This document discusses approaches for improving chart audit and coding to ensure accurate risk adjustment scores. It emphasizes the importance of accurate documentation and coding for determining risk adjustment payments. It recommends a "belt and suspenders" approach of explanation, evaluation, selection and analysis of documentation improvement methods. The document also discusses upcoming changes to HCC coding rules and the need for provider training to address these changes. Finally, it notes challenges in validating risk adjustment data across different HCC models and years.

1.
A
Belt
&
Suspenders
Approach
to
Chart
Audit
&
Coding
March
19,
2014

2. BUCKLE
UP…
ARE
YOU
READY
FOR
THE
RIDE?
2
One
foot
on
the
brake
and
one
on
the
gas,
hey
Well,
there's
too
much
traffic,
I
can't
pass,
no
So
I
tried
my
best
illegal
move
A
big
black
and
white
come
and
crushed
my
groove
again
Go
on
and
write
me
up
for
125
…Post
my
face,
wanted
dead
or
alive
Take
my
license,
all
that
jive
...I
can't
drive
55,
oh
no,
uh

3. ACCURATE
RISK
SCORES
BEGIN
WITH
DOCUMENTATION
Accurate
DocumentaNon
&
Coding
Complete
&
Timely
Data
Submission
Accurate
Risk
Score
&
Resources
3

4. ! Management
Challenge
6:
• PrevenNng
Improper
Payments
and
Fraud
in
Medicare
Advantage
• CMS's
reported
error
rate
for
MA
decreased
from
11.4
percent
for
• FY
2012
to
9.5
percent
for
FY
2013
• In
2008
the
announced
error
rate
was
30%
in
large
part
due
to
signature
issues
• CMS
implemented
RADV
to
reduce
the
errors
in
risk-­‐adjustment
data
and
resulNng
improper
payments
.
RADV
verifies
the
accuracy
of
plan-­‐reported
diagnoses
through
medical
record
review
and
recouping
improper
payments
idenNfied
by
these
audits.
• CMS
plans
to
audit
about
30
MA
contracts
per
year
• hZp://oig.hhs.gov/reports-­‐and-­‐publicaNons/top-­‐challenges/2013/
FY
2013
OIG
REPORT
4

5. DOCUMENTATION
IMPROVEMENT
STEPS
! Explain
• Communicate
the
changes
within
the
industry
and
provide
adequate
educaNon
to
the
providers
and
staff
! Evaluate
• Look
at
opNons
to
improve
the
clinical
documentaNon
• Analyze
or
review
to
idenNfy
potenNal
problems
! Select
• Methods
for
documentaNon
improvement
that
work
for
your
unique
office
and
staff
• Be
sensiNve
to
the
provider’s
Nme.
Make
it
worthwhile
for
providers
to
take
Nme
out
of
their
busy
day
to
discuss
a
case
or
go
over
a
review
! Analyze
• Analyze
methodologies
and
the
effecNveness
of
your
programs
to
ensure
the
program
structure
is
effecNve
5

6. CHANGES
TO
THE
RULES
OF
THE
ROAD
! Analyze
the
2014
PY
(25%/75%)
blended
model.
Train
coders
and
providers
accordingly
• What
codes
are
new?
• What
codes
dropped
off?
• Changes
in
Hierarchies
! Audit
to
ensure
documenta^on
is
complete
and
accurate
for
code
capture
in
the
revised
model
• Are
there
different
documentaNon
requirements?
• Look
for
areas
of
improvement
• Specificity
! U^lize
analy^cs
to
assist
with
loca^ng
poten^al
coding
and
documenta^on
errors
• Incorrect
documentaNon/coding
paZerns
• InpaNent
condiNons
coded
in
the
outpaNent
seeng
6

7. 7
! The
rules
of
the
road
change,
we
must
shib
gears
and
communicate
the
changes.
Let’s
offer
the
providers
the
opportunity
to
be
successful
• Provider
and
Coder
Training-­‐Who
will
be
your
audience?
• Primary
Care/Specialty
Care
• Coders/
Billers
• Office
Managers/Cooperate
Staff
• Large
Group
versus
Small
Group
! Be
crea^ve
in
the
planning
stages
• Don’t
rush
the
process.
Plan,
Plan,
Plan
you
want
to
drive
the
message
to
as
many
vehicles
as
possible
• Involve
Provider
RelaNons,
possible
making
it
a
contest
• Quarterly
Provider
meeNngs
are
a
good
venue
• Breakfast,
Lunch
or
Dinner
meeNngs
most
aZended.
Ø Feed
them
and
they
will
come
• Offer
CME’s
for
the
Providers
and
CEU’s
for
the
Coders
• Requirement
to
aZend
in
order
to
parNcipate
in
incenNve
programs
! The
right
planning
and
training
will
drive
higher
performance
HOW
DO
WE
DRIVE
THE
MESSAGE

