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Risk adjustment calculation

Risk Adjustment reimbursement is driven by accurate capture of ICD 10 codes. Here is a list of best practices to ensure that your practice’s HCC/ICD 10 diagnosis coding is accurate. Know about MEAT and the required specific MEAT for certain conditions. Bonus: Top 10 RADV documentation fails.

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Risk adjustment calculation

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  1. THE HCC’S OF HCC’S  United Healthcare, organized and implemented a company wide upcoding scheme, which United called “Project 7”. United implemented it as an attempt to significantly improve its overall operating income by close to $100 million

  2. PRIMARY CARE AND DON’T CARE – WHY YOU SHOULD Let’s say you are a Primary Care Doctor, with a few providers in your practice.  You participate in several MA Plans and you receive a letter with a list of your patients from the MA Plan asking you to verify some “conditions/diagnoses” that their coders/auditors/software, etc., noticed might be current Chronic Conditions.

  3. RISK ADJUSTMENT REIMBURSEMENT – DATA DRIVEN The HCC codes must be captured every 12 months for CMS to reimburse the MA plan, and if the HCC codes are captured outside of that scope of 12 months (for example, 12 months and 4 days), it will then generate a 6-month revenue gap for that MA plan

  4. DATA AND ME – THE PROVIDER Good documentation begins at the time of the patient’s face-to-face encounter with the physician. It means the physician documents the clinical findings in the medical record, and the medical record is used to determine ICD-10-CM codes. The pertinent information from the patient encounter is submitted to the MA organization for payment.

  5. THE RA GUIDING PRINCIPLE AND YOUR MEDICAL RECORDS Coded according to the ICD-10-CM Guidelines for Coding and Reporting; assigned based on dates of service within the data collection period. Submitted to the MA organization from an appropriate risk adjustment provider type and an appropriate risk adjustment physician data source

  6. THE WHO/WHAT/WHEN OF MEAT:    Was the condition Monitored, Evaluated, Assessed or Treated? MONITOR—Signs, Symptoms, Disease Progression, Disease Regression EVALUATE—Test Results, Medication Effectiveness, Response To Treatment ASSESS/ADDRESS—Ordering Tests, Discussion, Review Records, Counseling TREAT—Medications, Therapies, Other Modalities

  7. TOP TEN RADV DOCUMENTATION FAILS Failing to capture HCCs at least once every 12 months. Failure to ensure the medical record contains a legible signature with credential. For example, determine whether such as the electronic health record was unauthenticated (not electronically signed). Failure to ensure the diagnosis codes being billed and the actual medical record documentation match. Failure to document according to the M.E.A.T. principles. Diagnoses need to be monitored, evaluated, assessed/addressed, and treated. Failing to annually document status Z codes and chronic conditions.

  8. Failing to use a linking statement or document a causal relationship for manifestation codes. Failing to add any diagnosed HCCs or RxHCCs (prescription drug HCCs) to both the chronic problem list and the acute assessment. Failing to evaluate each of the HCCs/RxHCCs on a semiannual basis for updates. Failing to review all specialist documentation related to cardiology, master discharge summaries, radiology, specialty correspondence, pulmonary, echocardiograms, and x-rays, laboratory results, and previous encounters. Failing to submit more than the standard four ICD-10-CM codes (CMS allows up to 12, check with your EMR and clearinghouses on what they can accept)

  9. https://www.billingparadise.com/blog/hcc-of-hcc-best-coding-practices/https://www.billingparadise.com/blog/hcc-of-hcc-best-coding-practices/ Call Toll Free No 1-888-571-9069

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