day2pp3 claims submissions strepina bsenor final · •rendering provider npi vs. billing provider...

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Claims vs. RAPS Submission: Understanding the Difference

Sonia Trepina, MPA Director, Risk Adjustment & Ambulatory CDI ServicesEnjoinAsheville, NC

Brett Senor, MD, CRC, CCDSPhysician Associate, CDI Quality InitiativesEnjoinAsheville, NC

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Learning Objectives

• At the completion of this educational activity, the learner will be able to understand:

– Describe how HCCs are submitted to and validated by CMS

– Discuss challenges of claims and RAPS submission processes

– Identify the impact of the varying processes on an organization’s risk scores

– Explain how CDI can support accuracy and specificity for risk adjustment capture and scoring

2018 Copyright, HCPro, a brand of Simplify Compliance LLC. All rights reserved. These materials may not be copied without written permission.

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Polling Question #1

• What department/role do you represent?

1. CDI

2. Coding

3. Data analytics

4. Compliance

5. Other


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Polling Question #2

• What is your familiarity with HCCs?

1. I understand the concept and details

2. I understand the concept but have not worked with HCCs

3. I’ve heard the term before but don’t know what it means

4. I’ve never heard of HCCs before

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Age, Sex, Disability Status, etc.

Health Status

Adjusts Future

Payments

What Are HCCs?

• One risk adjustment methodology

• Predicts or explains future healthcare expenditures of individuals based on diagnoses and demographics

• Predicts the variations in resources required to care for different patients and to reimburse providers appropriately based on those variables

• Used for Medicare Advantage payment models, ACOs


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CMS Hierarchical Condition Categories (HCC)

HCC requirements:

• Face‐to‐face qualifying visit

• Eligible provider type

• Supported by documentation

• Captured at least once per calendar year

>71,000 ICD‐10 codes (conditions)

9,500 ICD‐10 codes associated with increased resource intensity

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categories

(HCCs)

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• A coefficient or “weight” is assigned to each category of chronic complex diagnoses as well as severe acute diagnoses

• Each HCC that applies is additive

E0800 Diabetes mellitus due to underlying condition with hyperosmolarity without nonketotic hyperglycemic‐hyperosmolar coma (NKHHC)

E0801 Diabetes mellitus due to underlying condition with hyperosmolarity with coma

E0810 Diabetes mellitus due to underlying condition with ketoacidosis without coma

E0811 Diabetes mellitus due to underlying condition with ketoacidosis with coma

E08641 Diabetes mellitus due to underlying condition with hypoglycemia with coma

E0900 Drug or chemical induced diabetes mellitus with hyperosmolarity without nonketotic hyperglycemic‐hyperosmolar coma (NKHHC)

HCC

CategoryDescription Label Coefficient

HCC01 HIV/AIDS 0.312

HCC02 Septicemia, Sepsis, Systemic Inflammatory Response Syndrome/Shock 0.455

HCC06 Opportunistic Infections 0.435

HCC08 Metastatic Cancer and Acute Leukemia 2.625

HCC09 Lung and Other Severe Cancers 0.970

HCC10 Lymphoma and Other Cancers 0.677

HCC11 Colorectal, Bladder, and Other Cancers 0.301

HCC12 Breast, Prostate, and Other Cancers and Tumors 0.146

HCC17 Diabetes with Acute Complications 0.318

HCC18 Diabetes with Chronic Complications 0.318

HCC19 Diabetes without Complication 0.104

HCC21 Protein‐Calorie Malnutrition 0.545

HCC22 Morbid Obesity 0.273

HCC23 Other Significant Endocrine and Metabolic Disorders 0.228

HCC27 End‐Stage Liver Disease 0.962

HCC28 Cirrhosis of Liver 0.390


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HCCs are grouped into related “families”

• Disease groupings with progressively higher severi es

• Establishes a hierarchy that allows the highest severity to receive the highest "weight"

