understanding hierarchical condition categories …...ehr. suitemed had growth of over 800% in the...

© 2018 Formativ Health Proprietary and Confidential

Understanding Hierarchical Condition Categories (HCC)

February 13, 2018

© 2018 Formativ Health Proprietary and Confidential 2©2018 Formativ Health, Proprietary and Confidential

The information enclosed was current at the time it was presented. Policies change frequently; links to the source documents have been provided within the document for your reference. This presentation was prepared as a tool to assist providers and is not intended to grant rights or impose obligations. Although every reasonable effort has been made to assure the accuracy of the information within these pages, the ultimate responsibility for the correct submission of claims and response to any remittance advice lies with the provider of services. Formativ employees, agents, and staff make no representation, warranty, or guarantee that this compilation of this information is error-free and will bear no responsibility or liability for the results or consequences of the use of this guide. This presentation is a general summary that explains certain aspects of Medicare and various commercial carriers, but is not a legal document. The official program provisions are contained in the relevant laws, regulations, and rulings. Formativ has provided no guarantees and/or warranties regarding acceptance by insurance carriers, nor any likelihoods, guarantees or warranties regarding costs, time periods related to credentialing and contracting, and/or available reimbursement rates.

Danielle Taimuty, MA, CPC, CEMC - Director of Client SuccessDanielle earned her Business Degree from Duff's Business institute. Danielle started her career as a Medical Administrative Assistant for a cardiology practice at Mercy Hospital in Pittsburgh. Her talents for billing were quickly realized after tripling the practice’s income and was promoted to Billing Manager within 6 months.

In 1993 she worked for a third party administrator where she was a Claims Adjudicator, within her first year, she was promoted to Claims Auditor. As an auditor, Danielle discovered that most physicians focus on patient care at the expense of the business and billing operations due to their dedication and compassion for patients. She decided to refocus her efforts on helping providersmaximize their revenue and started her own billing company, Medical Billing Solutions Services, Inc. (MBSS) in 1996.

About our speaker

Danielle became a Certified Professional Coder and a Certified Evaluation and Management Coder through the AAPC. She led MBSS to become an award winning billing company as well as one of Pittsburgh's fastest growing companies as named by the Pittsburgh Business Times in 2008.

Danielle was very active in the EHR adoption movement. Through those efforts, she became the Co-Founder, Manager and Chief Financial Officer of SuiteMed, LLC., developers of IMS (Intelligent Medical Software). She assisted in developing and deploying a business plan to ensure the success of a startup EHR. SuiteMed had growth of over 800% in the first 3 years. SuiteMed was listed as one of the top 20 EHRs of 2011.

In 2010, Danielle sold SuiteMed to Meditab to focus her efforts on MBSS. Her areas of expertise are coding, billing, credentialing, contracting, business development, consulting, business operations, EHR, implementations, training, practice management and auditing. Danielle was nominated as an Athena Award Finalist prior to selling MBSS in 2014 to Etransmedia which was acquired by Formativ Health in 2016. She serves as the Director of Client Success.

© 2018 Formativ Health Proprietary and Confidential 3©2018 Formativ Health, Proprietary and Confidential

The information enclosed was current at the time it was presented. Policies change frequently; links to the source documents have been provided within the document for your reference. This presentation was prepared as a tool to assist providers and is not intended to grant rights or impose obligations. Although every reasonable effort has been made to assure the accuracy of the information within these pages, the ultimate responsibility for the correct submission of claims and response to any remittance advice lies with the provider of services. Formativ employees, agents, and staff make no representation, warranty, or guarantee that this compilation of this information is error-free and will bear no responsibility or liability for the results or consequences of the use of this guide. This presentation is a general summary that explains certain aspects of Medicare and various commercial carriers, but is not a legal document. The official program provisions are contained in the relevant laws, regulations, and rulings. Formativ has provided no guarantees and/or warranties regarding acceptance by insurance carriers, nor any likelihoods, guarantees or warranties regarding costs, time periods related to credentialing and contracting, and/or available reimbursement rates.

