Risk Adjustment Coding And HCC Guide

2019Risk AdjustmentCoding and HCCGuidePower up your codingoptum360coding.com

ContentsIntroduction . 1History and purpose of RAF .1Key Terms Definitions .3Acceptable provider types/SOS.5The provider’s role .6Payment Methodology .8RAF Payment Timeline. .12Coding and Documentation . .15Explanation of impact of good documentation (table example). 15CMS Requirements. 20Coding Guidelines. 30Caveats. 44Tools (MEAT/TAMPER) . 48Coding Scenarios/Examples/Teaching . 59Audits . 79Medicare Advantage Risk Adjustment Data Validation (RADV) . 79Health Effectiveness Data & Information Set (HEDIS) . 87Internal Care and Quality Improvement Audits . 91Care and Quality Improvement Audits . 91Appendixes - Includes HCC with description, hierarchies, and ICD-10 Mappings . 103CMS HCCs .105Rx HCCs .335ESRD.395PACE .445HHS-HCC. 495RAF weights – tables .5352018 Optum360, LLCi

IntroductionThe traditional fee-for-service payment model has beenwidely used since the 1930s when health insurance plansinitially gained popularity within the United States. In thispayment model, a provider or facility is compensated basedon the services provided. This payment model has proven tobe very expensive. Closer attention is being paid to healthcarespending versus outcomes and quality of care, and this hasbeen compared to the healthcare spending of other nations.This has caused a need to develop a system to evaluate thecare being given.In the 1970s, Medicare began demonstration projects thatcontracted with health maintenance organizations (HMOs) toprovide care for Medicare beneficiaries in exchange forprospective payments. In 1985, this project changed fromdemonstration status to a regular part of the Medicareprogram, Medicare Part C. The Balanced Budget Act (BBA) of1997 named Medicare’s Part C managed care programMedicare Choice, and the Medicare Modernization Act(MMA) of 2003 again renamed it to Medicare Advantage (MA).Medicare is one of the world’s largest health insuranceprograms, and about one-third of the beneficiaries onMedicare are enrolled in a MA private healthcare plan. Due tothe great variance in the health status of Medicarebeneficiaries, risk adjustment provides a means of adequatelycompensating those plans with large numbers of seriously illpatients while not overburdening other plans that havehealthier individuals. Medicare Advantage plans have beenusing the Hierarchical Condition Category (HCC)/riskadjustment model since 2004.The primary purpose of a risk adjustment model is to predict(on average) the future healthcare costs for specificconsortiums enrolled in MA health plans. CMS is then able toprovide capitation payments to these private health plans.Capitation payments are an incentive for health plans toenroll not only healthier individuals but those with chronicconditions or who are more seriously ill by removing some ofthe financial burden.Section of 1343 of the Affordable Care Act of 2010 provides for arisk adjustment program for non-Medicare advantage planswhich are available in online insurance exchange marketplaces.Beginning in 2014, commercial insurances were able topotentially mitigate increased costs for the insurance plan andincreased premiums for higher-risk populations such as thosewith chronic illnesses by using a risk adjustment model. The riskadjustment program developed for use by non-Medicare plans ismaintained by the Department of Health and Human Services(HHS). This model also uses HCC diagnostic groupings; however,this set of HCCs differs from the CMS HCCs to reflect thedifferences in the populations served by each healthcare plantype.This publication will cover the following: History and purpose of RAF Key terms definitions Acceptable provider types Payment methodology and timeline Coding and documentation Tools for risk adjustment Coding scenarios Guidance for developing internal risk adjustmentcoding polices Audits HEDIS Risk adjustment tablesThe MA risk adjustment model uses HCCs to assess thedisease burden of its enrollees. HCC diagnostic groupingswere created after examining claims data so that enrolleeswith similar disease processes, and consequently similarhealthcare expenditures, could be pooled into a larger dataset in which an average expenditure rate could bedetermined. The medical conditions included in HCCcategories are those that were determined to mostpredictably affect the health status and healthcare costs ofany individual.2018 Optum360, LLC1