8. CHALLENGES
FOR
VALIDATION
FOR
2013/2014
ICD-­‐9-­‐CM
2013
HCC
Model
PY
2014
2014
HCC
Model
PY
2015
Status
Diabetes
Unspecified
250.00
19
19
No
change
DiabeNc
Renal
250.40
16
18
Category
Change
2014
Morbid
Obesity
278.01
0
22
Added
Code
2014
CKD-­‐Stage
1
585.1
131
0
Deleted
Code
2014
8
Some
codes
that
exist
in
both
models
had
category
changes

9. BUCKLE
UP
AND
LET’S
WORK
TOGETHER
9
CMS requests organizations’ best efforts to assist in
correcting and improving payment error

10. ECONOMICS
OF
HEALTHCARE
! The
Big
Picture
• Resources
are
being
spent
each
and
every
day
regardless
if
the
condiNons
were
documented
appropriately
• What
steps
are
you
taking
to
ensure
medical
record
documentaNon
support
chronic
condiNons?
• We
must
teach
our
providers
the
basic
requirements,
acceptable
verbiage,
the
differences
between
provider
documentaNon
and
the
official
coding
guidelines
• Direct
Feedback
to
the
coder
and
provider
should
be
provided
• Physicians
are
overwhelmed
and
just
want
to
treat
their
paNents,
however
Nme
constraints
someNmes
lead
to
minimal
documentaNon,
poor
specificity,
unsigned
records
and
missed
status
codes…
• Let’s
demonstrate
this
doesn’t
need
to
be
an
added
burden
• Provide
soluNons
and
tools
10

11. THE
COMPLETE
PICTURE
OF
HEALTH
! Documen^ng
and
coding
the
pa^ent’s
diagnosis
to
the
highest
specificity
in
the
medical
record
• Affects
the
accuracy
of
your
paNent’s
health
status
and
is
reflected
in
measures
of
paNent
outcomes
and
potenNally
reimbursement
• Drives
the
development
of
care
management
strategies
and
idenNfies
paNents
most
in
need
of
resources
• Shapes
the
coordinaNon
of
care
in
both
the
inpaNent
and
outpaNent
seengs
• Reflects
CMS’s
assessment
of
quality
of
care
delivered
• Drives
government
and
state
distribuNon
of
funding
to
support
enriched
paNent
services
• Under
coding
skews
the
cost
data
and
possibly
the
outcomes
as
well
11

12. IMPORTANCE
OF
MEDICAL
RECORD
DOCUMENTATION
! Accurate
documenta^on
and
coding
is
the
key
to
prompt
and
en^tled
reimbursement,
prac^ce
profiling
and
contract
nego^a^ons.
It
is
cri^cal
for
both
legal
and
financial
reasons
• The
medical
record
chronologically
documents
the
care
of
the
paNent
and
is
an
important
element
contribuNng
to
high-­‐quality
care
• The
progress
note
updates
the
paNent’s
clinical
course
of
treatment
and
summarizes
the
assessment
and
plan
of
care
! But,
the
role
of
documenta^on
has
expanded…
• TradiNonally,
documentaNon
was
used
mainly
by
the
provider
as
a
source
of
informaNon
to
assist
memory
of
paNent
care
from
one
episode
to
the
next
and
support
conNnuity
of
care.
• Today,
documentaNon
is
also
the
primary
means
of
communicaNon
among
an
extended
care
team
and
externally
to
health
plans
and
other
agencies
monitoring
health
care
quality
12
The
spoken
word
perishes…the
wri0en
word
remains

13. 2012
DIABETIC
FACT
SHEET-­‐UPDATED
3/2013
13
hZp://professional.diabetes.org/admin/UserFiles/0%20-­‐%20Sean/FastFacts%20March%202013.pdf
! Nearly
26
million
children
and
adults
in
the
United
States
have
diabetes
! 79
million
Americans
have
pre-­‐diabetes
! 1.9
million
Americans
are
diagnosed
with
diabetes
every
year
! Nearly
10%
of
the
en^re
U.S.
popula^on
has
diabetes,
including
over
25%
of
seniors
! As
many
as
1
in
3
American
adults
will
have
diabetes
in
2050
if
present
trends
con^nue
! The
economic
cost
of
diagnosed
diabetes
in
the
U.S.
is
$245
billion
per
year

