All Provider Meeting December 14, 2016 1 Agenda Call to order - - PowerPoint PPT Presentation
All Provider Meeting December 14, 2016 1 Agenda Call to order Richard Gough, MD FIHN Q3 Performance Results Richard Gough, MD Quality Reporting Timeline Jennifer Teeter MACRA/MIPS Requirements Jennifer Teeter MSSP
Richard Gough, MD
Richard Gough, MD
Jennifer Teeter
Jennifer Teeter
Jennifer Teeter
Richard Gough, MD
Richard Gough, MD
Charlotte Kohler
Richard Gough, MD
to Practice(s)
Access with each practice
CMS (approx. 4,216 patients)
if abstractor staff needs to come on-site
vendor, if necessary, for access to be granted
location of clinical data within EHR – speeds up abstraction process if we know where to look!
abstraction
ACO participants receive the ACO Quality Reporting Score
ACO Participants meet through ACO cost goals
ACO participants meet requirements through ACO activities
ACO participants receive weighted average score for ACO providers
$488,300 paid to FRHS for administrative costs
commercial payors
Medicare Shared Savings Program
Updated quality measures for Performance Year 2017 Beneficiary Assignment rules Audit Process Streamlined and more Robust Eligible Professionals flexibility to report separately from ACO
Modified reimbursement for Chronic Care Management Telehealth Services additional codes and place of service code Appropriate Use Criteria for Advanced Imaging
1) Mandatory PDMP Registration for CDS Prescribers & Pharmacists by July 1, 2017 2) Mandatory PDMP Use by CDS Prescribers & Pharmacists by July 1, 2018 3) CDS Prescribers & Pharmacists May Delegate PDMP Data Access to healthcare staff on their behalf.
Handout – Version III Maryland Prescription Monitoring Program PDMP = Prescription Drug Monitoring Program
changes to its current registration renewal process
file their renewal within 30 days after the expiration
expiration date will result in the retirement of the registrant’s DEA without reinstatement and would require a new application.
All Provider Meeting February 22, 2017 (6pm – 7:30pm) May 10, 2017 (7am – 8am) August 23, 2017 (6pm – 7:30pm) November 29, 2017 (7am – 8am) PCP POD Meeting January 5, 2017 (6pm – 8pm) April 6, 2017 (6pm – 8pm) July 6, 2017 (6pm – 8pm) October 5, 2017 (6pm – 8pm)
Kohler HealthCare Consulting, Inc.
410.461.5116
Section I
10-CM Section II – Specific HCCs 1. Diabetes Mellitus and Associated Manifestations 2. Diseases of the Respiratory System 3. Cardiovascular Conditions 4. Mental and Behavioral Health Disorders 5. Chronic Kidney Disease (CKD) 6. Cancer and Metastatic Diseases MANIFESTATIONS
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submitted for each member and demographic data into a predictive model
reflected
certain conditions
care
complex patients receive the appropriate care
improve reimbursements
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Allows CMS to better predict and budget cost of care Supports delivery of high-quality care Comparison of performance and quality across
Mitigates impact of potential adverse selection
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Use of Data Obtained Impact bonus pools to physicians and commercial insurance payer premiums
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– Identify potential new problems early; – Reinforce self-care and prevention strategies; – Coordinate care collaboratively; – Avoid potential drug-drug/disease interactions; – Improving the overall patient health care evaluation process; – Improving office practice patterns and communication among the patient’s health care team Commitment to risk adjustment will help providers meet their own CMS provider obligations supported by medical record documentation.
