approved by the AAPC, AMA, AAFP and CCMC)
  • HCC Coding Tools Download
  • 25% off any HCC Tools ordered within 14 days of the event.


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.

Download the agenda / flyer 






Saturday, January 9, 2021

Medicare Risk Adjustment Operations

 


APPROVED by the AAPC for 5 CEUs

Course Overview

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:

  • Value-based contracting
  • Clinical documentation and coding
  • Delivering high quality care
  • Managing utilization

This course will touch on all four essential areas of MRA Operations.

Learn more or Register here


Review the Agenda below:


Risk Adjustment Operations

  • Medicare Risk Adjustment Overview
  • History of Medicare Risk Adjustment
  • Key Concepts and Terms
  • Risk Adjustment Data
  • Risk Adjustment Process
  • Risk Adjustment Data Validation


CMS-HCC Risk Models

  • PY 2020 CMS HCC Risk Adjustment Model
  • PY 2021 CMS HCC Risk Adjustment Model
  • PY 2022 CMS HCC Risk Adjustment Model


Calculating Risk Scores and Payments

  • General Payment Rules
  • Data Submissions and Payments
  • PY 2020 Risk Score Calculations
  • PY 2020 CMS-HCC Payment Calculation Example
  • PY 2021 Risk Score Calculations
  • PY 2021 CMS-HCC Payment Calculation Example


Optimizing RA Operations

  • Network Adequacy Guidance
  • Medicare Star Ratings
  • Growth and Retention
  • Reports and Resources

Visit www.ERM365.org to see more courses. 



Friday, January 8, 2021

MIPS Extreme and Uncontrollable Circumstances Exception Application Deadline Extended to February 1, 2021



For the 2020 performance year, MIPS eligible clinicians, groups, and virtual groups can submit an application to the Centers for Medicare and Medicaid Services (CMS) asking the agency to re-weight one or more performance categories to 0% due to the COVID-19 public health emergency. This means if you have concerns about the impact of the COVID-19 public health emergency on your performance data – including cost measures – you can submit an application to CMS and cite COVID-19 as the reason for your application.

CMS has recently announced that it will be extending the deadline for COVID-19-related 2020 Merit-based Incentive Payment System (MIPS) Extreme and Uncontrollable Circumstances Exception applications to February 1, 2021.

If you have concerns about the effect the COVID-19 public health emergency will have on your performance data for the 2020 performance period, including cost measures,  submit an application now and make sure you cite COVID-19 as the reason for your application. The deadline to submit a MIPS Promoting Interoperability Performance Category Hardship Exception application or an Extreme and Uncontrollable Circumstances application not related to COVID-19 remained December 31, 2020. If you are already exempt from reporting Promoting Interoperability data, you don’t need to apply.

Once you have an approved application, you can still receive scores for the Quality, Improvement Activities and Promoting Interoperability performance categories if you submit data. If the Cost performance category is included in your approved application, you will not be scored on cost measures even if other data are submitted. It is important to note that you cannot submit an application to override data for program year 2020 that has already been submitted and any data submitted either before or after an application has been approved will be scored. 


MIPS Extreme and Uncontrollable Circumstances Exception Application Deadline Extended to February 1, 2021 – Policy & Medicine


Saturday, November 21, 2020

Let’s Talk About Risk On-Demand

 



Let’s Talk About Risk On-Demand

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

https://erm365.org/courses/lets-talk-about-risk-on-demand/


Review the Agenda:

Section 1 – Risk Adjustment Basics

This section will cover basic concepts and terminology in the CMS-HCC Model of Risk Adjustment.

  • What is an HCC?
  • Why are HCCs important?
  • How is a risk score calculated?
  • What is the value of an HCC?
  • What are the most common HCCs?

Section 2 – Rules of the Road

This section will cover ICD-10 Guidelines and other “rules” related to clinical documentation and coding within the CMS-HCC Model of Risk Adjustment.

  • When should a diagnosis be coded?
  • How often can a diagnosis be coded
  • What clinical documentation is needed to support the diagnosis?
  • Is it okay to code for resolved conditions?
  • Would it be acceptable to code a diagnosis documented as “suspected” in an outpatient setting such as a provider’s office?

Section 3 – HCC Coding

This section will review the most common HCC’s for Medicare enrollees based on MedPAC data.

