2014 Advance Notice Released

On Friday, 2/15/2013, CMS issued the combined 45 day Advance Notice and Call letter,  which describes proposed changes related to the CY 2014 Medicare Advantage (MA) and Part D payment methodos.  Some important Medicare Advantage proposals in the notice include:

  

·         Growth Rates – The transition to the payment methodology enacted in the ACA will cause the pre-ACA payment methodology to be phased-out over several years through MA county rates.
 

·         Coding Intensity Adjustment – In 2010, CMS began applying a coding intensity adjustment to the Part C risk scores to account for the difference in coding patterns between MA and  FFS Medicare.  In the Advance Notice,  CMS is proposing an MA coding pattern difference adjustment of 4.91% for payment year 2014, which is the minimum coding intensity adjustment required under the ACA as amended by the American Taxpayer Relief Act of 2012.  The coding intensity adjustment applied in 2013 was 3.41%

·         Clinical Update and Recalibration of the CMS HCC Risk Adjustment Model – CMS has proposesd an updated CMS HCC Risk Adjustment model for 2014 tas a result of a clinical review of diagnoses included in each HCC. 

The changes are intended to address higher rates of coding of some HCCs by MAOs compareed to FFS providers.  If implemented, the number of HCCs will increase from 70 to 79  and CMS plans to recalibrate the model. 

This will cause a reduction in the value of a number of HCCs.  CMS is proposing a phased-in implementation of the new model over a multi-year period.  For 2014, CMS would implement coefficients of the revised model but would transition over a multi-year period to the revised model denominator.

·         Fee-for-Service Normalization Factor –   The estimated FFS Normalization Factor for 2014 will be 1.026.  It was 1.028 in 2013.

·        Medicare Advantage Health Risk Assessments – CMS notes that Health Risk Assessments (HRAs) are being done to assess the health of MA members, but feels that they are also used to  identify diagnoses for submission to CMS for risk adjustment purposes.  CMS is concerned that in some cases, diagnoses are reported without follow-up care or treatment being provided to MA members.  CMS intends to implement a data collection that will require that MA organizations flag those diagnoses collected as part of an HRA, beginning with 2013 dates of service.   CMS will also be considering ways to ensure the accuracy and completeness of this risk assessment information.  Beginning in 2015, CMS may exclude a  diagnosis from risk adjustment payment  any HRA diagnoses that are not confirmed by a subsequent clinical encounter by an approved provider type (e.g., the member's PCP) for risk adjustment. 

Final provisions will be released on April 1, 2013, and we will post them as soon as possible.  You can review the Advance Notice and Proposed Model Diagnoses on HCCUniversity.com.

 

 

 

 

New Medicare Web Based Training (WBT) Modules

CMS has re-vamped their World of Medicare training course. Formerly, it was a single 1 hour WBT.  Now it is 4 parts, and is followed by either the Your Office in the World of Medicare or Your Institution in the World of Medicare.  These WBTs provide a great introduction to fee-for-service Medicare.  If you've ever been confused by the many rules of Medicare, you may want to check out these WBTs. 

 

The World of Medicare targets both physicians and providers as well as administrative staff.  Your Office and Your Institution are aimed at physicians, providers and their staff who are enrolling in the Medicare program, to provide assistance in completing the 855 (enrollment) forms.

 

These and all of the Medicare WBTs can be accessed at http://cms.meridianksi.com/kc/ilc/course_info_enroll_lnkfrm_f1.asp?lgnfrm=wbt&table=crs&function=course_info_enroll&strBuildingID=5&strFunctionID=37&strFunctionPath=37&strFrom=Search&topic=All&keywords=

What's New on HCC University?

We've continued to add a number of documents to HCC University to make your documentation and coding go more smoothly!

We've updated our Annual Wellness Visit (AWV) with Health Risk Assessment (HRA) package to incorporate information on 5Star coding.  Since physicians are already capturing the data, we want to help make it easy to remember to submit it on the Superbill.  You can also review a presentation on completing the AWV with HRA.

We'll be posting more documents on HCC University in the near future. 