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CMS-HCC HCC Description 8 Metastatic Cancer and Acute Leukemia 10 Lymphoma and Other Cancers 11 Colorectal, Bladder, and Other Cancers 12 Breast, Prostate, and Other Cancers and Tumors 17 Diabetes with Acute Complications 18 Diabetes with Chronic Complications 19 Diabetes without Complication 40 Rheumatoid Arthritis and Inflammatory Connective Tissue Disease 58 Major Depressive and Bipolar Disorders 85 Congestive Heart Failure 96 Specified Heart Arrhythmias 111 Chronic Obstructive Pulmonary Disease
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High cost medical condition (current cancer, heart disease, hip fracture) – Highest weighted: HIV, Sepsis, Opportunistic Infections and Cancers Acute, chronic, status codes, etiology and manifestation – Hip fracture, COPD, status amputation of great toe, diabetic neuropathy Common conditions, rare conditions, conditions that can be cured, non-curable, congenital and acquired, but… – Must be current and impact the encounter in terms of requiring either…
Diagnoses are excluded from mapping when… – They do not predict future cost (e.g., appendicitis) – There is a high degree of discretion or variability in diagnosis, diagnostic coding, or treatment (e.g., symptoms, osteoarthritis) Diagnosis codes from lab, radiology and home health claims are not used because they are not reliable and may indicate rule-out diagnoses
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CMS-HCCs (Medicare) HHS-HCCs (Non-Medicare) ICD-10 CM Codes: 9,548 ICD-10-CM Codes: 7,768 HCCs: 79 HCCCs: 127 HCC Range: 1-189 HCC Range: 1-254 Accepted Provider Types:
Accepted Provider Types:
Data Linkages:
& retrospective review
Data Linkages:
procedures
7,645 ICD-10-CM diagnoses are found in both methodologies
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Chronic condition must be supported by a medical record Radiology and lab findings must be addressed in progress note Interactive, immaterial, and unaddressed conditions should not be submitted Suspected, ruled out, probable, likely diagnosis should not be submitted to CMS Don’t forget to sign and date your medical records with a credentialed provider
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conditions every calendar year
coding practices
highest level of specificity (ICD-10)
Management
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The Provider’s Role is Critical
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Basic: All billable preventive and care management services provide an opportunity for reporting HCC related diagnosis. Setting up by hiring right staff to create a team-based model of
revenue they can generate. These staff members are following patients – medication management; coordinating care with patient’s other providers; set up for needed visits. For care management, when 20 minutes per month is documented, the Practice receives about $42 payment. Make sure all diagnoses are documented even if not treated.
Diagnoses submitted from a face-to-face encounter must indicate how the conditions are being treated, managed or assessed. Every diagnosis reported as an active chronic condition must be documented with an assessment and plan of care, reflecting that the provider is applying the concept of MEAT.
treatment
Simply listing a diagnosis in the medical record does not support reporting an HCC code.
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TOP 10 Medicare Coding Errors For Risk Adjustment 1. The record does not contain a legible signature with credential. 2. The electronic health record (EHR) was unauthenticated (not electronically signed). 3. The highest degree of specificity was not assigned the most precise ICD-10-CM code to fully explain the narrative description of the diagnosis in the medical chart. BE SPECIFIC. 4. A discrepancy was found between the diagnosis codes being billed versus the actual written description in the medical record. The diagnosis code and the description should mirror each other. 5. Documentation does not indicate the diagnoses are being monitored, evaluated, assessed/addressed, or treated (MEAT).
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TOP 10 Medicare Coding Errors For Risk Adjustment (con’t.)
7. Chronic conditions, such as hepatitis or renal insufficiency, are not documented as chronic.
the specific type of arrhythmia).
record at least once per year.
there is a failure to report the manifestation.
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Exception: It is inappropriate to document/code “history of” when documenting some status conditions (e.g., amputation). 2. Improve specific documentation:
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Incorrect Documentation Correct Documentation H/O CHF, Meds Lasix Compensated CHF, stable on Lasix H/O Angina, Meds Nitroquick Angina, stable on Nitro H/O COPD, Meds Advair COPD controlled w/Advair
Obtain new ICD-10 book each year (effective October 1st of each year) Update encounter forms, billing forms, electronic medical records Print out detailed list from CMS
– https://www.cms.gov/Medicare/Health- Plans/MedicareAdvtgSpecRateStats/Risk-Adjustors-Items/IDC10Mappings.html – https://www.cms.gov/About-CMS/Agency-Information/Aboutwebsite/Help.html – Also - https://www.cms.gov/Medicare/Health- Plans/MedicareAdvtgSpecRateStats/Downloads/RiskAdj2017ProposedChanges. pdf – https://www.cms.gov/About-CMS/Agency-Information/Aboutwebsite/Help.html
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factor surrounding manifestation or related problems; however, in ICD-10- CM, there is usually only one combination code that will describe both Types of Diabetes as well as any related manifestation (E08.2)
manifestation such as nephropathy (E08.21)
there is more than one diabetic manifestation
specificity to ensure the correct risk adjustment value for your member and for disease management and quality of care purposes
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Provider needs to state cause- and-effect in one of following ways:
– “Due to” – “Secondary to” – “Diabetic” – “PVD due to Diabetes” Must be stated with cause-and- effect language. – e.g., Diabetes with Neuropathy identifies a relationship between diabetes and
provider lists diabetes as one problem and then lists neuropathy as another problem, then the two cannot be assumed to be related.
