Urban Coding Legends: Morbid Obesity

Should you code morbid obesity when a patient has a BMI of 36?

This is one of my favorite questions to ask physicians, coders and healthcare executives when I am teaching. Why? Because it is guaranteed to elicit the following three responses:

A.      Yes, absolutely! As long as the patient has 3 or more chronic conditions….

B.      No, I never use that code. I don’t want to upset anyone with open notes and patient portals…

C.      No, morbid obesity should only be coded with a BMI of 40.0 or more…

One-third of the audience will select “A” as the correct answer, one-third will select “B” and one-third will choose “C”. This scenario will play out the same way in Miami, Philadelphia, Austin, Chicago, Little Rock or any other city in America. Why? Because it is an urban coding legend…

Urban Coding Legend #1:

Morbid obesity should always be coded when a patient has a BMI greater than 35.0 and 3 or more chronic conditions.  True or False? The answer is false. Obesity is defined and classified by both the United States Preventive Task Force and The National Institutes of Health and National Heart, Lung, and Blood Institute using the following classification: Obesity is divided into three classes. The third class, extreme obesity, also called severe obesity, is synonymous with the term “morbid obesity” and is diagnosed based on a BMI of 40.0 or greater. According to the NHLBI: A person with a BMI (body mass index) value of 40 or greater would be considered morbidly obese. An adult who has a BMI of 30 or higher is considered merely "obese.". Grade 3 overweight (commonly called severe or morbid obesity) is a BMI greater than or equal to 40 kg/m2. The Origins This “urban coding legend” originated from the corridors of “risk adjustment optimization” teams, searching for “low hanging fruit” and the clinical evidence to “support” it. The following events, recommendations and guidelines set the stage and a story was born… 1.       USPTF Updates Recommendations In 2012, the U.S. Preventive Services Task Force (USPSTF) issued updated recommendations regarding the screening and management of obesity for adults. 2.       The American Academy of Family Physicians The AAFP publishes clinical evidence to support the USPTF Recommendations: From the AAFP: In patients with a BMI of 25 kg/m2 or greater, further evaluation of risk factors is required. Blood pressure and lipid levels should be measured, and fasting glucose tested. Bariatric surgery may be considered in adults who have not achieved weight loss with dietary or other treatments and who have a BMI of 40 kg/m2 or greater, or for those who have a BMI of 35 kg/m2 or greater with significant obesity-related comorbidities (e.g., severe hypertension, type 2 diabetes, obstructive sleep apnea).  Bariatric surgery may also benefit patients with obesity-related comorbidities who have a BMI of 35 kg/m2 or lower, but it is not routinely recommended for these patients 3.      Medicare Payment Guidelines: In response to the updated USPTF Guidelines and AAFP clinical evidence supporting the benefit of gastric bypass surgery as a treatment for obesity Medicare updated their payment policies for this procedure: 150.6 - Claims Guidance for Payment (Rev. 2841, Issued: 12-23-13, Effective: 09-24-13, Implementation: 12-17-13) Covered Bariatric Surgery Procedures for Treatment of Co-Morbid Conditions Related to Morbid Obesity Medicare contractors acting within their respective jurisdictions may determine coverage of stand-alone LSG for the treatment of co-morbid conditions related to obesity in Medicare beneficiaries only when all of the following conditions are satisfied: ·         The beneficiary has a body-mass index (BMI) ≥ 35 kg/m2; ·         The beneficiary has at least one co-morbidity related to obesity; and ·         The beneficiary has been previously unsuccessful with medical treatment for obesity. 4.       Revised HCC Model On April 1, 2013 CMS released the Announcement of Calendar Year (CY) 2014 Medicare Advantage Capitation Rates and Medicare Advantage and Part D Payment Policies and Final Call Letter. In the Final Call Letter, CMS confirmed that they would be implementing the updated, clinically revised CMS-HCC risk adjustment model proposed in the Advance Notice for CY2014. The new model expanded the current number of Condition Categories from 70 to 79. Under the revised model, the “Metabolic” category was expanded from one (HCC 21) to three (HCC 21, HCC 22, HCC 23). Given the prevalence of obesity, the new HCC 22 “morbid obesity” was quickly identified as a “low hanging fruit” for optimization teams. By coding morbid obesity with a BMI of 35.0 vs. 40.0 the prevalence rates, A.K.A. payments, to the plans would greatly increase. The previous three events were loosely woven together to form support for the practice and an urban coding legend rose like a phoenix from the ashes. HCC 22 includes the following ICD-10 Codes:  Do you see a BMI under 40 in the above chart? Remember clinical, coding and payment guidelines can not be substituted to fit the situation as needed. ERM Consulting Inc. Kameron Gifford, CPC

Book Your Onsite Risk Adjustment Workshop Today!

