Encounter Data Filtering Logic Updates

As you probably know, CMS has provided guidance regarding the filtering of encounter data for risk adjustment purposes.  This doesn't mean that either Medical Groups or Health Plans should not submit certain encounters- CMS requires that ALL encounter data must be submitted to them.

Currently, encounter data represents 25% of the calculation of risk scores.  CMS plans to increase the weighting of encounter data-based risk scores over the next couple of years by moving to a risk score incorporating 50% of the encounter data/FFS-based risk score in 2018, a risk score incorporating 75% of the encounter data/FFS-based risk score for 2019, and a risk score of 100% encounter data/FFS-based risk score in 2020,

The logic that they use to determine what encounters are included is laid out in this 2015 memo from CMS to health plans.  At the same time, CMS released a list of procedure codes that would be used for filtering professional and outpatient hospital encounters.  

Recently, CMS released the list of 2015 codes and preliminary 2016 codes to be used for encounter data filtering.

When determining which encounters may be used in calculating risk scores, health plans and provider groups should refer to these documents, as well as reports received from CMS and health plans.  As CMS moves forward with using only encounter data for risk score calculation it will become more important than ever that your encounter data be accepted by the health plan and ultimately by CMS.  We will continue to provide you as much information as possible on our Encounter Data/ICD-10 Page.  CMS is currently hosting teleconferences with health plans, to keep them informed about changes to encounter data processing.  We'll post webinar slides like these, on duplicate record and demographic data fields processing, so you can stay up to date as well.

What other tools would be helpful to you?  Remember, if you have suggestions for HCC University, or the blog, you can contact us at coding@scanhealthplan.com.

Risk Adjustment Changes for 2014

CMS has announced a new CMS-HCC Model for payment year 2014 in their combined  Announcement of Calendar Year (CY) 2014 Medicare Advantage Capitation Rates and Medicare Advantage and Part D Payment Policies and Final Call Letter, published April 1, 2013.  You can download a copy of the ICD-9 codes that CMS released at the time of the Advance Notice [here].  CMS has not informed us of any changes in this listing, but we will advise you immediately if they do.

Important provisions of the announcement, related to Risk Adjustment:

•                          Clinically Revised CMS-HCC Model.  CMS will implement the new risk adjustment model, but will phase-in changes over a two year period.  In 2014, CMS will blend 75 percent of the 2014 model risk score with 25 percent of the 2013 model risk score.  The new model will be fully phased-in by January 1, 2015.

 

•                          Medicare Enrollee Health Risk Assessment.  As we noted when the Advance Notice was published, CMS is considering excluding from risk adjusted payment any diagnosis data collected from MA enrollee Health Risk Assessments which are not confirmed by a subsequent clinical encounter.  CMS planned to collect flags in 2013 of these risk assessments.
Based on comments received, CMS is delaying the collection of flags until calendar year 2014.  Further determination about exclusion of these data will be published in the 2015 Advance Notice

 

•                          Coding Intensity Adjustment.  The Coding Intensity Adjustment for 2014 is 4.91 percent.

 

•                          Normalization Factor.  Because 2014 payment will be based on a blend of the old and new CMS-HCC Models, there will be two normalization factors:

• 2013 CMS-HCC model: 1.041.

• 2014 CMS-HCC model: 1.026.

 

You can review all of the changes for 2014 in the Announcement, posted [here].   Look for new training programs to help SCAN providers understand the changes to the model on HCC University soon!

What's New On HCC University

We've posted an updated list of Payment Year 2013 (2012 DOS) diagnoses in the CMS HCC model on the Tools Page.  You can download the Excel file here.

In addition, we've updated our Risk Adjustment 101 presentation.  You may want to use it in training new staff.  It's on our Training and Presentations page.

New Specialties Approved for Risk Adjustment

Effective January 2012, the following CMS Physician Specialties are approved for risk adjustment submission:

• 21   Electrophysiology
• 23   Sports Medicine
• C0  Sleep Medicine

CMS has indicated that they will publish a complete specialty listing soon. When the listing is published, we'll post it to the Tools section of HCCUniversity.com

Documentation--Why Bother?

Today, we have a guest posting from Debra Braden, CPC, CUC, HCC Coding Project Specialist in our Risk Adjustment Data Validation (RADV) department.

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Since the advent of the HCC model, documentation has become more important than ever.  Because CMS reimburses for HCC’s they will also conduct audits to make sure the payments were justified.

