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Medicare

Medicare. Overview: Risk Adjustment. Risk adjustment. Program establish by Centers for Medicare and Medicaid Services [CMS]. GOAL : to allocate resources to those patients who most need them, based on each patient’s severity of illness.

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Medicare

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  1. Medicare Overview: • Risk Adjustment

  2. Risk adjustment • Program establish by Centers for Medicare and Medicaid Services [CMS] GOAL: to allocate resources to those patients who most need them, based on each patient’s severity of illness • Risk Adjustment Factor [RAF] score, is a metric tied to each individual member which reflects the health status of that member and is used by CMS to calculate payment • [2 components]: • Hierarchical Condition Category • (HCC) risk adjusting diagnoses codes submitted via encounter data claims • IDEAL SCORE: >1.00 demographic (age, sex, Medicaid status, and disability)

  3. 1. Risk adjustment Encounter Data By January 1st of each year, CMS cleans the slate for all patients and each patient is considered “cured” of all their chronic conditions “Very important” to evaluate each senior patient for an annual health assessment where each medical problem is properly documented, coded and reported via submission of encounter data • Three key components need to be validated by the provider(s): • Diagnosis (es) • Status of each chronic condition [i.e. new, stable, improved, worsening] • Plan [outlines the management of each chronic condition

  4. 1. Risk adjustmentInitial / Annual Health Assessment for senior members Also one of priority STAR program clinical measures, “ ADULTS’ ACCESS TO PREVENTIVE/AMBULATORY HEALTH SERVICES” Requirements to be eligible for bonus incentive: • Must meet eligibility with the IPA • IHA/AHA form must be completed in its entirety (diagnosis, status and plan section must be validated) • A CMS 1500 form must accompany the IHA/AHA form (if there are more ICD-9 CM diagnoses codes than the form can accommodate, please follow the CMS guidelines in accordance with 837 or 5010 requirements)

  5. 1. Risk adjustmentInitial / Annual Health Assessment for senior members con’t Must be billed using HCPCS codes: • G0402 [Initial Preventive Physical Exam] aka “Welcome to Medicare Visit” • G0438 [Annual Wellness Visit, initial visit] • G0439 [Annual Wellness Visit, subsequent visit] Importance to both IPA and PCP office: • to ensure that our members are getting quality of care and that their needs are addressed • to meet the CMS guideline of seeing the members at least once annually • to qualify for the CMS STAR and HEDIS program incentives – must be at least 3.5 stars

  6. Hcc Coding • 3 KEY COMPONENTS [DSP] • “FOREVER CONDITIONS” – CONDITIONS THAT DO NOT GO AWAY, E.G. CHF, COPD, DM, RA, MS, AMPUTATIONS….ETC… • DO NOT USE “HISTORY OF” FOR CONDITIONS THAT ARE STABLE AND CONTROLLED • DM CODING GUIDELINES- ALWAYS USE 2 CODES WHENEVER THERE IS A COMPLICATION • PULMONARY/RESPIRATORY PROBLEMS – IF PT IS ON O2 – CHRONIC RESPIRATORY FAILURE, CHRONIC SMOKER –SMOKER’S COUGH • CVA – USE LATE EFFECTS OF..

  7. CHRONIC KIDNEY DISEASE – MONITOR GFR • CKD 1 GFR>90 w PROTEINURIA/MICROALBUMINURIA • CKD 2 GFR 60-89 w PROTEINURIA/MICROALBUMINUR • CKD 3 GFR 30-59 • CKD 4 GFR 15-29 • CKD 5 GFR <15 • CKD 6 ESRD • CANCER • PSYCH • MALNUTRITION • FECAL IMPACTION VS CONSTIPATION • SIGNATURE REQUIREMENT

  8. New changes in 2014 • CKD I, II, III will no longer risk adjust AFTER 2013. It is still IMPORTANT to look for and stage CKD as you have been since it is A) excellent quality medicine to identify and treat CKD I, II early. B) It will still support “Diabetes with Renal Manifestation” to be Dxd and captured. C) The CKD will still continue to risk adjust for Pharmacy. So with the above considered, continue as you all have been looking and diagnosing CKD at all stages. • OLD MI, Hx of MI will no longer risk adjust AFTER 2013, however it is A) still important to be looking for and diagnosing it this year and B) consider ANGINA 413.9 in all patients with CAD, Hx of MI.

  9. New changes in 2014 • HYPOXIA will no longer risk adjust AFTER 2013, meaning it is IMPORTANT to diagnose “Chronic Respiratory Failure 518.83” (which will still risk adjust) in COPD patients with hypoxia. • MORBID OBESITY will RISK ADJUST in 2013. It is important that the BMI is calculated and interpreted by the provider if greater than or equal to 40 as Morbid Obesity. Additionally a BMI greater than or equal to 35 with a CO-MORBID diagnosis of DM, CHF, HTN, Sleep Apnea or moderate to severe DJD Knees/Hip may be diagnosed as Morbid Obesity

  10. New changes in 2014 • Diabetic Neuropathy will no longer risk adjust AFTER 2013 however, just as with CKD, it is still important to continue to screen and Dx in patients since it will support “Diabetes with Neurologic Manifestation”. • Stage 1 and 2 PRESSURE ULCERS will not risk adjust AFTER 2013 but it is obviously important to be screening for them for early care.

  11. Questions?

  12. Thank you

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