Train your entire team onsite with our 1/2 day, 1 day and 2 day workshops!                

• AAPC CEUs available for your coders, CDI specialists, compliance team and auditors.
• AAFP and AMA CME available for all physician training.

 2017 dates are filling up quick!

• Intro to Risk Adjustment
• Advanced Risk Management for Value Based Care
• Intro to HCC Coding
• Advanced HCC Coding
• CDI for Risk Adjustment
• Risk Adjustment Validation
• Rapid Practice Innovation (TCPI)

    

      Half-day Workshops start at $3500

      One-day and Two-day Workshops start at $5000

      Visit ERM Consulting to learn more or email Kameron Gifford

    

    

How Can We Improve?

Are you looking for the very best in risk adjustment education?

If so, join us in Orlando, Florida on July 21, 2017 for a day of risk adjustment, clinical documentation improvement and HCC coding.

Why Should I Come?

• CME / CEU available from AAPC, AMA and AAFP

• Network with plan leaders, managed care executives, medical directors, primary care physicians, fiancé leaders and coders from across the country.

• Have your toughest questions answered by risk adjustment experts.

• Best of all, you will take home great tools!

             Bring the whole team and save 20% on 3 or more

Agenda:

• Review the different risk adjustment models and their impact on medical practice management.

• Discuss the impact of shifting from RAPS to EDS. What does this mean for office based claims.

• Take a deep dive into HCC Coding and Documentation. Review real examples to see what validates, what doesn’t, and why.

• Avoid risk adjustment pitfalls. Recent litigation relating to false risk adjustment certifications and  overpayments.

• Tips for engaging physicians.Learn how to leverage frontline staff to be successful in the world of risk adjustment and value based payments.

Who Should Attend:

• Managed Care Executives

• Physicians / Medical Directors

• ACOs, MSOs, IPAs and Health Alliance Members

• CMS TCPI Participants

• Value Based Care Organization

• Medicare Advantage, Commercial and Medicaid Plans

• Rural Health Centers and FQHCs

 

Each Attendee will Receive:

• Clinical Documentation and Coding Guide $ 99 Value

• HCC Quick Coder (Mappings to ICD-10 Codes) for MA and Commercial Models

• Risk Adjustment Workbook and Appendix with Easy to Use Templates

• Laminated Coding and Documentation Tools

Click Here to Download the Workshop Agenda

Click Here to Register for the Workshop

FOR DISCOUNTED HOTEL RATES:

Call to 407-964-7165 between 8:30am and 5:00pm,

Monday through Friday to book your room.

For More Events Visit ERM Consulting

AAPC CEU and AAFP CME Available!

This Live activity, Advanced Risk Management and CDI for Primary Care, from 07/21/2017 - 07/01/2018, has been reviewed and is acceptable for up to 5.75 Prescribed credit(s) by the American Academy of Family Physicians. Physicians should claim only the credit commensurate with the extent of their participation in the activity. 

AMA/AAFP Equivalency:

AAFP Prescribed credit is accepted by the American Medical Association as equivalent to AMA PRA Category 1 credit(s)™ toward the AMA Physician’s Recognition Award. When applying for the AMA PRA, Prescribed credit earned must be reported as Prescribed, not as Category 1.

The Centers for Medicare & Medicaid Services (CMS) announced predictive Qualifying APM Participant (QP) status for 2017 Advanced APMs.

Predictive Qualifying APM Participants

The Centers for Medicare & Medicaid Services (CMS) announced predictive Qualifying APM Participant (QP) status for 2017 Advanced APMs. By looking at historical Part B claims data, CMS predicts that nearly 100% of eligible clinicians in Advanced APMs with data currently available will be QPs in performance year 2017.

Click on the links for additional Information:

• Predictive QP Methodology Fact Sheet (PDF)
• Quality Payment Program web site

What is the Predictive QP status analysis?