• CMS pays for themost severe form of disease reported in a given year

HCC

CategoryDescription Label

HCC08 Metastatic Cancer and Acute Leukemia

HCC09 Lung and Other Severe Cancers

HCC10 Lymphoma and Other Cancers

HCC11 Colorectal, Bladder, and Other Cancers

HCC12 Breast, Prostate, and Other Cancers and Tumors

Hierarchical

Condition Category

(HCC)

If the Disease Group is Listed in this column…

Hierarchical Condition Category (HCC) LABEL

8 Metastatic Cancer and Acute Leukemia9 Lung and Other Severe Cancers

10 Lymphoma and Other Cancers

11 Colorectal, Bladder, and Other Cancers

Coefficient

2.625

0.970

0.677

0.301

0.146

…Then drop the

Disease Group(s)

listed in this column

9,10,11,1210,11,12

11,12

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• Some combinations of diseases have a synergistic impact on complexity and cost

• When both conditions are documented, coded and submitted on claim:

– The weights from both conditions are added

– Model triggers an additional increase in RAF score

Disease interaction description label Weight

Cancer*Immune Disorders 0.893

Congestive Heart Failure*Diabetes Group 0.154

Congestive Heart Failure*Chronic Obstructive Pulmonary Disease 0.190

Congestive Heart Failure*Renal Group 0.270Cardiorespiratory Failure Group*Chronic Obstructive Pulmonary Disease Group 0.336

• CY 2018 disease interactions and weights• Community, NonDual, Aged category weight


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How It All Adds Up

Demographics

Diagnoses supported in encounter

documentation

Interaction coefficients

added by CMS

Risk score

Risk adjustment payment

All conditions precisely documented

84 yr old Female --Full Benefit (FB) dual aged

0.739

COPD J44.9 (HCC 111) 0.422

Type II Diabetes w/ Diabetic CKD E11.22 (HCC 18)

0.346

CKD Stage 5 N18.5 (HCC 136)

0.244

Chronic Diastolic CHF I150.32 (HCC 85)

0.355

Disease Interaction (Diabetes and CHF)

0.205

Disease Interaction (CHF and Renal Failure)

0.271

Disease Interaction (CHF and COPD)

0.240

Total RAF: (Demographics and HCC)

2.582

PMPM Payment $2,066

Annual Payment $24,787

$800 PMPM base rate. Values are for illustrative purposes only

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When Are Diagnoses Used for HCC Capture?

• Quality program submission

• ACO submission

• Medicare Advantage (MA) submission

– Changes in submission process for MA

• Percent EDS/FFS/RAPS


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MA Submission Processes/Systems

• Fee‐for‐service (FFS) claims

• Risk Adjustment Processing System (RAPS)

• Encounter data system

Amazon CMS 1500 order

CSSCOperations MA Communications Handbook

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2019 Risk Adjustment Model Updates

• Data used to calculate risk scores:

– 75% calculated with 2017 CMS‐HCC model and diagnoses submitted on RAPS and FFS claims

– 25% calculated 2019 CMS‐HCC model (without count variable) and diagnoses submitted on encounter data records, RAPS inpatient records, and FFS claims


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Encounter Data Transition

Transition Plan

2015

RAPS EDS

2016

RAPS EDS

2017

RAPS EDS

2018

RAPS EDS

2019

RAPS EDS

2020

RAPS EDS

2015

RAPS EDS

2016

RAPS EDS

2017

RAPS EDS

2018

RAPS EDS

2019

RAPS EDS

Actual

Centers for Medicare & Medicaid Services’ Transition from Risk Adjustment Processing System (RAPS) Data to Medicare Advantage (MA) Encounter Data for Risk Score Calculation; GAO‐17‐223Medicare Advantage Rates & Statistics; Announcements 2015‐2019; https://www.cms.gov/Medicare/Health‐Plans/MedicareAdvtgSpecRateStats/Announcements‐and‐Documents.html?DLSort=2&DLEntries=10&DLPage=1&DLSortDir=descending.