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those in acute exacerbation.
condition
Specific Coding Guidelines for COPD, Asthma & Acute Respiratory Failure
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– Develops over time – Requires long-term treatment – Specificity: Hypoxia or Hypercapnia – Selection of primary or secondary diagnoses – Sequencing guidelines
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Emphysema is a chronic lung disease caused by damage to the alveoli, the tiny air sacs in the lung where exchange of oxygen and carbon dioxide takes place. Air becomes trapped in the alveoli and causes them to expand and rupture. When coding for emphysema be sure to include an additional code to identify, when applicable, any related factors:
tobacco smoke (Z77.22)
environmental tobacco smoke (Z57.31)
Excludes:
(J98.3)
vapors (J68.4)
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Chronic Obstructive Pulmonary Disease (COPD) is a lung disease characterized by chronic obstruction
normal breathing and is not fully reversible. Chronic Bronchitis and Emphysema are no longer used. What are the conditions caused by?
Agents
Conditions in this category include:
emphysema
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Chronic Obstructive Pulmonary Disease, Including Bronchiectasis J44.0 Chronic obstructive pulmonary disease with acute lower respiratory infection. 160 (ACA) J44.1 Chronic obstructive pulmonary disease with (acute) exacerbation. 111 (MA) J44.9 Chronic obstructive pulmonary disease, unspecified
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Asthma is a chronic lung disease in which the airways narrow and swell and produce extra mucus. It affects more than 25 million Americans. Asthma symptoms include coughing, wheezing, shortness of breath, and chest tightness. Asthma is not curable, just controlled. Codes in this category distinguish between uncomplicated cases and acute exacerbations. Coding for Asthma expanded greatly in ICD-1o-CM to include intermittent, mild persistent, moderate persistent, and severe persistent. Provider documentation is extremely important to assign the correct code based on the symptoms and severity.
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Intermittent Mild Persistent Moderate Persistent Severe Persistent
Symptoms 2 or less days per week More than 2 days per week Daily Throughout the day Nighttime Awakenings 2 times per month or less 3-4 times per month More than once per week but not nightly Nightly Rescue Inhaler Use 2 or less days per week More than 2 days per week but not daily Daily Several times per day Interface with Normal Activity None Minor limitation Some limitation Extremely limited Lung Function FEV1>80% predicted and normal between exacerbations FEV1>80% predicted FEV1 60-80% predicted FEV1 less than 60% predicted
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HCC HCC Description ICD-10- CM Code Description 114 (MA)
Aspiration and Specified Bacterial Pneumonias and Other Severe Lung Infections
J15.0 Pneumonia due to Klebsiella pneumoniae J15.1 Pneumonia due to Pseudomonas J15.20 Pneumonia due to staphylococcus, unspecified J15.211 Pneumonia due to Methicillin susceptible Staphylococcus aureus J15.212 Pneumonia due to Methicillin resistant Staphylococcus aureus J15.29 Pneumonia due to other Staphylococcus J15.5 Pneumonia due to Escherichia coli J15.6 Pneumonia due to Aerobic Gram-negative bacteria J15.8 Pneumonia due to other specified bacteria J69.0 Pneumonia due to inhalation of food and vomit J69.1 Pneumonia due to inhalation of oils and essences J69.8 Pneumonitis due to inhalation of other solids and liquids
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well as if the patient is experiencing Angina.
many combination codes have been created.