One of the Quality Payment Program’s goals is to be clear about your Qualifying APM Participant (QP) or Partial QP status. 

For the 2017 Predictive QP analysis, this is how CMS determined if you, from your participation in one of the following Advanced APMs, are predicted to be a QP for the 2017 performance year and are likely to be eligible for the 5% APM Incentive Payment in the 2019 payment year. These calculations are predictive in nature, meaning they are a prediction of your QP status in performance year 2017, if you participate in at least one of these Advanced APMs in performance year 2017:

• Comprehensive ESRD Care (CEC) -Two-Sided Risk
• Comprehensive Primary Care Plus (CPC+)
• Next Generation Accountable Care Organization (ACO) Model
• Medicare Shared Savings Program -Track 2
• Medicare Shared Savings Program -Track 3

For this analysis, CMS used administrative claims with dates of service between 1/1/16 and 8/31/16 that were processed between 1/1/16 and 11/30/16. Actual QP determinations will use claims data from the relevant performance year as of three points in time, or “snapshot” dates: March 31, June 30, and August 31.

If you are a participant in the Comprehensive Care for Joint Replacement Model (CJR)—CEHRT Track, CMS did not make predictions about your QP status for performance year 2017. The CJR-CEHRT Track did not begin until 2017 so there are no historical claims data available.

In addition, CMS did not make predictions for the Oncology Care Model (OCM)—Two-Sided Risk Arrangement as there are no OCM practices currently participating in this arrangement.

What were the Predictive QP & Partial QP determination steps?

CMS took the following steps to estimate QPs and Partial QPs in our 2017 predictive analysis.

1. Identified eligible clinicians participating in Advanced APMs using the APM Entity participation lists.
2. Identified attribution-eligible beneficiaries from Medicare Parts A and B administrative claims data and Medicare beneficiary enrollment information.
3. Identified beneficiaries attributed to Advanced APM Entities.
4. Calculated payment amount Threshold Scores.
5. Calculated patient count Threshold Score.
6. Determined predictive QP or Partial QP status for an APM Entity group based on the payment amount or patient count. We applied the more advantageous QP Status to the eligible clinicians participating in the APM Entity.

How did CMS identify attribution-eligible beneficiaries?

CMS found beneficiaries to be attribution-eligible to an APM Entity if during the historical assessment period they:

• Weren't enrolled in Medicare Advantage or a Medicare Cost Plan.
• Didn't have Medicare as a second payer.
• Were enrolled in both parts A and B for the entire QP performance period.
• Were at least 18 years of age on January 1.
• Were a United States resident.
• Had at least one claim for E/M services furnished by one or a group of eligible clinicians used in assignment in an APM Entity during the historical assessment period.

To match the attribution eligibility criteria with each APM’s attribution methodology, we may apply exceptions to the evaluation and management requirement for attribution-eligible beneficiaries. Such an exception will be applied in 2017 to the CEC model, including the predictive QP analysis.

Download the Fact Sheet to Read More

CMS Is Accepting Future Measures and Activities for Three MIPS Performance Categories

CMS' Annual Call for Measures and Activities for the Merit-based Incentive Payment System (MIPS) track of the Quality Payment Program (QPP) is accepting Quality and Advancing Care Information measure proposals through June 30, 2017 for the 2018 program year; measures submitted beginning July 1, 2017 will be considered for the 2019 program year.

CMS encourages clinicians, measure stewards, organizations, and other stakeholders to identify and submit measures and activities to be considered for the Quality, Advancing Care Information, and Improvement Activities performance categories of MIPS in future years.

Submission Details

• Quality: Measures proposed for inclusion should be submitted through JIRA. Submissions should include the JIRA Measures under Consideration (MUC) template and other associated documents CMS deems necessary for the submission process.


• Advancing Care Information: Measures proposed for inclusion should be sent using the Advancing Care Information Submission Form to CMSCallforMeasuresACI@ketchum.com.


• Improvement Activities: Activities proposed for inclusion should be sent using the Improvement Activities Submission Form to CMSCallforActivitiesIA@ketchum.com.

Measures and activities should be relevant, reliable, and valid at the individual clinician level. To be considered, proposals must include measure specifications, related research, and background.