Risk Adjustment Coding and HCC GuideCoding Scenario 1Patient Name: Betty SmithElectronically Signed: Dr. B. Johnson, D.O.DOB: 07/28/1963Appt. Date/Time: 4/5/2017Insurance: Medicare Advantage (HMO)Appt. Type: MCEChief Complaint: Follow up hyperlipidemia, HTN, OA, MDDVitalsThe provider should also bequeried for E66.2 Morbid (severe)obesity with alveolarhypoventilation. The body massindex (BMI) is noted to be 36.6 onthe DOS and the patient hascomorbidities of hypertension,hyperlipidemia, and obstructivesleep apnea (OSA).BP: 134/71 sitting L armBP Cuff Size: adultPulse: 61 bpm regularT: 97.8 F oralO2Sat: 93% RAHt: 62 inW: 200lbsBMI: 36.6ROSPatient reports no frequent nosebleeds, no nose problems, and no sinus problems: congestion.She reports dry mouth but reports no sore throat, no bleeding gums, no snoring, no mouth ulcers,and no teeth problems. She reports arthralgia/joint pain (right knee) but reports no muscle aches,no muscle weakness, no back pain, and no swelling in the extremities. She reports frequent orsevere headaches but reports no loss of consciousness, no weakness, no numbness, no seizures,no dizziness, and no tremor. She reports fatigue. She reports no fever, no night sweats, nosignificant weight gain, no significant weight loss, and no exercise intolerance. She reports no dryeyes, no vision change, and no irritation. She reports no difficulty hearing and no ear pain. Shereports no chest pain, no arm pain on exertion, no shortness of breath when walking, no shortnessof breath when lying down, no palpitations, and no known heart murmur. She reports no cough,no wheezing, no shortness of breath, no coughing up blood, and no sleep apnea. She reports noabdominal pain, no nausea, no vomiting, no constipation, normal appetite, no diarrhea, notvomiting blood, no dyspepsia, and no GERD. She reports no incontinence, no difficulty urinating,no hematuria, and no increased frequency. She reports no abnormal mole, no jaundice, no rashes,and no laceration. She reports no depression, no sleep disturbances, feeling safe in a relationship,no alcohol abuse, no anxiety, no hallucinations, and no suicidal thoughts. She reports no swollenglands, no bruising, and no excessive bleeding. She reports no runny nose, no sinus pressure, noitching, no hives, and no frequent sneezing.History—updated 04/05/2017This note validates that the breastcancer is an active problem whichis being treated. The providerdocumented that the patient isundergoing treatment withtamoxifen and is seeing anoncology provider. The historyportion of this note also showsthat it was updated on the date ofservice (DOS).Breast cancer—stable, sees oncology, on tamoxifen for 2 yearsDepressive disorder—major, partially managed on SSRIOSA—refuses CPAPPhysical ExamPatient is a 54-year-old female.ConstitutionalGeneral Appearance: well-developed, appears stated age, and obese.Level of Distress: comfortable.PsychiatricMental Status: alert and normal affect.Orientation: oriented to time, place, and person. Insight: good judgment.CardiovascularPrecordial Exam: no heaves or precordial thrills and non-displaced focal PMI. Rate And Rhythm:regular.Heart Sounds: no rub, gallop, or click and normal S1 and physiologically split S2.Systolic Murmur: not heard.Diastolic Murmur: not heardExtremitiesNo cyanosis, edema, or peripheral signs of emboliNeurologicMotor: tremor of neck and face and arms2018 Optum360, LLC59

Risk Adjustment Coding and HCC GuideCoding Scenario 1 (continued)It is necessary to query theprovider for additionalinformation about thedepression. There is insufficientdocumentation to code majordepressive disorder.A/P1.2.3.4.5.Mixed hyperlipidemia—continue medsBenign essential hypertension—continue medsInsomnia—discussed sleep hygiene/caffeine curfewAnxiety/depression—continue meds/consider seeing psychObesity—discussed increasing activity and decreasing caloric intakeICD-10-CM CodeDescriptionHCC 580.395F33.41 Major depressivedisorder, recurrent, in partialremissionNoYesHCC 12C50.919 Malignant0.146neoplasm of unspecified siteof unspecified female breastYesYesHCC 22E66.2 Obesityhypoventilation syndrome(OHS)0.273NoYesDemographics54-year-old, female, notMedicaid eligible0.263YesYes0.4091.077Total RAF60Validated byImprovedCurrentDocumentation DocumentationHCC CategoryRAF Value2018 Optum360, LLC

Risk Adjustment Coding and HCC GuideCoding Scenario 2Result type: History and Physical NotePerformed By/Author: Black MD, Brian on January 11, 2018Result date: January 11, 2018Verified By: Black MD, Brian on January 11, 2018Result status: Auth (Verified)Encounter info: (IPE) Emergency - IP, 1/11/2018 - 1/12/2018Result Title/Subject: History and Physical* Final Report *History and PhysicalPatient: MILLER, PAUL CAge: 91 yearsAssociated Diagnoses: NoneDOB: 12/27/1926Sex: MaleChief Complaint: slurred speech, facial droop, fall Author: Black, MD BrianHistory of Present Illness91 yo M PMH significant for A-fib not on anticoagulation, HTN, asthma, colon CA s/p resection 2years prior who is BIBA f for acute onset of slurred speech, left lower facial droop following fall.Patient and wife note around 830 PM last night, he sustained a slow fall in his home. He is unsure ifhe lost balance but had difficulty standing back up on his own but was able to be seated into chairby his wife. He then noticed that he had a difficult time speaking and his wife noted he had a leftlower facial droop. She suspected he has having a stroke and gave him approximately 250 mg ofAspirin. Wife then called EMS, and patient and wife both note that his symptoms were improvingalready in the ambulance. Symptoms were essentially resolved by the time he arrived to the EDhere, which was approximately 30 mins after onset of symptoms. He had otherwise been feelingwell except for a mild cough which started about 10 days ago and has mostly resolved. He notes hewas given a cough suppressant with bactrim by PCP, which he has since completed. He otherwisedenies any fevers, chills, dizziness, shortness of breath, chest pain, palpitations, nausea/vomiting,bowel changes, urinary changes, blood in stool.Review of Systems12 point ROS reviewed and negative except as abovePast Medical Historyas noted above.Allergies (1) Active Reaction: quiNIDine Affect his liverSocial Historydenies tobacco, quit in 1986denies etoh or drug useFamily Historymother- colon CABrother- throat CAHome Medications (6) Activeatenolol 25 mg oral tablet See Instructionsfinasteride 5 mg oral tablet 5 mg 1 tab, PO, dailyloratadine 10 mg, PO, dailymultivitamin 1 cap, PO, dailytamsulosin 0.4 mg oral capsule 0.4 mg 1 cap, PO, dailyUnlisted Med See Instructions2018 Optum360, LLC61