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Encounter Data Process

ProvidersSubmit Data

CMS IDRStores Data

MAO SubmitData

CMSEDFESEdits

CMSEDPSEdits & Format Data

• Encounter Data Front‐End System (EDFES) edits• Encounter Data Processing System (EDPS) edits

– DME claims– Professional claims– Institutional claims

• Integrated Data Repository (IDR)– CMS accesses this data for risk adjustment calculations and data

analyses


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Why Is This Important?

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Finding Discrepancies?

• Payer provides risk scores but different from internal analytics

• You receive a list of open or suspected HCCs but can’t validate them through medical record reviews

• You reach out to providers with volumes of HCCs to capture and realize the list contains false positives


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RAPS vs. Encounter Data

Characteristics RAPS data Encounter dataNumber of data elements 24–86 data elements 154–202 data elements

Types of data elements Diagnoses Diagnoses, procedures, items provided to enrollees and costs

Maximum number of diagnoses May include up to 10 diagnosis groupings

Up to 12 diagnoses for professional services Up to 25 diagnoses for institutional services

Process for identifying diagnoses for risk adjustment purposes

Identified and submitted by MA Identified by CMS, which requires MA organizations to submit all encounters regardless of whether they contain diagnoses used for risk adjustment

Types of providers submitting data Collected from physicians and hospital inpatient and outpatient facilities

Collected from physicians, hospital inpatient facilities, hospital outpatient facilities, ambulance providers, clinical laboratories, durable medical equipment suppliers, home health providers, mental health providers, rehabilitation facilities and skilled nursing facilities

Frequency of data submission Submitted at least quarterly by MA organizations

Submitted every week, every other week or every month by MA organizations, depending on their number of enrollees

Source: GAO summary of Centers for Medicare & Medicaid Services Information. GAO‐17‐223

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What’s the Impact of the Variances?

• Study conducted in 2017 with eight Medicare Advantage payer accounting for approx. 1 million beneficiaries to compare difference in scores and HCC capture based on methodologies

RAPS• Prevalence rate for top 10 HCCs

• 11.5% in 2014 • 12.2% in 2015

• % of HCCs per patient• 28.2% with 0 HCCS• 25.3% with 1 HCC• 15.5% with 2 HCCs• 29.0% with 3 or more HCCs

EDS• Prevalence rate for top 10 HCCs

• 6.9% in 2014 • 9.2% in 2015

• % of HCCs per patient• 39.3% with 0 HCCS• 24.7% with 1 HCC• 15.3% with 2 HCCs• 20.7.% with 3 or more HCCs

RAPS to EDS Collaboration: A Data‐Driven Analysis; National Medicare Advantage Summit; April 2017


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Inputs and Edits

ProvidersSubmit Data

CMS IDRStores Data

MAO SubmitData

CMSEDFESEdits

CMSEDPSEdits & Format Data

• Minimum set of required data elements, not every FFS claim field

• Rendering provider NPI vs. billing provider NPI

– HCC capture is limited to eligible providers

• Qualifying visit type based on HCPCS

• Ability to resubmit claims could lead to duplicated services

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Why Does This Matter?

• Impacts HCC CDI program design and development

– Must be face‐to‐face visit

• HCPCS filter edits for this

– Must be eligible provider type

• Rendering provider NPI


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Eligible Provider Types

CSSC Operations Acceptable Physician Types

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Why Does This Matter?

• Impacts HCC CDI program design and development– Must be face‐to‐face visit

• HCPCS filter edits for this

– Must be eligible provider type

• Rendering provider NPI

• Actionable data & information support program development and evolution

• Helps organization stay compliant with documentation, coding, and billing practices


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Polling Question #3

• What is the focus of your current ambulatory CDI program?

1. HCCs

2. E/M

3. Combination of HCCs and E/M

4. Emergency department

5. Other

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Designing & Implementing Your Program


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Starts With Data

• Determine what to analyze based on your organization’s priorities and data availability

• Understand the data

– What is the source?

– What has been filtered?

• Organize the data into actionable information

• Use the data to drive decisions on priorities and next steps

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Ends & Evolves With Data

• Back to the analysis!

