Risk Adjustment Overview

Hello and welcome to the Results and Recognition program, the webinar topic today is Risk Adjustment: The Importance of Coding.

Today we will discuss what risk adjustment is and the process, medical record retrieval and coding, provider coding education, hierarchical condition categories and common errors; lastly, best practices.

Now, before we dive in, just a little disclaimer that us CQILs are not certified coders, nor are we risk adjustment specialists.

We do not ever tell network providers how to code, because you all code according to the services you render, and the documentation in the medical record must support any codes used.

The purpose of this presentation is to relay information to you in an effort to stress the importance of coding.

If you have any questions related to the content, there will be an email for the Risk Adjustment Department provided at the conclusion.

Risk adjustment and the process.

What is risk adjustment?

It is the process where health plans are equitably reimbursed based on the expected cost to care for their member population.

And the purpose of this system is to adequately cover the cost of care by providing covered benefits for enrollees, including those with complex conditions.

So essentially, risk adjustment ensures that insurers receive appropriate revenue for the healthcare cost of the population they are insuring.

Providers have an important role to play in risk adjustment too.

According to the AAPC, which is the advancing the business of healthcare, an engaged partnership between the provider and the health plan is vital to bringing valuable benefits for enrollees.

For instance, insurers may have premiums and risk adjustment payments to offer its members enrollment and exercise programs, case or disease management, transportation to medical appointments and other services.

The health plan uses diagnosis codes that providers submit on claims to identify what types of programs are needed and, more specifically, who needs them.

So, for the providers, risk adjustment simply means that the documentation should capture the patient's full health story, including all of the conditions that may affect how they're manage and/or treated.

All current and coexisting diagnoses should be documented during every encounter and submitted to the highest level of specificity. In addition, all relevant conditions must be captured on an annual basis year over year.

Let's walk through the risk adjustment process.

A patient visits a health care provider, either in-person or virtually.

The provider documents all relevant medical conditions in the patient's medical record.

And claims are submitted to support what was completed during the visit, which would include the diagnosis codes as well as quality codes.

The plan receives the codes and are able to predict risk scores for financial purposes.

The plan also submits claims to the regulatory bodies such as The Centers for Medicare and Medicaid Services, known as CMS, and the state.

Now, for the regulatory action, based on applicable risk adjustment model, risk scores and reimbursements are calculated.

The plan data is reviewed and audit plan encounters submissions are completed.

Risk adjustment coding.

Medical record retrieval, MRR, and coding ensures Horizon knows and understands the full health status of our members and allows Horizon to identify provider educational opportunities centered around improving coding and documentation.

The benefit of this includes providing feedback to providers on any missed diagnosis codes that weren't included on claims, and that is an under payment risk, as well as unsupported diagnosis codes included on claims that would be an overpayment risk.

This process may identify provider billing issues, such as EMR diagnosis code restrictions.

And another benefit is complete and accurate clinical diagnosis to drive comprehensive care and improve clinical outcomes.

At some point in the future, there will be a shift focusing on documentation improvement and building of diagnosis codes, which would reduce the need to retrieve such a high volume of medical records.

We are going to review a couple of helpful acronyms to help capture the full health status of a patient.

It is very important that providers document the patient's full health history as previously mentioned.

The first acronym is M.E.A.T.

It is an acronym used to describe 4 factors that help providers with proper documentation to establish the presence of a diagnosis during an encounter.

M - For manage or monitoring signs and symptoms (whether it improves or worsens) of the condition.

E - Is for evaluate. Such as test results, medication effectiveness, response to treatment.

A - For assess. Such as ordering tests, reviewing the record, and counseling.

And T - for treating, which includes medications, therapies, and other treatment and procedures.

The next helpful acronym to help capture the full health status of a patient is the TAMPER approach.

And this involves reviewing the medical record for acceptable documentation and evidence, and pulling it all together to tell a comprehensive and accurate story about the patient for ongoing and future care.

This acronym stands for:

T - For treatment, and this can include surgery, medication therapy, procedure, counseling, education, DME (ordered or given), labs ordered.

A - For assessment. Acknowledging, giving status, and level of condition.

M - For monitoring or medicate. Such as ordering medication, referencing labs and other tests, and also prescribing medication.

P - For plan. Plan for management or follow-up of condition.

E - For evaluate. Examining, as in a physical exam.

R - For referral. Referral to specialists for treatment or consultation of a confirmed condition.

HCC stands for Hierarchical Condition Categories, and these are sets of medical codes that are linked to specific clinical diagnoses, and each HCC represents multiple diagnoses with similar clinical complexity and expected annual care costs.

So these diagnoses have been assigned a value for risk adjustment.

HCC models rely on the reported ICD-10 codes to establish the patient's health status annually.

So thorough clinical documentation and complete diagnosis coding are crucial to accurately report HCCs.

Risk adjustment, coding common errors.

We will now review a few situations where an audit has shown inaccuracies in reporting, which leads to an inaccurate HCC.

The first one is HCC 74. Disorder of the immune mechanism.

Diagnosis codes D84.9, which is the immunodeficiency/unspecified, or D89.9, disorder involving the immune mechanism unspecified.

The above codes should not be reported for immunosuppression resulting from use of drugs to treat auto immune conditions such as rheumatoid arthritis, multiple sclerosis, or inflammatory bowel disease.

For the reporting of immunodeficiency conditions, documentation must specify the type of immunosuppression, such as primary, defined by an inherent absence or quantitative deficiency of cellular, humoral, or both components that provide immunity.

Secondary, is acquired and defined by loss or qualitative deficiency in cellular or humoral immune components that occur as a result of a disease process, or its therapy.

Common error, Hierarchical Condition Categories.

HCC 132/88. Unstable angina and other acute ischemic heart disease.

