CDI and Risk Adjustment for the Coder/Biller Amber Condren, BS, B Ed, CPC, CEMC, CHA, CMDP AHIMA ICD-10-CM/PCS Approved Trainer Senior Managing Consultant 9/26/2019 www.soerriescodingandbilling.com 1
Disclaimer The speaker has no financial relationship to any products or services referenced in this program. The program is intended to be informational only. The speaker is not an authoritative source by law. Attendees are advised to reference payer specific provider manuals, on-line or otherwise, for verification prior to making changes to their coding, documentation and/or billing practices. 9/26/2019 www.soerriescodingandbilling.com 2
Agenda For this session: • We will discuss the importance of risk adjustment codes and how to accurately capture them in both the inpatient and outpatient setting. • Cover best-practices for compliant queries to perpetrate the accuracy and of quality of documentation to ensure that all codes are documented and reported to their highest level of specificity. • And explore options for how coders and the CDI experts can work together to achieve the goals of the organization. 9/26/2019 www.soerriescodingandbilling.com 3
What We Know About Risk Adjustment • Risk Adjustment (RA) is a statistical process that takes into account the underlying health status and health spending of the enrollees in an insurance plan when looking at their health care outcomes or health care costs. https://www.healthcare.gov/glossary/risk-adjustment/ • Risk adjustment is an actuarial tool used to calibrate payments to health plans or other stakeholders based on the relative health of the at-risk populations. • A well-designed risk-adjustment system is one that properly aligns incentives, limits gaming, and protects risk-bearing entities (e.g., insurers, health plans). https://www.actuary.org/pdf/health/Risk Adjustment Issue Brief Final 5-26-10.pdf 9/26/2019 www.soerriescodingandbilling.com 4
Why is RA Important? • Predictive modeling – An analytical review of know data elements to establish a hypothesis related to the future health care needs of a patient with varying certainty. • Risk Adjustment is a method to evaluate and measure all patients on an equal scale – levels the playing field • Analyzes and reviews current and past medical conditions to predict future costs. • Concept was introduced to minimize the incentive to choose enrollees based on their health status and encourage competition among health plans based on quality, efficiency, and premium stabilization. 9/26/2019 www.soerriescodingandbilling.com 5
Important Items to Remember • There is more than one risk-adjustment model. • Each model may contain different HCCs. • You must look at each model. • Must be familiar with ICD-10-CM guidelines • Must be familiar with how to look up ICD-10-CM codes in either the alphabetic or tabular index. • And when reporting RA codes, sequencing does not apply. 9/26/2019 www.soerriescodingandbilling.com 6
Acronym Description Definition Total score of all risk factors for one patient for a total year. It RAF Risk Adjustment Factor is used to predict future healthcare costs for health plan enrollees. A value that contributes to an aggregated reimbursement Hierarchical Condition HCC that reflects the severity of the patient’s illness, to pay for Categories resources projected for patient care. RADV Risk Adjustment Data Random or targeted review of MA plans Validation Clinical Documentation Ensuring the content of the medical record accurately CDI Improvement represents the status of the patient’s health. Risk Adjustment Processing RAPS The systems through which risk adjustment data is processed System Encounter Data Processing CMS is transitioning from RAPS to EDPS which will allow for EDPS System risk adjustment payments to include more detailed records 9/26/2019 www.soerriescodingandbilling.com 7
How Does This Affect Reimbursement? • Each patients entire risk profile must be documented in the medical record. These will be completely coded on the claims and any other encounter data. • RA will assist in improving the overall patient care. • May affect the financial health of the practice and/or the facility. • Using a predictive analysis to predict future costs and reimbursement. • Will be used to forecast trends and future needs of patients. 9/26/2019 www.soerriescodingandbilling.com 8