  • What are the twenty most common HCC categories for Medicare enrollees?
  • What are the most common ICD-10 codes included in each category?
  • How can clinical documentation impact code selection?
  • What are common errors leading to inaccurate risk scores?

Section 4 – Tips for Success

This section will cover simple tips that will make a big impact. At the end of this lesson you will be able to work smarter not harder.

  • What should be included in the problem list?
  • Why does clinical documentation need to clarify active vs. history of?
  • What small changes can you start making today that will have a big impact on the accuracy of your risk scores?

 

Who Should Attend? 

  • Coders, Billers, and Auditors
  • Physicians, NPs and PAs
  • Medical Assistants and Front Office
 
Price: $14.99
  • Purchase includes a copy of the presentation and other resources. 
  • 180 days of access to course and materials. 

 

On Demand Course Instructions for CEUs:

  1. Login or Register for a FREE account with ERM365.
  2. Purchase the course.
  3. Click on “My Dashboard” and then “My Courses” to access.
  4. Download the handouts and other resources.
  5. Watch the video.
  6. Pass the post quiz.
  7. Download CEU Certificate. 

Would you prefer to attend a LIVE event? Visit https://erm365.org/events/ to view the schedule and register. 




Advanced Risk Management and HCC Coding ON-DEMAND



 

Advanced Risk Management and HCC Coding for Value Based Payments On-Demand

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

https://erm365.org/courses/advanced-risk-management-and-hcc-coding-for-vbp-on-demand/


KEY TOPICS INCLUDE:

  • Vast changes are coming to Medicare risk adjustment in 2021 and beyond. Is your team ready? What are the potential impacts to your revenue?
  • 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?

  • Physicians and Other Providers
  • Coders, CDI Specialists and Auditors
  • Nurses, Medical Assistants and Scribes
  • Medical Directors and CIOs
  • MA, Medicaid and Commercial Plans
  • ACO, MSO and IPA Teams
  • Hospitals and Academic Centers
  • Community Health, RHCs and FQHCs
  • Health Alliance Members

PRICE: $49

On Demand Course Instructions for CEUs:

  1. Purchase the course 
  2. Download the handouts
  3. Watch the video
  4. Pass the post test
  5. Download CEU Certificate
  6. Submit post course survey

Would you prefer to attend a LIVE event? We have several upcoming LIVE events - view the schedule and/or register here https://erm365.org/events/










Thursday, October 22, 2020

HHS Extends COVID-19 Related Public Health Emergency Through January 20, 2021



On October 2, 2020, Health and Human Services (HHS) Secretary, Alex M. Azar II, announced the renewal of the public health emergency declaration due to the continued consequences of the COVID-19 pandemic. The 90-day renewal is effective October 23, 2020, and extends until January 20, 2021.

The renewal impacts a number of regulatory flexibilities and temporary rules applicable to health care providers including, but not limited to, 1135 WaiversHIPAA enforcement discretion, and fraud and abuse enforcement discretion – all of which are effective only for the duration of the public health emergency.

  1. 1135 Waivers

Section 1135 of the Social Security Act grants HHS the power to waive and/or modify certain federal healthcare requirements during a federal emergency to (i) ensure individuals enrolled in Medicare, Medicaid, and the Children’s Health Insurance Program (CHIP) have sufficient access to health care items and services and (ii) protect health care providers furnishing such items and services in good faith during emergency conditions against penalties for noncompliance.

Presently, HHS and the Centers for Medicare and Medicaid Services (CMS) have issued numerous “blanket” waivers and state-specific Medicaid waivers in connection with the COVID-19 public health emergency (including waivers related to sanctions under the physician self-referral law (Stark Law) for COVID-19 purposes).

These waivers afford health care providers enhanced flexibility with regard to Medicare telehealth services, waive certain physician hospital privilege requirements/credentialing process requirements, and suspend many reporting requirements.

  1. HIPAA Enforcement Discretion

The HHS Office of Inspector General (OIG) has issued various guidance providing for OIG enforcement discretion with regard to certain provisions of HIPAA (e.g., privacy, security, and breach notification rules) as it relates to permissible telehealth practices, business associates making disclosures for public health purposes, and community-based testing sites (CBTSs).

Note that in conjunction with the relaxation of certain federal HIPAA privacy and security rules during the public health emergency, health care providers should continue to be cognizant of compliance with other applicable state privacy laws to the extent they are still in effect.