If coronary artery disease I25.10 is documented in the medical record without any evidence of a clinical syndrome of angina, whether it be stable or unstable being addressed, and atherosclerotic heart disease of native coronary artery with unstable angina pectoris, I25.110 cannot be reported.

Medical record documentation for an acute coronary syndrome, I24.8 and/or unstable angina I20.0 and other correlated conditions must specify a definitive diagnosis along with supportive evidence that may include the underlining disease and associated symptoms.

Moving on to HCC 142/96 specified arrhythmias.

To correctly report an arrhythmia condition, such as I48.91, unspecified atrial fibrillation, or I47.1, supraventricular tachycardia, documentation must include a definitive diagnosis of the type of arrhythmia being addressed.

Avoid contradictory documentation for which the final diagnosis does not support the evaluation.

Also, the treating condition in the medical record should be clear, whether it's a nurse versus a physician.

Diagnosis codes I48.91 or I47.1 can be captured when the documentation contains the following:

The specific type of atrial fibrillation such as paroxysmal, persistent, whether it be long standing or other, chronic or permanent.

The specific type of arrhythmia such as brady arrhythmias, premature or extra beats, supraventricular arrhythmias, and ventricular arrhythmias.

Always report the highest level of disease specificity documented by the treating physician.

HCC 2 – Septicemia, sepsis, systemic inflammatory response syndrome, or shock.

Report diagnosis 841.9, sepsis, when documentation specifically addressed the quality of care the patient is receiving and includes an underlying system infection, treatment of condition with medications, and tests such as blood cultures.

ICD-10-CM guidelines section 1 states, the term urosepsis is a non-specific term and does not have a code in ICD-10.

It is not to be considered synonymous with sepsis.

If a provider uses the term urosepsis, he should be queried for clarification.

HCC 8 metastatic cancer.

If metastatic cancer C77.0 is a valid patient diagnosis, the documentation should specifically indicate both the primary and the secondary malignant sites and include supportive evidence that the primary site has metastasized even though it was removed, and the secondary malignancy is active.

Specify the histology or behavior of the neoplasm, if known, as benign, primary malignant, secondary malignant, in situ, or uncertain.

As per the, ICD-10 guidelines, only multiple myelomas or leukemia conditions can be categorized as in remission.

Other types of cancer are identified as active, current, or history of.

Moving on to HCC 42/33, Peritonitis, gastrointestinal perforation, nectorizing enterocolitis.

Perotinoitis code range K65.0 - K65.9.

When reporting a peritonitis condition, determine its underlying cause and treatment.

Does documentation include pertinent information regarding body fluids?

Treatment usually involves antibiotics to fight infection, medication for pain, and drainage of fluid when necessary.

Gastrointestinal perforation code K63.1. This condition is usually associated with Crohn's Disease and malignancy.

When reporting gastrointestinal perforation, document the specific treatment and the nature of the disease process that caused the perforation.

HCC 42 or 154 (age related)/107, peritonitis, gastrointestinal perforation, necrotizing enterocolitis.

Necrotizing Enterocolitis, code range K55.011 to K55.9.

This serious condition occurs when inflammation, infection, or ischemia leads to intestinal necrosis.

While necrotizing enterocolitis is most commonly seen in premature infants, the condition can occur in term infants, and infants outside of the newborn period, as well as in adults.

When reporting this condition, the age of the patient needs to be determined.

The specific treatment depends on the nature of the disease and should be documented.

Coders should carefully review the documentation for proper code abstraction and should know how to differentiate diseases processes.

HCC 82/55 -Drug dependence.

Code F13.20. Sedative, hypnotic, or anxiolytic dependence, uncomplicated.

When documentation clearly indicates dependence of a current prescribed drug the patient is actively taking, documentation of drug dependence solely in the past medical history should not be linked to a current medication or drug without the dependence documented in the patient's assessment and plan within the medical record.

Proper documentation should include the following: pattern of harmful usage, whether it be dependence, abuse, or use, the current state (it can be uncomplicated), intoxication or remission.

The relationship to any identified mental, behavioral or physical disorder, such as anxiety, mood disorder, or sleep disorder.

It is important to note if documented drug use is not treated or noted as affecting patient’s health, do not code for drug dependency.

HCC 88/59 major depressive disorder or bipolar disorders.

So major depressive disorder could range F32 to F33.9.

When documenting major depressive disorder a record must contain information regarding the episode, (whether it is single or recurrent), severity (mild, moderate, severe, with or without psychotic features), state of remission (partial/full), or not in remission.

Providers should document if depression is well controlled with medication or active therapy, should note result of a depression screening, and if suicide risk was assessed.

Bipolar disorders, code range F30.10 to F31.9

When documenting bipolar disorder, the providers should report whether the current episode is hypomanic, manic, depressed, or mixed. Severity, whether it be mild, moderate, severe or severe and psychotic. State of remission, whether it be full or partial remission.

Suggested best practices.

Treat every visit as if it's the only opportunity to capture a patients’ health status in the year regardless of the reason for the visit.

Fully document all applicable conditions for each patient you treat by including the appropriate ICD-10 codes on every claim submission.

Document all current and coexisting diagnoses during every encounter and submit to the highest level of specificity.

All relevant conditions must be captured on an annual basis.

In addition to submitting ICD-10 codes, ensure you also submit quality codes to close HEDIS care gaps.

Adopt technologies, such as electronic health record or voice translation software, to improve accuracy and efficiency.

Engage clinicians to accurately capture primary conditions and present comorbidities, particularly in the more complex cases.

Involve coders and office staff to ensure the use of coding best practices.

Standardize coding process to minimize disruption to the billing work flow.

So, this concludes the presentation. If you have any questions please email the risk adjustment team at the email you see noted here.

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