Preparation Steps • Standardize Processes • For medical record documentation, coding, queries, etc. This will help minimize disruption and keep the process flowing. • Develop Internal Checkpoints • Theses checkpoints should be for the most common documentation and coding errors/questions. They should be set up prior to processing claims or submitting documentation. CDI’s are valuable in this area. • Utilize Tools and Resources • This will help identify incomplete coding and/or documentation. CDI’s can also assist in this area. • Review • Reviewing documentation for errors, specificity for capturing the complete code. This area most pertains to the CDI’s. 9/26/2019 www.soerriescodingandbilling.com 9
Patient Risk Scoring In order to accurately reflect a patient’s risk profile, more than the standard ICD codes, commonly seen in current billing practices, are required. ICD-10-CM codes that report to HCC categories HCC Categories 9/26/2019 www.soerriescodingandbilling.com 10
Audit & Compliance • Review audits to verify: • The accuracy and specificity of the diagnosis codes for submission. • The documentation supports the diagnoses codes. • Verify the providers signature • The providers credentials (MD, DO, PA, NP, LCSW, OT, PT, etc.) 9/26/2019 www.soerriescodingandbilling.com 11
Coding Guidelines Please Note: The inpatient coding guidelines are only referred to when a full inpatient record is being reviewed as one encounter (one stay). Outpatient coding guidelines are used if stand-alone documents such as discharge summaries, inpatient consults, etc., are for the provider and coded separately as single encounters. 9/26/2019 www.soerriescodingandbilling.com 12
Inpatient Coding Guidelines General guidance applicable to coding inpatient facility records using inpatient coding guidelines. 1. Confirm the admission and discharge dates are evident in the record. These should typically appear on the Discharge Summary. 2. Confirm that the encounter was ordered as an “admission.” Encounters that are ordered as an “ observation ” should be coded using outpatient coding guidelines with the admission date as the from/thru date (even if the discharge occurred 1-2 days later). Observation encounters are not classified as true admissions and must be coded as an outpatient encounter. 9/26/2019 www.soerriescodingandbilling.com 13
Inpatient Coding Guidelines 3. In order for the record to be supported as an inpatient record, confirm that a minimum set of inpatient documents are present (admission record, discharge summary, history & physical, physician orders/physician progress notes/consultation reports, procedure reports [if applicable]). 4. Confirm the Discharge Summary is compliantly signed (see Signature guidance pages 7-8). 5. Code capture all current conditions listed on the discharge summary that meet inpatient coding guidelines and received treatment. 9/26/2019 www.soerriescodingandbilling.com 14
Inpatient Coding Guidelines 6. Uncertain diagnosis. If the diagnosis at the time of discharge is qualified as “probable,” “suspected,” “likely,” “questionable,” “possible,” “still to be ruled out,” or other similar terms indicating uncertainty, code the condition as if it existed or were established. The basis 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, and psychiatric facilities. (Per ICD-10-CM guidelines Section II. H.) a. Ruled-out conditions upon discharge should not be coded 9/26/2019 www.soerriescodingandbilling.com 15
Inpatient Coding Guidelines 7. When applicable, code any chronic conditions that received treatment and met requirement. 8. When applicable, further specificity of a condition that is listed as a final diagnosis may be obtained from procedure or pathology reports. Ex. Femur fracture that is further specified to site and laterality on an x-ray) 9. Review all documents that are pertinent to the stay and query if further clarification is needed. 10. A Discharge Summary report is not required for lengths of stay less than 48 hours. In lieu of a discharge summary, a final discharge progress note is acceptable when a list of final discharge diagnoses, final disposition and follow-up is documented by the attending physician. 9/26/2019 www.soerriescodingandbilling.com 16
Outpatient Coding Guidelines General guidance applicable to coding outpatient records using outpatient coding guidelines. 1. Only one date of service is an encounter. Unlike inpatient where the entire stay is coded as one encounter. 2. There are 7 components of each encounter. • History • Exam • Medical Decision Making • Counseling • Coordination of Care • Nature of the Presenting Problem • Time 9/26/2019 www.soerriescodingandbilling.com 17
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