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Additional Codes Used to Identify Related Factors
Z77.22 Exposure to Environmental Tobacco Smoke Z87.891 History of Tobacco Use Z57.31 Occupational Exposure to Environmental Tobacco Smoke F17._ Tobacco Dependence Z72.0 Tobacco Use
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Congestive Heart Failure (CHF) occurs when the heart cannot pump enough blood to meet the body’s needs and often develops after other conditions have weakened or damaged the heart muscle. Proper coding of CHF will require knowledge if the CHF is acute, chronic, acute on chronic, or unspecified. Coding Related Factors:
disease (I13._)
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ICD-10-CM Heart Failure Codes 150.1 Left Ventricular Failure
150.2_ Systolic (Congestive) Heart Failure 150.3_ Diastolic (Congestive) Heart Failure 150.4_ Combined Systolic And Diastolic (Congestive) Heart Failure 150.9_
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chronic elevated blood pressure of the arteries, which makes the heart muscle work harder than normal.
pressure is not considered a diagnosis of hypertension, however, a Dx of high blood pressure is considered equivalent to HTN (I10)
Hypertension table, codes have been simplified, and many combination codes have been created in this chapter.
has new hypertensive codes.
reading of 140/90 or above, then high blood pressure is present.
“Cause and Effect” between the hypertension and the complication.
both hypertension and CKD in the same encounter, we can assume the two conditions are related to one another.
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HTN and heart disease are coded when the provider documents a cause and effect relationship between the hypertension and the heart disease. Examples of heart disease diagnosis can include:
– Cardiomyopathy, myocarditis, arteriosclerotic cardiovascular disease, cardiomegaly, and unspecified heart disease (I50._ or 151.4-151.9)
When there is a cause and effect relationship, the hypertensive heart disease codes should be reported instead of the regular hypertension code (I11._).
– I11.0 Hypertensive heart disease with heart failure – I11.9 Hypertensive heart disease without heart failure
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reported whenever a patient has hypertension as well as CKD-related diagnosis in the same encounter.
(N18._).
(I12.0) + use additional code to identify the stage of CKD (N18.5, N18.6).
encounter should be used instead of the regular hypertension codes (N12._).
stage 1-4 CKD, or unspecified CKD (I12.9) + use additional code to identify the stage of CKD (N18.1-N18.4, N18.9).
heart failure is reported when all three conditions co-exist. Use combination codes (I13.0-I13.2) and use additional codes to identify type of heart failure (I50._) and to identify the stage of the CKD (N18.1- N18.9).
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Pneumonia is an infection of the lung that can be caused by nearly any class of organism known to cause human infection. Approximately 4 out of every 100 children in the U.S. develop pneumonia each year. 3 million cases of pneumonia are reported each year, and about 60,000 people die as a result of the condition. About 1/3 of pneumonia cases occur in people over age 65. If pneumonia is due to an Influenza, code the associated Influenza first. If the provider records “suspected” or “possible” or “probable” influenza of any kind, code from Category J11.
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Medicare Advantage Risk Adjustment Model
Disorders
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categories F10-F19 requires the provider’s clinical judgement. The appropriate codes for “In remission” are assigned ONLY on the basis of provider documentation.
correctly assigning codes in these categories
USE, ABUSE, and DEPENDENCE of a substance (alcohol, opioid, cannabis, etc.), only one code should be assigned to identify the pattern based on the established hierarchy.
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Coding Guidelines
documented, assign only the code for ABUSE.
are documented, assign only the code for DEPENDENCE.
documented, assign only the code for DEPENDENCE.
are all documented, assign only the code for DEPENDENCE.
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1 Center for Behavioral Health Statistics and Quality. (2015). Behavioral health trends in the United States: Results from the 2014 National
Survey on Drug Use and Health (HHS Publication No. SMA 15-4927, NSDUH Series H-50). Retrieved from http://www.samhsa.gov/data/,
In 2014, an estimated 15.7 million adults age 18 or older in the U.S. had at least one major depressive episode in the past year (6.7% of all U.S. adults).1
mood disorder in which feelings of sadness, loss, anger, or frustration interfere with daily life for weeks or longer.
ages 15-44 (NIMH).
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Psych
Bipolar, and Paranoid Disorders
Substance Abuse
Psychosis
Abuse
Proposed Changes For New Quality Measures Are Under Consideration
Management (Part C)
Providers or at High Dosages in persons without Cancer (Part D)
with Dementia (APD) (Part D)
CMS has proposed changes that address behavioral health for Risk Adjustment and Quality.