  1. Fraud and Abuse Enforcement Discretion

In connection with applicable HHS waivers, the HHS Office of Inspector General (OIG) has issued guidance relaxing the imposition of administrative sanctions under the Anti-Kickback Statute and Stark Law for certain COVID-19 response activities (see also this OIG Policy Statement regarding physicians and other practitioners that reduce or waive amounts owed by federal health care program beneficiaries for telehealth services during the public health emergency).

Note that HHS retains the discretion to terminate the public health emergency at any time and is not required and/or obligated to extend the present declaration beyond its January 20, 2021 expiration. Accordingly, health care providers should be mindful of termination, expiration, and renewal timelines applicable to COVID-19 related emergency measures, which could immediately eliminate current regulatory flexibilities (such as the ones discussed herein).

[View source.]

Visit www.erm365.org to learn more. 

Tuesday, October 20, 2020

CMS Proposes a Regulatory Definition of Medically "Reasonable and Necessary"

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.

"Reasonable and Necessary"

CMS explains that it is proposing to establish in regulations the factors it has historically used in making "reasonable and necessary" determinations under Section 1862(a)(1)(A), with "some modification." 85 Fed. Reg. at 54329. It acknowledged that stakeholders have expressed interest in codifying this definition for many years and that the proposed definition is "familiar and functional." 85 Fed. Reg. at 54328. The factors used by CMS for this purpose are set forth in the Medicare Program Integrity Manual (MPIM) and state that:

An item or service is considered "reasonable and necessary" if it is

  1. (1) safe and effective;
  2. (2) not experimental or investigational; and
  3. (3) appropriate, including the duration and frequency that is considered appropriate for the item or service, in terms of whether it is
    • furnished in accordance with accepted standards of medical practice for the diagnosis or treatment of the patient's condition or to improve the function of a malformed body member;
    • furnished in a setting appropriate to the patient's medical needs and condition;
    • ordered and furnished by qualified personnel;
    • one that meets, but does not exceed, the patient's medical need; and
    • at least as beneficial as an existing and available medically appropriate alternative.

MPIM, CMS 100-08, ch. 13, § 13.5.4.

In addition to codifying the above criteria, CMS is proposing to include a separate basis under which an item or service would be "appropriate for Medicare patients" based on commercial health insurers' coverage policies (non-governmental entities that sponsor health insurance plans). And, CMS states that an "item or service deemed appropriate for Medicare coverage based on commercial coverage would be covered on that basis without also having to satisfy the bullets listed above." 85 Fed. Reg. at 54328.

By considering commercial health insurer coverage policies, CMS states that it would bring together the expertise of private payers and the Medicare program. Under this separate basis, CMS proposes that an item or service would satisfy factor (3) above if it is "covered under a plan(s) coverage policy if offered in the commercial insurance market, unless evidence supports that differences between Medicare beneficiaries and commercially insured individuals are clinically relevant." 85 Fed. Reg. at 54332. Under this proposal, CMS would exclude Medicaid managed care, Medicare Advantage, and other government administered health care coverage programs from the types of coverage CMS would consider, as these enrollees are not in the commercial market. CMS believes this definition is a "significant step in meeting the E.O.'s directive to bring clarity to coverage standards."

CMS specifically seeks comment on a myriad of issues related to this proposed definition, which include, among others, the following:

  • The sources of data that could be used to implement this policy;
  • The most appropriate source(s) for these coverage policies and best way to determine which commercial plan(s) it would rely on for Medicare coverage;
  • Whether beneficiaries, providers, innovators, or others wishing to gain coverage for an item or service demonstrate that the item or service is covered by at least one commercial insurance plan policy. If they can provide CMS with evidence of commercial coverage or if CMS or its MACs identify such coverage from its review of compilations of health insurance offerings or data from other sources, CMS would consider factor (3) to be satisfied;
  • Whether CMS should limit its consideration of commercial plan offerings or covered lives to a subset of the commercial market in the interest of simplicity, including looking at geographic subsets, subsets based on number of enrollees, subsets based on plan type (HMO, PPO, etc.), or other subsets of plans – including utilizing a singular plan; and
  • Whether CMS should adopt the most or least restrictive coverage policy since commercial plans may impose certain restrictions on an item or service (related to clinical criteria, disease stage, or number and frequency of treatment).