14. RAF
SCORES
! Plans
should
not
assume
that
the
RAF
scores
assigned
to
their
members
are
accurate.
Even
if
your
RAF
score
seems
good,
that
score
may
not
truly
represent
the
actual
prevalence
of
chronic
diseases
in
the
MA
popula^on
you
manage.
You
could
be
missing
a
significant
opportunity
to
have
the
appropriate
financial
resources
necessary
to
manage
the
popula^on
! Members
are
not
always
seen
on
a
regular
basis,
which
will
result
in
low
RAF
scores
! Reality
is
the
providers
are
strapped
for
^me
and
see
mul^ple
pa^ents
each
day.
Some^mes
the
importance
of
iden^fying
the
burden
of
disease
in
the
popula^on
they
are
managing
can
be
lost.
! Physicians
need
to
examine
popula^on
data
about
chronic
condi^ons,
which
will
help
them
focus
not
only
on
individual
member
screenings,
but
also
on
the
en^re
popula^on
they
manage.
By
doing
so,
they
can
bejer
understand
the
true
burden
of
disease
in
this
popula^on
of
oben
chronically
ill
members
14

15. DATA
VALIDATION
AUDIT
! DVA
–
Data
Valida^on
Audit
! Data
valida^on
involves
retrospec^ve
comparison
of
diagnos^c
data
(ICD-­‐9-­‐CM)
reported
to
the
actual
documenta^on
within
the
medical
record
! DVA’s
should
be
performed
for
compliance
,
educa^onal
purposes
and
to
monitor
and
assess
the
quality
of
coding.
During
the
review
the
auditor
specifically
verifies
the
following
• Dates
of
service
are
within
the
data
collecNon
period
• Provider
signature/credenNals
are
present
on
the
note
for
each
DOS
submiZed
• The
service
was
provided
by
an
acceptable
provider
type
and
place
of
service
• The
diagnoses
are
properly
supported
by
the
medical
record
documentaNon
and
official
coding
guidelines
were
followed
• Billing
codes
without
appropriate
supporNng
documentaNon
is
a
compliance
issue
and
creates
risk
for
invesNgaNon
as
fraud
15

16. COMMON
DOCUMENTATION
&
CODING
ISSUES
! Lack
of
suppor^ve
documenta^on
for
acute
and
chronic
condi^ons
(No
MEAT)
! Diabe^c
complica^ons,
manifesta^ons
and
specificity
missing
or
lacking
Example:
Diabe^c
CKD,
Stage
CKD
! Incorrect
specificity
when
selec^ng
the
ICD-­‐9
code,
the
documenta^on
should
match
the
ICD-­‐9
selected
! Coding
resolved
or
history
of
diagnoses
as
ac^ve,
may
code
resolving
diagnosis
! Coding
acute/current
cancers
without
the
status
or
ac^ve
treatment
documented
16
! Metasta^c
Cancer/
site
not
documented
or
coded
(one
of
the
highest
HCCs)
! Acute
stroke
coded
in
the
outpa^ent
semng
when
most
likely
the
residual
or
history
of
stroke
should
have
been
coded
! Fracture
codes
reported
when
the
fracture
isn’t
in
the
acute
phase
! Unconfirmed
diagnoses
coded
example:
probable,
suspected,
consistent
with,
rule
out,
rather
code
signs
and
symptoms
un^l
defini^ve
! Not
documen^ng
status
codes
yearly
• Ostomy
Status
Morbid
Obesity
• AmputaNon
Quadriplegia/Paraplegia
• Dialysis
Status
Non
Compliance
with
Dialysis

17. ICD-­‐10-­‐CM
DOCUMENTATION
IMPROVEMENT
! ICD-­‐10-­‐CM
does
not
require
an
increase
in
quan^ty
of
documenta^on,
however
high
quality
documenta^on
will
increase
benefits
of
the
new
coding
system
which
is
increasingly
being
demanded
by
other
ini^a^ves
! Analyze
ICD-­‐9-­‐CM
frequency
data
and
focus
educa^onal
efforts
on
most
frequently-­‐coded
condi^ons
! Preliminary
ICD-­‐10-­‐CM
CMS-­‐HCC
&
Rx-­‐HCC
Model
• hZp://www.cms.gov/Medicare/Health-­‐Plans/
MedicareAdvtgSpecRateStats/Risk-­‐Adjustors.html
17

18. ICD-­‐10-­‐CM
–
LET’S
HAVE
SOME
FUN!
! Spacecrab
Collision
Injuring
Occupant
V95.43XA
! Dependence
on
other
enabling
machines
and
devices
Z9989
• Do
they
mean
Crackberry
or
Smartphone?
! Burn
due
to
water-­‐skis
on
fire
V91.07S
! Swimming
pool
of
prison
as
the
place
of
occurrence
of
the
external
cause
Y92.146
18

19. FINISH
LINE…
QUESTIONS,
THANK
YOU!
19
Next phase has to focus on
compliance, education and
systemic change.

20. AltegraHealth.com
(310)
874-­‐0539
Carol
Olson,
CCS,
CCS-­‐P,
CPC-­‐I,
CPC-­‐H,
CEMC,
CCDS,
AHIMA
Ambassador
ICD-­‐10-­‐CM
PCS
Approved
Trainer
Vice
President
of
Educa=on
&
Consul=ng
Carol.Olson@AltegraHealth.com