There are other reasons that documentation is important.  Good documentation can help protect both the patient and the physician.  It is good patient care to clearly document why the patient is having the visit, the conditions they have and what the plan of treatment is.  This aids the current and any subsequent healthcare providers in knowing exactly what is going on with the patient and enables them to monitor and/or treat conditions.  Another important reason is in the case of a malpractice issue.  The court would be able to clearly see what is wrong with the patient and what the physician has done to care for the patient.

In order to pass CMS or Plan audits there is information that should be included in the medical record.  The patient’s name and one other identifier (date of birth, medical record or chart number) should be on every page.  The date of service, legible signature and credentials must be documented.  For a new condition the documentation should include the diagnosis, rationale, any related labs used for assigning the diagnosis and the plan of treatment.  For an established condition the documentation should include the diagnosis, status of the condition and the plan of treatment.

Based on findings from the Medicare Advantage Risk Adjustment Data Validation CMS-HCC Pilot Study several errors were found to be common.

·        Documentation to substantiate the diagnosis code was not in the medical record.

·        Chronic conditions coded but not documented in the report at the time of the visit.

·        Documentation was not in the medical record to support the specificity of conditions.

·        Truncated codes - Not using required 4^th or 5^th digits.

·        Physician unable to locate the medical record.

·        Coding for rule out, questionable or suspected conditions in the office.

·        Coding for acute conditions when the patient was status post or had a history of the condition.

·        Selecting codes incorrectly from superbills.

·        Not coding for documented conditions.

Keep in mind that just because an Electronic Medical Record is used doesn’t mean that it will automatically pass an audit.  Cloning notes from prior visits that a member had with a physician can cause inconsistencies within a note that would make it difficult for a certified medical coder to abstract a particular diagnosis even if it meets the criteria:  a) state the diagnosis, b) show logic or assessment and c) state plan.  Other problems can arise from use of an EMR including the use of an incorrect diagnosis selection lists.  The one thing that EMRs will solve is legibility, but unless intelligent notes are implemented, don’t expect an EMR to help you attain appropriate documentation.

Also keep in mind that good documentation doesn’t mean that the medical record has to be lengthy.  Good documentation simply means that specific information should be in the documentation that shows that a condition was evaluated and/or treated on the date of service.

CMS Releases Updated Acceptable Physician Specialty List

CMS posted an updated listing of acceptable physician types for risk adjustment purposes on the CSSC Operations Website.

Note that CMS has deleted specialty 70, Multi-Specialty Physician Group as an acceptable type, and added Interventional Pain Management (09), Speech Language Pathology (15), Hospice and Palliative Care (17), and Geriatric Psychiatry (27).

These changes were announced in the Announcement of Calendar Year (CY) 2012 Medicare Advantage Capitation Rates and Medicare Advantage and Part D Payment Policies and Final Call Letter released on April 4, 2011, effective January 1, 2010.

Both documents will be posted on the HCCUniversity.com website in the near future.

2012 Announcement Posted on the CMS Website

You can download the announcement here: 2012 Announcement.

As CMS indicated in the Advance Notice, there will not be a change to the CMS-HCC model for 2012, so that plans and providers can focus on other upcoming changes.

CMS also added several specialties to the acceptable physician specialties for risk adjustment, and deleted one tyep.

The additions are: Interventional Pain Management (IPM) (code 09), Speech Language Pathologist (code 15), Hospice and Palliative Care (code 17), and Geriatric Psychiatry (code 27). Note that Multispecialty Clinic or Group Practice (code 70) is not an Acceptable Physician Specialty Type.

More information will be posted as it becomes available.

New ICD-9 Codes Added to CMS-HCC Model

CMS published the new codes for the CMS-HCC model today on their website.  The new codes are effective 1-1-2011, and include a number of the new 2011 ICD-9 codes.  *While the ICD-9 codes are effective 10-1-2010, they are not included in the model until 1-1-2011.*

You can find the file on HCC University on our Tools Page.

The following codes have been added to the CMS-HCC or the RxHCC model:

Please note that there may be new codes added in 2011 due to changes in the CMS-HCC model.  The first (proposed) announcement of this will occur in February, with the final announcement of changes in April.  These changes will be posted here as soon as they become available.

New ICD-9-CM Codes for 2011 (Effective Date 10-1-2010)

We’ve posted a copy of the new, revised and deleted ICD-9-CM codes for 2011 codes on our Tools page (Tools) As soon as the full text copies of ICD-9 have been posted, we’ll post them there too.

Note that CMS has not indicated which, if any, of these codes will be included in the CMS-HCC risk adjustment model.  As soon as new information becomes available, we’ll post it here.