Empirical Risk Management

1. Empirical Risk Management Coding For Compliance

2. Medicare Faces Serious Challenges •  The 65-and-over population expected to double by 2030, increasing from some 36 million to 72 million people • Medicare’s growth will place significant strain on the federal budget • Medicare's annual costs were 3.2 percent of Gross Domestic Product (GDP) in 2007, or nearly three quarters of Social Security's. • They are projected to surpass Social Security expenditures in 2028 and reach 10.8 percent of GDP in 2082. It’s difficult to imagine the program surviving in its current form given these realities. 

3. The History of Medicare Advantage • The Balanced Budget Act of 1997 gave Medicare beneficiaries the option of receiving their benefits through private health plans, a program called "Medicare+Choice" or "Part C." • Upon passage of the Medicare Prescription Drug, Improvement and Modernization Act of 2003, the program became known as Medicare Advantage, and prescription drug coverage was added. • As of February 2012, 29% (12.8 million) of beneficiaries were enrolled in Medicare Advantage plans (including 37% of those enrolling in Medicare Part D for prescription-drug coverage).

4. The following 10 principles guided the creation of the CMS-HCC diagnostic classification system: • Principle 1—Diagnostic categories should be clinically meaningful. • Principle 2—Diagnostic categories should predict medical expenditures. • Principle 3—Diagnostic categories that will affect payments should have adequate sample sizes to permit accurate and stable estimates of expenditures. • Principle 4—In creating an individual’s clinical profile, hierarchies should be used to characterize the person’s illness level within each disease process, while the effects of unrelated disease processes accumulate. Because each new medical problem adds to an individual’s total disease burden, unrelated disease processes should increase predicted costs of care. However, the most severe manifestation of a given disease process principally defines its impact on costs. Therefore, related conditions should be treated hierarchically, with more severe manifestations of a condition dominating (and zeroing out the effect of) less serious ones. • Principle 5—The diagnostic classification should encourage specific coding.

5. Principle 6—The diagnostic classification should not reward coding proliferation. The classification should not measure greater disease burden simply because more ICD-9-CM codes are present. • Principle 7—Providers should not be penalized for recording additional diagnoses (monotonicity). This principle has two consequences for modeling: (1) no condition category (CC) should carry a negative payment weight, and (2) a condition that is higher ranked in a disease hierarchy (causing lower-rank diagnoses to be ignored) should have at least as large a payment weight as lower-ranked conditions in the same hierarchy. • Principle 8—The classification system should be internally consistent (transitive). • Principle 9—The diagnostic classification should assign all ICD-9-CM codes (exhaustive classification). • Principle 10—Discretionary diagnostic categories should be excluded from payment models.

6. Characteristics of CMS-HCC Model

7. CMS-HCC Model • What is a Hierarchical Condition Category? • Category of medical conditions that map to a corresponding group of ICD-9 diagnosis codes • 2,913 ICD-9 Codes Map to 1 of 70 HCC’s *Per the ICD-9-CM Official Guidelines for Coding and Reporting: “Code all documented conditions that coexist at the time of the encounter/visit, and require or affect patient care treatment or management.”

8. Hierarchies • Hierarchies are imposed among related CCs, so that a person is coded for only the most severe manifestation among related diseases. • For example , ICD-9-CM Ischemic Heart Disease codes are organized in the Coronary Artery Disease hierarchy, consisting of four CCs arranged in descending order of clinical severity and cost, from CC 81 Acute Myocardial Infarction to CC 84 Coronary Atherosclerosis/Other Chronic Ischemic Heart Disease. A person with an ICD-9-CM code in CC 81 is excluded from being coded in CCs 82, 83, or 84 even if codes that group into those categories were also present. • Similarly, a person with ICD-9-CM codes that group into both CC 82 Unstable Angina and Other Acute Ischemic Heart Disease andCC83 Angina Pectoris/Old Myocardial Infarction is coded for CC 82, but not CC 83. • After imposing hierarchies, CCs become Hierarchical Condition Categories, or HCCs. https://www.cms.gov/Medicare/Health-Plans/MedicareAdvtgSpecRateStats/downloads/Evaluation_Risk_Adj_Model_2011.pdf