A final list of measures and activities for MIPS clinicians will be published in the Federal Register no later than November 1 of the year prior to the first day of the performance period. Please note that some Advancing Care Information measures finalized in the 2018 final rule may not take effect until 2020, depending on the functionalities and workflow changes needed for implementation.

For More Information
Remember to review the Annual Call for Measures and Activities fact sheet to learn more and understand the process for submitting measures for the MIPS performance categories. Please direct any questions on measure and activity submissions to the QPP Service Center at QPP@cms.hhs.gov.

CMS’ Accountable Health Communities Model

CMS’ Accountable Health Communities Model selects 32 participants to serve as local ‘hubs’ linking clinical and community services

Last year, the Centers for Medicare & Medicaid Services (CMS) released a Funding Opportunity Announcement (FOA) for applications for the Center for Medicare and Medicaid Innovation’s (Innovation Center) Accountable Health Communities (AHC) model. Over a five-year period, CMS will implement and test the three-track AHC model to support local communities in addressing the health-related social needs of Medicare and Medicaid beneficiaries by bridging the gap between clinical and community service providers. Social needs include housing instability, food insecurity, utility needs, interpersonal violence and transportation.

Today, CMS has announced the participants for two of the tracks, the Assistance and Alignment Tracks, of the AHC model. By addressing critical drivers of poor health and high health care costs, the model aims to reduce avoidable health care utilization, impact the cost of health care, and improve health and quality of care for Medicare and Medicaid beneficiaries. The organizations in the AHC Assistance Track will provide person-centered community service navigation services to assist high-risk beneficiaries with accessing needed services. The organizations in the AHC Alignment Track will also provide community service navigation services, as well as encourage community-level partner alignment to ensure that needed services and supports are available and responsive to beneficiaries’ needs.

“We know that innovation at the state and community level is essential to improve health outcomes and lower costs. In this model, we will support community-based innovation to deliver local solutions that address a broader array of health-related needs of people across the country,” said Dr. Patrick Conway, CMS Deputy Administrator for Innovation & Quality. “As a practicing pediatrician, I know the power of a model like this to help address the health and social support needs of beneficiaries, and their families and caregivers.”

CMS received applications for the Assistance and Alignment Tracks from a variety of organizations across the country. After a review process, 12 Assistance Track and 20 Alignment Track bridge organizations representing rural and urban communities across 193 counties in 23 states were chosen to participate in the model. The 32 bridge organizations in the AHC model are diverse —varying in type (e.g., county governments, hospitals, universities, and health departments), size, location, and beneficiary demographics.

As two examples of how AHC bridge organizations will operate:

• In the AHC Assistance Track, Community Health Network Foundation in Indianapolis will partner with the Eastside Redevelopment Committee, an organization representing 50 businesses and community-based organizations focused on improving health through high-quality support services, educational programs, and workforce development. Together, they will serve residents of East Indianapolis, a community where 40% of the population received Indiana Medicaid services in 2015 and an emergency room utilization rate above the national average. Through their participation in the AHC Assistance Track, they hope to reduce health care costs for high-risk beneficiaries who receive navigation services.
• 
  
• In the AHC Alignment Track, the Oregon Health & Science University (OHSU) will seek to reduce healthcare utilization and cost to beneficiaries across nine rural counties in Oregon by working with over 50 clinical sites, community service providers, and local health departments. In Oregon, the AHC model is targeting over 300,000 Medicare and Medicaid beneficiaries. OHSU will coordinate the model activities through the Oregon Rural Practice-based Research Network, a statewide network of primary care clinicians, community partners, and academicians dedicated to studying the delivery of health care to rural residents and to reducing rural health disparities.

The Assistance and Alignment Tracks of the Accountable Health Communities Model will begin on May 1, 2017 with a five-year performance period.

To view a list of the Assistance and Alignment Tracks bridge organizations in the Accountable Health Communities Model, please visit: https://innovation.cms.gov/initiatives/ahcm.

The Accountable Health Communities Model is authorized under Section 1115A of the Social Security Act, which established the Innovation Center to test innovative payment and service delivery models to reduce Medicare, Medicaid, and Children’s Health Insurance Program expenditures while maintaining or enhancing the quality of beneficiaries’ care.

For more information about the Accountable Health Communities Model, please visit: https://innovation.cms.gov/initiatives/ahcm.