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Diseases of the Genitourinary System (N00-N99)
Patients with Chronic Kidney Disease often have higher risk adjustment value scores to identify additional needs.
Causes of Kidney failure in the United States
Source: Health, United States, 2011: table 51. End-stage renal disease patients, by selected characteristics: United States, selected years 1980–
Updated 2011. Accessed December 20, 2013.
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from the body.
– Progressive illness – over months or years – CKD can cause cardiovascular disease, pericarditis, and anemia – Labs such as Creatinine and GFR are key factors in diagnosing and staging CKD – Coders may not assign CKD based on a review of lab values – Treating provider must document diagnosis to its highest specificity
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abnormalities of the kidneys for >3 months, as manifested by either:
decreased GFR, as defined by:
including abnormalities in the composition of the blood or urine
without kidney damage
The term “GFR” is the best way to measure kidney function in health and disease as it measures a kidney’s ability to filter blood. Patients are often encouraged to “Know your number!”
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Stage Description GFR (ml/min/1.73 m2) Prevalence* N (1000s) % 1 Kidney Damage with Normal
90 5,900 3.3 2 Kidney Damage with Mild GFR 60-89 5,300 3.0 3 Moderate GFR 30-59 7,600 4.3 4 Severe GFR 15-29 400 0.2 5 Kidney Failure < 15 or Dialysis 300 0.1
Stages and Prevalence of CKD (Age > 20) Stages 1-4 from NHANES III (1988-1994). Population of 177 million with age 20. Stage 5 from USRDS (1998), includes approximately 230,000 patients treated by dialysis, and assuming 70,000 additional patients not on dialysis. GFR estimated from serum creatinine using MDRD Study equation based on age, gender, race and calibration for serum creatinine.
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In 2016, an estimated 1,685,210 new cases of cancer will be diagnosed in the U.S., and 595,690 people will die from the disease. The most common cancers in 2016 are projected to include*:
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– Breast Cancer – Lung and Bronchus Cancer – Prostate Cancer – Colon and Rectum Cancer – Bladder Cancer – Melanoma of the Skin – Non-Hodgkin's Lymphoma – Thyroid Cancer – Kidney and Renal Pelvis Cancer – Leukemia – Endometrial Cancer – Pancreatic Cancer
*Metastatic Cancer. National Institute of Health: National Cancer Institute. www. Cancer.gov. Retrieved: April 16, 2016.
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the documentation ?
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current = Active treatment through medication (radiation or chemotherapy).
still present, followed by the metastatic disease.
cancer being treated and the primary cancer has already been removed or eradicated, then only code the metastatic cancer.
diagnose when malignancy may be present, assign a code for signs and symptoms unless confirmation of the diagnosis is made.
remission.” Codes for leukemia, multiple myeloma, and malignant plasma cell neoplasm indicate whether the condition has achieved remission.
previously excised or eradicated and there is no further treatment directed, a code from the category Z85, Personal history should be used.
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identified.
encounter/visit shown in the medical record to be chiefly responsible for the services provided.
What Was the Reason for the Encounter or Admission?
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immunotherapy and conditions caused by any of these treatments, especially if they require evaluation, monitoring, treatment, or hospitalization.
the malignancy.
chemotherapy, immunotherapy, or radiation therapy, assign the appropriate Z51 code (encounter for other aftercare). This code should be listed as the first or principle diagnosis, and the diagnosis or problem for which the service is being performed should be listed as the secondary diagnosis.
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Accurate Health Status = Precise Reimbursement Generates Referrals to CM and DM Improves Provider and Member Rapport
Benefits of Proper Documentation and Coding
Significant Improvement and Higher Specificity Compliant Records Pass Audits
Timely Claims Payment and Reduces Administrative Burden
Charlotte Kohler, [RN], CPA, CVA, CPAM, CPC, CHBC President ckohler@kohlerhc.com (443) 956-1434 – Cell Kohler HealthCare Consulting, Inc. www.kohlerhealthcareconsulting.com (410) 461-5116 – Office
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