11. Top 10 HCC’s • COPD $3112 • 496 COPD • 493.20 Asthma w/chronic COPD (Chronic Obstructive Asthma) • 491.9 Chronic Bronchitis • 492.8 Emphysema • CHF $3198 • 428.0 CHF • 425.4 Primary Cardiomyopathy (Ischemic is not an HCC) • 402.91 Hypertensive Heart Disease w/heart failure Vascular Disease $2465 • 443.9 Peripheral Vascular Disease • 443.81 PVD in other diseases (diabetes) • 453.40 Acute DVT • 440.0 Atherosclerosis of Aorta • 441.4 Abdominal Aortic Aneurysm Cancer $1622-$8213 • All malignant neoplasm’s including Melanoma but not skin cancer • All secondary malignant neoplasm’s – • Highest HCC if site is documented $17,753 Ischemic Heart Disease $2215 • 411.1Unstable Angina Specified Heart Arrhythmia $2285 • 426.0 Complete AV block • 427.31 Atrial Fibrillation • 427.81 Sick Sinus Syndrome Diabetes $1264 - $3962 • all diabetes (250.XX) and most of the manifestations Ischemic or Unspecified Stroke $2067 • 436 CVA • 434.91 Unspecified cerebral artery occlusion, with infarction • Angina/Old MI $1903 • 413.9 Angina • 412 Old MI Rheumatoid Arthritis & Inflammatory Connective Tissue Disease $2699 • 714.0 Rheumatoid Arthritis • 710.0 SLE www.empiricalriskmanagement.com

12. Diabetes Coding *CMS Medicare Database

13. Diabetes Coding • What if I have a patient who has multiple manifestations or complications??? • Code the 250.xx with the highest RAF • Then code the buddy code – the corresponding complication or manifestation • Then code all other complications • They are additive!

14. Buddy Codes • Required when 4th digit is 1-8 • Peripheral Neuropathy due to Diabetes • 250.60 Diabetes with neurological manifestations • 357.2 Polyneuropathy in Diabetes • Diabetic Peripheral Vascular Disease • 250.70 Diabetes with peripheral circulatory disorders • 443.81 PVD in Diabetes • Diabetic Calf Ulcer • 250.80 Diabetes with other specified complications • 707.12 Ulcer

15. Linking Words • Linking words create a relationship between diseases and manifestations • Assures coders of a cause and effect between disease and manifestation, as we cannot assume. • Appropriate terms: • Due to • Secondary to • Use of associative suffix ‘ic’ or ‘ive’ (diabetic ulcer or hypertensive heart disease) • The terms “probable” and “more than likely” do not provide linkage

16. EMR’s and Compliant Coding • "There are regulatory and accreditation directives that require providers to supply documentation in order to support code assignment. Providers need to have the ability to specifically document the patient's diagnosis, condition, and/or problem. Therefore, it is not appropriate for providers to list the code number or select a code number from a list of codes in place of a written diagnosis."(Q 1 2012 Coding Clinic) • 250.40--Diabetes with renal manifestationsAs you can see, this is not a diagnosis, but a category of diseases, or in ICD-9 terms, a statistical classification.The clinician is responsible for providing a diagnosis, so they may need to add to the short descriptor of a diagnosis code in the EMR.  For example: • 250.40--Diabetes with renal manifestations - CKD 4 due to DMThis provides an actual assessment (diagnosis) of the patient's condition, that allows correct coding.EMRs can be tremendous time savers, but physicians and clinicians must ensure that they meet coding and documentation requirements.

17. When Documenting think MEAT • You must follow the rules of ICD-9 coding when coding chronic conditions. You must also have "MEAT" to code these chronic conditions... • M=Monitor, E=Evaluated, A=Addressed/Assess, T=Treated • If no "MEAT" is found for conditions stated, you cannot code. • Providers must also follow CMS signature guidelines. • REMEMBER: If it is not documented, it didn’t happen!!!

19. Documentation Guidelines • History of • Means that the patient no longer has the condition • Frequent documentation errors regarding use of history of: • Coding a past condition as active • Coding history of when condition is still active • Exception: It is appropriate to document / code “history of” when documenting some status conditions (e.g. Amputation).