Transforming Clinical Practice Initiative

The Transforming Clinical Practice Initiative is designed to help clinicians achieve large-scale health transformation. The initiative is designed to support more than 140,000 clinician practices over the next four years in sharing, adapting and further developing their comprehensive quality improvement strategies. The initiative is one part of a strategy advanced by the Affordable Care Act to strengthen the quality of patient care and spend health care dollars more wisely. It aligns with the criteria for innovative models set forth in the Affordable Care Act:

• Promoting broad payment and practice reform in primary care and specialty care.
• Promoting care coordination between providers of services and suppliers,
• Establishing community-based health teams to support chronic care management, and
• Promoting improved quality and reduced cost by developing a collaborative of institutions that support practice transformation.

Background

Since the launch of the Affordable Care Act, CMS has launched numerous programs and models to help health providers achieve large-scale transformation. Programs and models, such as the Hospital Value-Based Purchasing Program, Accountable Care Organizations, and the Partnership for Patients initiative with Hospital Engagement Networks, are striving to help clinicians and hospitals move from volume-based towards patient-centered quality health care services. This has resulted in fewer unnecessary hospital readmissions, reductions in healthcare-associated infections and hospital-acquired conditions, and improvements in quality outcomes and cost efficiency.

To date, there has been no large–scale investment in a collaborative peer-based learning initiative designed as an investment that ensures that clinicians who participate will be part of leading and creating positive change for the entire health care system. CMS estimates that only about 185,000 of the nation’s clinicians currently participate in existing programs, models, and initiatives that facilitate practice transformation.

The Transforming Clinical Practice Initiative is one of the largest federal investments uniquely designed to support clinician practices through nationwide, collaborative, and peer-based learning networks that facilitate large-scale practice transformation.

Initiative Details

Practice Transformation Networks

The Practice Transformation Networks are peer-based learning networks designed to coach, mentor and assist clinicians in developing core competencies specific to practice transformation. This approach allows clinician practices to become actively engaged in the transformation and ensures collaboration among a broad community of practices that creates, promotes, and sustains learning and improvement across the health care system. The following organizations are the Practice Transformation Networks:

• Arizona Health-e Connection
• Baptist Health System, Inc.
• Children's Hospital of Orange County
• Colorado Department of Health Care Policy & Financing,
• Community Care of North Carolina, Inc.
• Community Health Center Association of Connecticut, Inc.
• Consortium for Southeastern Hypertension Control
• Health Partners Delmarva, LLC
• Iowa Healthcare Collaborative
• Local Initiative Health Authority of Los Angeles County
• Maine Quality Counts
• Mayo Clinic
• National Council for Behavioral Health
• National Rural Accountable Care Consortium
• New Jersey Innovation Institute
• New Jersey Medical & Health Associates dba CarePoint Health
• New York eHealth Collaborative
• New York University School of Medicine
• Pacific Business Group on Health
• PeaceHealth Ketchikan Medical Center
• Rhode Island Quality Institute
• The Trustees of Indiana University
• VHA/UHC Alliance Newco, Inc.
• University of Massachusetts Medical School
• University of Washington
• Vanderbilt University Medical Center
• VHQC
• VHS Valley Health Systems, LLC
• Washington State Department of Health

Support and Alignment Networks

The Support and Alignment Networks will provide a system for workforce development utilizing national and regional professional associations and public-private partnerships that are currently working in practice transformation efforts. Utilizing existing and emerging tools (e.g., continuing medical education, maintenance of certification, core competency development) these networks will help ensure sustainability of these efforts. These will especially support the recruitment of clinician practices serving small, rural and medically underserved communities and play an active role in the alignment of new learning. The following organizations are the Support and Alignment Networks:

• American College of Emergency Physicians
• American College of Physicians, Inc.
• HCD International, Inc.
• Patient Centered Primary Care Foundation
• The American Board of Family Medicine, Inc.
• Network for Regional Healthcare Improvement
• American College of Radiology
• American Psychiatric Association
• American Medical Association
• National Nursing Centers Consortium

Support and Alignment Networks 2.0

A second round funding opportunity announcement of the Support and Alignment Networks (2.0) was announced on June 10, 2016. This opportunity will provide up to $10 million over the next three years to leverage primary and specialist care transformation work and learning that will catalyze the adoption of Alternative Payment Models at very large scale, and with very low cost. The Support and Alignment Networks 2.0 represents a significant enhancement to the TCPI network expertise and will help clinicians prepare for the proposed new Quality Payment Program, which CMS is implementing as part of bipartisan legislation Congress passed last year repealing the Sustainable Growth Rate.