Medical Record Guidance

We often get questions about what constitutes a complete medical record.  To date, there is no all-encompassing official definition, although CMS provides their requirements during a Risk Adjustment Data Validation.

For offices, groups and health plans trying to develop coding compliance policies, there hasn't been a lot of information available.  Recently, the American Health Information Management Association (AHIMA) has tackled the issue head on in Defining the Core Clinical Documentation Set for Coding Compliance.  This useful article will help anyone tasked with creating a coding compliance policy.  You can find a copy of this paper here.

Coding versus Interpreting

As coders, we're required to code based upon the physician's documentation, and not to read into what the physician has actually written. 

Recently, we received the following question and follow up questions in the Coding@scanhealthplan.com inbox. 

Original Question: 

I would like to know some opinions regarding to coding the following documentation by Physician:  “ Vascular Dementia”.   

Our Answer: 

Vascular dementia NOS is indexed to 290.40.  I don’t see any alternative code.

Then, we received a follow up:

Follow up Question: 

In my opinion I’ll use 290.40 plus 437.0.   Please see instructional notes “ Use additional code to identify cerebral atherosclerosis”.  I need your opinion.

Our Answer:

You only use an additional code if it’s documented. It’s not something you automatically do.  Based on your email, the physician only documented vascular dementia.  If he had said vascular dementia due to cerebral atherosclerosis, then you would code it.

 The instructional notes for 250.40 say:

Use additional code, to identify manifestation, as: 
        chronic kidney disease  (585.1-585.9) 
             diabetic: 
             nephropathy NOS  (583.81) 
             nephrosis  (581.81) 
             intercapillary glomerulosclerosis  (581.81) 
             Kimmelstiel-Wilson syndrome  (581.81) 
 But you don’t code all those things unless they are documented.
I hope that clarifies.

In response, the questioner indicated that they planned on coding cerebral atherosclerosis  (437.0) because:

"Vascular dementia, Arteriosclerotic Dementia, Multi-infarct Dementia and Atherosclerotic disease are synonyms.   In my opinion the documentation of Vascular Dementia is the same as  Atherosclerotic Dementia or multi-infarct Dementia.    

Please look Dementia
                                       Multi-infarct(cerebrovascular) ( see also Dementia, arteriosclerotic)"

 
I don't believe I did a good enough job explaining why you wouldn't code something not documented.  But the reality is that cerebral arteriosclerosis is not the only cause of vascular dementia, although it may be the most common cause.  Multi-infarct dementia (MID), due to multiple strokes or TIAs,  or mixed type due to MID and Alzheimers, or many other

 conditions that reduce blood flow to the brain, including certain autoimmune diseases (e.g., lupus eythematosus, temporal arteritis), certain inherited (genetic) diseases, infections of the heart (endocarditis), brain hemorrhage, profoundly low blood pressure can also cause vascular .   Since arteriosclerosis is not the sole cause, coding 437.0 without documentation of cerebral arteriosclerosis is not appropriate.  As coders, we must code what's documented, without inserting our knowledge of disease states or opinions into the process.

SCAN CME Course -Dementia - Depression, Acute Behavioral Change, and Decision Making Capacity

As you know, dementia prevalence increases with age.   This free CME course will help ensure that you're able to:

 •Provide structured assessments with focus on problems that are prevalent amongst patients with dementia

 •Determine decision making capacity

 •Play an important role in providing education, psychosocial support, and referrals for these identified problems, among others, for patients and caregivers

 The target audience for this free CME program is physicians; nurses; social workers; and other healthcare professionals.

 

Click here to take this free CME program today!

What's New on HCC University?

We've done a little re-arranging on HCCUniversity.com.  While all of the old ICD-9 files are still there, we've put everything prior to 2012 in an archive that you can reach from the Tools page.   This will make navigating the Tools page easier, with less scrolling.

In addition, we've put a new widget on the Tools page.  Need to find an ICD-10 code?  Need to crosswalk an ICD-10 back to the equivalent ICD-9 code?  You can do it here on the ICD-10 widget.

What new documentation or coding tools would help you?  Send us your suggestions to coding@scanhealthplan.com.