What's New For the rest of 2014 and Beyond?

It seems like Risk Adjustment for Medicare Advantage is ever-evolving.   According to a Final Rule, published by CMS in the Federal Register on May 23, 2014, the one thing we can certainly expect more of is audits.

CMS will be introducing a Recovery Audit Contractor (RAC) for Part C, slated before the end of 2014.  RAC auditors use a combination of methods, including medical record review and automated edits, to identify improper payments.  Currently, there are RAC contractors in Part A, B and D--so the addition of a Part C RAC will mean that all of Medicare is under RAC audits.

We don't yet know what RAC audits for Part C will look like--but if you want to stay ahead of the curve, you should be looking at your data for any anomalies now.  Speaking at an America's Health Insurance Plans conference, Sonja Brown, a health insurance specialist in the Center for Program Integrity in CMS’s Division of Plan Oversight and Accountability,initial areas of review are end-stage renal disease (ESRD), hospice and Medicare as Secondary Payer (MSP).

In addition to the RAC, beginning in 2015, the OIG will be doing their own Risk Adjustment Data Validation Audits (RADV), which we assume will look just like a CMS RADV, but may be more targeted.

This means that with so many audits going on simultaneously, it will be the rare medical group that is not affected.  Medical groups should be doing their own internal chart reviews to determine where more physician education is needed.

We'll continue to keep you up to date on new and changing rules from CMS as we become aware of them.

Inpatient Coding Guidelines

We often get questions about when to use the Inpatient Coding Guidleines--can they be used for a discharge summary alone, or a consultation that took place during an inpatient stay?  According to CMS' RADV Q&A from 2009, the answer is NO:

Q15: Are practitioner visits during a hospital admission acceptable as "PHYSICIAN" records? If yes, what coding rules will apply to these records?

A15: If a member has an inpatient hospital discharge that supports the HCC, it is usually best to select the inpatient discharge and submit the entire inpatient medical record for coding. However, if the entire inpatient medical record cannot be obtained, the organization can submit medical record documentation from an inpatient physician visit for review and it would be reviewed in accordance with the Diagnostic Coding and Reporting Guidelines for Outpatient Services. When submitting these forms of documentation please note the following:

In the outpatient setting, coders do not code diagnoses documented as "probable" "suspected," questionable," or "rule out" but rather coders code the condition to the highest degree of certainty for that encounter/visit (i.e., symptoms, signs, abnormal rest results.) This limited documentation may not support the HCC. Acceptable inpatient physician visit medical records are: inpatient history and physical examinations, progress notes, consultation reports, and discharge summaries. When submitting medical record documentation from an inpatient physician visit, the organization has two options:

1. Select a service date from the stored risk adjustment data listed in Section 3A of the coversheet (i.e., RAPS data) for a PHYSICIAN visit. The RAPS record most likely was for the physician claim for inpatient visit services. Be sure that the record you are submitting exactly matches the date of the selected service date. For example, the coversheet is

checked with a service date of 9/5/2003 through 9/5/2003 and a signed inpatient physician consultation report dated 9/5/2003 is attached for review.

2. Submit an "in lieu of" medical record by completing Section 3B of the coversheet for a PHYSICIAN visit. Be sure that the record you are submitting exactly matches the date of the selected service date. For example, Section 3B of the coversheet has a service date of 10/3/2003 through 10/3/2003 and a signed inpatient physician admission history and physical examination report dated 10/3/2003 is attached for review.

The reason for this is the nature of the Inpatient Coding Guidelines for coding uncertain diagnoses: 

H. Uncertain Diagnosis
If the diagnosis documented at the time of discharge is qualified as "probable", "suspected", "likely", "questionable", "possible", or "still to be ruled out", or other similar terms indicating uncertainty, code the condition as if it existed or was established. The bases for these guidelines are the diagnostic workup, arrangements for further workup or observation, and initial therapeutic approach that correspond most closely with the established diagnosis.
Note:

This guideline is applicable only to inpatient admissions to short-term, acute, long-term care and psychiatric hospitals

As you can see, this guideline requires that the diagnostic workup and initial therapeutic approach correspond to that uncertain diagnosis.  Simply saying "rule out MI" in a consultation note, or even a discharge summary, does not show that diagnostic workup or therapeutic approach.  You need the entire chart (or the majority of it) to support this.  So, standalone documents from an inpatient stay are always coded as if they are outpatient documents.

Have a coding question related to risk adjustment, or risk adjustment data validation (RADV)?  Send it to us at Coding@scanhealthplan.com

Recently Posted Tools and Documents on HCC University

We want to ensure that HCC University and the HCC University blog are your favorite risk adjustment related websites.  So, over the past few weeks, we’ve posted a large number of tools and documents on HCCUniversity.com.  Since none of us has time to check every day, we thought we’d give you an overview of what’s gone up on the site recently.

Full Encounter Data Information -  ICD 10/Full Encounter Data Page

Updates from the CMS Work Group Conference Calls have been posted:

Capitated and Staff Model Plans Summary Notes

Encounter Data Newsletter - Quarter 2

Encounter Data Work Group Summary Notes for Editing and Reporting: Key Findings and Recommendations #2

Third Party Submitters Work Group

Risk Adjustment Tools

2011 HCC List-Diagnosis Code Grouping - this file shows diagnosis codes grouped by HCC category.  Categories or codes with problematic guidelines have documentation and coding notes. - Excel file here.

Risk Adjustment Data Validation Tools

This checklist was used in the last National RADV to assist health plans in selecting the "One Best Medical Record" for submission.  Download here.

CMS Pilot RADV Findings—for services rendered July 1, 2001 through June 30, 2002, Published July 27, 2004.  Study findings here.

Annual Wellness Visit Tools

Annual Wellness Visit Presentation --Power Point Presentation.

Annual Wellness Visit form, instructions, and USPSTF Preventive services schedule - Zip File Here.

If you have questions, comments, or suggestions for new tools, leave us a comment here, or email us at coding@scanhealthplan.com.