Through this initiative, the Support and Alignment Network 2.0 awardees will identify, enroll, and provide tailored technical assistance to advanced clinician practices in order to accelerate transformation and diffuse this learning throughout the TCPI initiative. Support and Alignment Network 2.0 awardees’ activities, coaching, and technical assistance should result in the rapid transition of practices through five phases of transformation:

• Set aims
• Use data to drive care
• Achieve progress on aims
• Achieve benchmark status
• Thrive as a business via pay-for-value approaches

The period of performance for the Support and Alignment Networks 2.0 is September 2016 through September 2019. The period of performance includes three 12-month budget periods. Support and Alignment Networks must achieve reasonable progress to the aims of the initiative as supported by their own proposed specific targets and milestones. Continued funding is contingent on adequate progress, compliance with the terms and conditions of the previous budget period, and the availability of funds.

For additional information, please contact transformation@cms.hhs.gov

Rapid Practice Innovation (RPI) 

If your organization is participating in a TCPI Network or just looking to improve. ERM has a solution that is guaranteed to deliver results in just 24 weeks. 

Rapid Practice Innovation is an evidence based practice transformation program that ensures your organization is “risk ready.” Over the last 4 years, we have worked with medical practices, IPAs, MSOs FQHCs, health alliances, rural health networks and health plans to improve the delivery of care from the initial point of contact and sustain that change through RPI.

Two RPI Tracks for 2017 and 2018:

• 24 Week Practice Transformation - Our proprietary 24 week curriculum re-designs the primary care office from the ground up to ensure success in the new world of value-based reimbursement. 

• 52 Week "Risk Ready" Practice Transformation - This track combines the 24 week curriculum followed by 28 weeks of monitoring and follow-up for certification. Practices who successfully complete both the 24 week curriculum and the 28 week post-transition follow-up will be awarded a “Risk Ready” Certificate. 

Email Kameron Gifford at kgifford@ermconsultinginc.com for more information.

Advanced Risk Management and Office Based CDI Workshop

NEW DATES ADDED FOR 2017

* Workshops Consistently Rated 4.9 / 5.0 Stars By Attendees *

JOIN US FOR A DAY OF RISK ADJUSTMENT : 

    

§Review the different risk adjustment models and their impact on medical practice management.

§Discuss the impact of shifting from RAPS to EDS. What does this mean for office based claims?

§Take a deep dive into HCC Coding and Documentation. Review real examples to see what validates, what doesn’t, and why. Tips for engaging physicians.

§Learn how to leverage frontline staff to be successful in the world of risk adjustment and value based payments. 

APPROVED BY THE AAPC FOR 6 HOURS CEU

WHO SHOULD ATTEND?

•Medical Coders and Billers

•Providers / Medical Directors

•CDI Specialists

•Executive Leaders

•Compliance Professionals

•Health Alliance Members

•Rural Health Centers

•ACO, MSO and IPA Teams

•Medicare Advantage , Medicaid and Commercial Plans

EACH ATTENDEE WILL RECEIVE:

• Clinical Documentation and Coding Guide  $ 99 Value
• HCC Quick Coder (Mappings to ICD-10 Codes) for MA and Commercial Models
• Risk Adjustment Workbook and Appendix with Easy to Use Templates
• Laminated Coding and Documentation Tools 

WORKSHOP $399 –  EARLY BIRD $299 (Ends May 1st)

REGISTER TODAY - LIMITED SEATING AVAILABLE

July 21, 2017 - Orlando, FL

MELIÁ ORLANDO SUITE HOTEL AT CELEBRATION 

Download Complete Agenda - PDF

Register for the Orlando Workshop

Additional 2017 Workshops:

Boca Raton, Florida - September 12, 2017

Download Complete Agenda

Register for the Boca Raton Workshop


Ft Lauderdale, Florida - October 19, 2017

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Register for the Ft Lauderdale Workshop






Visit www.ermconsultinginc.com to learn more