85 Fed. Reg. at 54332-54333.

In sum, CMS is proposing to define the term "reasonable and necessary" based on the factors currently found in the MPIM, plus an alternative basis for meeting factor (3) based on any coverage in the commercial market. As CMS states, it is soliciting comment on this proposed definition of reasonable and necessary as well as other mechanisms or definitions it could establish for the term "reasonable and necessary" and the merits and drawbacks associated with each, including the potential impact on Medicare program expenses or complexity.

Key Takeaways

To be sure, CMS did not propose this regulatory definition in a vacuum. This definition, if finalized, would be codified within 42 C.F.R. Part 405, Subpart B, which addresses "Medical Services Coverage Decisions that Relate to Health Care Technology." In this proposed rule and not discussed in detail here, CMS also seeks national Medicare coverage for breakthrough devices that are FDA market-authorized and used consistent with the FDA approved or cleared indication for use. For these devices, CMS will deem coverage under the MCIT pathway "reasonable and necessary under section 1862(a)(1)(A) of the Act because the device has met the unique criteria of the FDA Breakthrough Devices Program." 85 Fed. Reg. at 54329.

What is markedly absent from this proposed regulatory definition is an explicit requirement that this new regulatory definition be used solely for medical devices participating in the MCIT pathway and/or the FDA Breakthrough Devices Program. In fact, CMS explains:

Further, under our proposal, each MAC would be responsible for reviewing commercial offerings to inform their LCDs or claim by claim decisions, which would include individual medical necessity decisions. We may also allow the MACs to develop approaches to address any or all of the considerations outlined above, parallel to their current practice of making coverage decisions in the absence of an NCD or national policy.

85 Fed. Reg. at 54332.

While it remains to be seen whether claim adjudicators may utilize this proposed regulatory definition for other services or items outside of the FDA Breakthrough Devices Program or MCIT pathway, this could be useful for individual consideration of Medicare claims since any additional clarification to the subjective "reasonable and necessary" is helpful.


Read more



Friday, September 25, 2020

2021 ICD-10 Updates

 



Effective Dates

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.


Downloads

2021 Coding Guidelines (PDF)

2021 POA Exempt Codes (ZIP)

2021 Code Descriptions in Tabular Order (ZIP)

2021 Addendum (ZIP)

2021 Code Tables and Index (ZIP)

2021 Conversion Table (ZIP)


Overview of Changes

The final update includes hundreds of new ICD-10-CM codes including (but not limited to):

  • 128 additions to Chapter 19: Injury, poisoning and certain other consequences of external causes for adverse effects and poisoning by fentanyl and tramadol as well as other synthetic narcotics.
  • 125 additions to Chapter 20: External causes of morbidity, including more specific codes for collisions involving electric scooters and other nonmotor vehicle accidents.
  • 57 musculoskeletal codes, including several in category M24.- (other specific joint derangements) for other articular cartilage disorders, disorders of ligament, pathological dislocation, recurrent dislocation, contracture, and ankylosis.
  • 21 codes to describe withdrawal from substances including alcohol, cocaine, and opioids.
  • 18 detailed codes for sickle cell anemia. New codes such as D57.213 (sickle-cell/Hb-C disease with cerebral vascular involvement) and D57.431 (sickle-cell thalassemia beta zero with acute chest syndrome) specify complications related to the condition.
  • Three codes to capture stage 3 chronic kidney disease (CKD) in two new sub-stages. 
  • The new Chapter 22: Codes for Special Purposes (U00-U85) so far includes just two codes: U07.0 (vaping-related disorder) and U07.1 (COVID-19), which took effect in the early part of this year.
  • The final update deletes code Q51.20 (other doubling of uterus, unspecified) and all codes within subcategory T40.4X- (poisoning by adverse effect of and underdosing of other synthetic narcotics), without code replacements.

Visit ERM365 to learn more

Wednesday, September 23, 2020

Incorrect Acute Stroke Diagnosis Codes Submitted by Traditional Medicare Providers Resulted in Millions of Dollars in Increased Payments to Medicare Advantage Organizations

 



Why OIG Did This Audit

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.

How OIG Did This Audit

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.

What OIG Found

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.

What OIG Recommends and CMS Comments

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




Saturday, September 12, 2020

Billions in Estimated Medicare Advantage Payments From Diagnoses Reported Only on Health Risk Assessments Raise Concerns

 


Key Takeaways:

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.

Read the full report here