• Analyze areas with opportunity and adjust plans based on data

• Data will drive the next steps in program evolution


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Monitoring for HCC Opportunity

0

1

2

3

4

5

6

Sum of Open HCC wt. by Provider

Yr 1 Q1 Yr 1 Q2

Opportunities by Physician

Provider 1

Provider 2

Provider 3

Provider 4

Provider 5

Provider 6

Provider 7

Provider 8

Provider 9

Provider 10

Provider 11

Trending by provider and/or by practice can help prioritize education efforts and

provides friendly competition for organization

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Organizational Impact of HCCs

Quality Dept.

Contracting Dept.

Finance Dept.

Revenue Cycle

ACO Physician Group

HIM Compliance

Image Source: http://www.industryweek.com/change‐management/why‐do‐silos‐form‐and‐how‐can‐we‐knock‐them‐down

Documentation Integrity is at the core of success for all these departments

HCCs are important for the following programs:

• Medicare Advantage plans

• CPC+ programs

• ACOs

• Quality Payment Program (QPP)

• Medicare Spending per Beneficiary measures


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In Summary

• Understand the source of your data

• Realize that processes impact your data

• Understand the inputs, analytics logic, and outputs

• Use the information to drive decisions –– but only after understanding the data and information!

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References

• Barton, D. and Court, D. “Making Advanced Analytics Work for You.” Harvard Business Review, October 2012, Volume 90, Number 10, pp. 78–83. https://hbr.org/2012/10/making‐advanced‐analytics‐work‐for‐you

• Medicare Advantage Rates & Statistics; “Announcements” 2015–2019. https://www.cms.gov/Medicare/Health‐Plans/MedicareAdvtgSpecRateStats/Announcements‐and‐Documents.html?DLSort=2&DLEntries=10&DLPage=1&DLSortDir=descending.

• Murrin, S. “Medicare Advantage Encounter Data Show Promise for Program Oversight, But Improvements Are Needed.” DHHS Office of Inspector General (OEI‐03‐15‐00060), January 2018. https://oig.hhs.gov/oei/reports/oei‐03‐15‐00060.asp

• Palmetto GBA. “Medicare Advantage & Part D Communications Handbook.” August 2018. https://www.csscoperations.com/internet/cssc4.nsf/files/Medicare%20Advantage%20Communications%20Handbook%2020180810.pdf/$FIle/Medicare%20Advantage%20Communications%20Handbook%2020180810.pdf

• Risk Adjustment for EDS & RAPS User Group. April 19, 2018. https://www.csscoperations.com/internet/cssc4.nsf/DocsCat/CSSC~CSSC%20Operations~Medicare%20Advantage%20Encounter%20Data%20and%20RAPS%20Data~User%20Group~AZJ8PF0127?open&navmenu=MedicareÂdvantageÊncounter^Dataând^RAPS^Data||||

• Risk Adjustment for EDS & RAPS User Group. May 17, 2018. https://www.csscoperations.com/internet/cssc4.nsf/DocsCat/CSSC~CSSC%20Operations~Medicare%20Advantage%20Encounter%20Data%20and%20RAPS%20Data~User%20Group~AZJ8TX8643?open&navmenu=MedicareÂdvantageÊncounter^Dataând^RAPS^Data||||

• Swadi, A. “RAPS to EDS Collaboration: A Data‐Driven Analysis.” National Medicare Advantage Summit. April 6, 2017. http://www.ehcca.com/presentations/medadvsummit/swadi_ms2.pdf

• The Henry J. Kaiser Family Foundation. “Medicare Advantage” Fact Sheet. October 2017. https://www.kff.org/medicare/fact‐sheet/medicare‐advantage/

• United States Government Accountability Office. “Medicare Advantage: Limited Progress Made to Validate Encounter Data Used toEnsure Proper Payments.” GAO‐17‐223, January 2017. https://www.gao.gov/assets/690/682145.pdf


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Thank you. Questions?

Sonia Trepina – [email protected] Senor – [email protected]

In order to receive your continuing education certificate(s) for this program, you must complete the online evaluation. The link can be found in the continuing education section at the front of the program guide.