20. CKD and HTN (403.xx) Relationship may be assumed between these conditions if both are reported. Dual code required when 403 series is used, indicating the related CKD (585.x) • Hypertensive* CKD Stage 4 • 403.90 & 585.4 • HTN and ESRD on dialysis • 403.91, 585.6 and V45.11

21. COPD • COPD is a non specific “umbrella term” for a host of conditions, and is used when type of COPD is non specified • 491 Chronic Bronchitis • 492 Emphysema • 493 Asthma • Documentation for COPD • Code selection must be based upon terms as documented • 491. 20 Chronic bronchitis without exacerbation of COPD • 491.21 Chronic bronchitis with COPD exacerbation • Acute exacerbation of COPD • Decompensated COPD • 491.22 COPD with acute bronchitis

22. Emphysema • 492.0 Emphysematous bleb usually found on imaging studies • 492.8 Other emphysema – lung or pulmonary, centriacinar, centrilobular, obstructive, panacinar, panlobular, unilateral, vesicular Asthma *4th digit defines type • 493.0 Extrinsic, or allergic asthma • 493.1 Intrinsic asthma • 493.2 Chronic obstructive asthma – occurs in the presence of COPD • 493.8 Other forms of asthma • 493.81 exercise induced bronchospasm • 493.82 cough variant asthma • 493.9 Asthma, unspecified *5th digit defines current encounter • 0 – unspecified • 1- with status astmaticus • 2 – with acute exacerbation

23. Common Missed HCC’s • Old MI (8 weeks +) • A. Fib (coumadin) • Chronic and Acute DVT • Chronic Hepatitis • Do not write Hep B or Hepatitis C • Inflammatory Bowl Disease • Ulcerative Colitis, Crohn’s disease *Non HCC - constipation, unspecified 564.00 • Pancreatic Disease • Intestinal Obstruction / perforation (fecal impaction) • Nephritis • RA • Uro Sepsis • Pneumonia • Enteritis • Major Depressive Disorder • Protein Calories Malnutrition • Parkinson’s • Metastatic Cancer

24. Decubitus Ulcer of skin* Must Document site and stageChronic Ulcer of Skin of various locations, except decubitus Documentation is critical and buddy codes are required for both types: Stage 1 pressure ulcer lower back 707.03 and 707.21 Diabetic Calf Ulcer – 250.80 and 707.12

25. Is this really important??? • Each year, CMS conducts Risk Adjustment Data Validation (RADV) audits to determine if submitted diagnoses are documented in the medical record. • Health plans, hospitals and physicians offices must submit medical records that are requested for audit. • Improperly documented diagnoses may result in loss reimbursement. Recovery Audit Contractors (RAC) – Coming to an office near you….

26. Methodological Changes for CY 2013 for Medicare Advantage • CMS is implementing an updated version of the MA aged/disabled risk adjustment model. This recalibration of the Hierarchical Condition Categories (HCC) will result in some diseases being paid more and others being paid less. CMS is also recalibrating the Part D RxHCC model which may result in changes in risk scores for individual beneficiaries and average plan risk scores. • In 2013, standard Part D will cover 21 percent of generic coverage and 2.5 percent of brand coverage in the gap. • The Draft Call Letter clarifies policy on the treatment of Part C supplemental benefits to assure, for example, that care coordination and disease management services are classified as integral to the care provided by plans. • CMS is strengthening its value-based purchasing policies by issuing Notices offering a Special Enrollment Period to beneficiaries enrolled in plans with fewer than three stars for three years and disabling the on-line enrollment feature on the Medicare Plan Finder for new enrollees seeking to enroll in a plan with a low-performing icon.

27. Changes to the CMS-HCC Risk Adjustment Model • For 2013, CMS will implement an updated version of the aged/disabled CMS Hierarchical Condition Category (HCC) risk adjustment model. The disease groupings are the same as in past models, however the factors are different. • For the CY 2013 recalibration, CMS used 100 percent of FFS claims for the years 2008 and 2009.(The current model uses a five percent claims sample from 2004 and 2005 data.) The updated model also uses revised constraints. Updating also adjusts the model for increases in predicted FFS expenditures between calibration years. • The risk adjustment models for ESRD and PACE will not change from 2012

28. New Measures Survey measures of care coordination from the 2012 CAHPS survey include questions related to the following areas: • Whether the doctor had medical records and other information about the enrollee’s care • Whether follow-up occurred with the patient to provide test results • How quickly the enrollee received test results • Whether the doctor spoke to the enrollee about prescription medicines • Whether the enrollee received help managing care; and • Whether the personal doctor is informed and up-to-date about specialist care.