Patrick Lovelace, BSN, RN, CCS - Director of SalesPatrick earned his nursing degree from Augusta University – Medical College of Georgia and started his career as a Hospital ICUnurse in the early 1990’s. His career since has spanned other health care arenas, including consulting in clinical documentationmanagement, patient access management and recently population health analytics for value-based reimbursement programs.

As a consultant, Patrick became a certified coding specialist or CCS, which was used to support coding initiatives specific to both Part A and Part B hospital based reimbursement. He has also held the certification in patient access by the National Associationof Healthcare Access Management. Earlier in his career, he was a certified Critical Care Registered Nurse (CCRN) and an instructor of the American Heart Association’s Advanced Cardiovascular Life Support (ACLS). Today, he continues to support the American Heart Association as a volunteer and guest lecturer.

About our guest speaker

With the advent of technology in healthcare, Patrick built an expertise around supporting provider evaluations of non-EHR best of breed solutions. His clinical training and experience prove valuable to clinicians wanting to maximize or maintain their operational efficiency when adding more responsibilities with care coordination, quality of care, and risk based reimbursement programs.


Agenda

1. How hierarchical condition category coding will impact your

practice

2. How you can use these codes to increase quality, and improve

the patient experience

3. Receive appropriate reimbursements

Formativ Health’s webinars are intended to build upon a

foundation set with topics discussed in a series of presentations.

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History

HCC coding is part of an effort to move from a “pay-for-service” to a “value-based” health care system:

• Since the early 2000s, the health care industry has tried to replace the pay-for-service

model of reimbursement with a model based on quality and outcomes.

• A value-based system moves risk from payers to patients and physicians.

• Health care providers are not paid for the volume of work they do. Instead, the system

pays providers for the quality and value of the services they deliver.

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Risk Adjustment

• The key to creating a value-based reimbursement system is risk adjustment.

• Risk adjustment is “A statistical process that takes into account the underlying

health status and health spending of the enrollees in an insurance plan when

looking at their health care outcomes or health care costs.”

• CMS has introduced risk adjustment programs that reward payers who take

on high risk patients, including those with chronic conditions.

• HCC coding is a risk adjustment program.

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What is HCC Coding?

• The Centers for Medicare and Medicaid Services (CMS) introduced the

Hierarchical Condition Category (HCC) in 2003.

• HCC coding is based on the ICD-10 codes – the thousands of codes used every

day to report patient conditions and co-occurring conditions.

• The HCC codes reflect patient “acuity” – or the severity of illnesses facing a

plan’s members.

• A Medicare member’s health status in a given year is used to predict costs in

the following year.

• CMS uses HCC to determine reimbursements to Medicare Advantage plans.

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MIPS scoring

• 2011 – The Affordable Care Act (ACA)

• Provisions and incentives to boost quality and cut costs by tying quality to patient

expenditures.

• 2015 - Medicare Access and CHIP Reauthorization Act (MACRA).

• Medicare began to deny claims that lacked diagnosis specificity.

• Created the Merit-Based Incentive Payment System (MIPS), which determines

Medicare payment adjustments to practices based on scores in several key

categories, including how well they report patient acuity using HCC codes.

• MIPS scores can result in a practice receiving a bonus payment or paying a

penalty.

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Risk-Adjustment Process

The CMS risk-adjustment process:

Demographics + Diagnosis/Diagnoses = Risk Adjustment Factor (RAF) Score

Demographics:

• Age

• Gender

• Whether the individual lives in the community or in a skilled nursing facility

• Whether the individual is enrolled in Medicare, Medicaid, or dually eligible for both

programs

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(Source: American Academy of Family Physicians)


Risk-Adjustment Process

The CMS risk-adjustment process continued:

Demographics + Diagnosis/Diagnoses = Risk Adjustment Factor (RAF) Score

Determining Risk Adjustment Factors

• RAF values are assigned to HCCs

• RAF score for HCC is higher if the patient is sicker

• RAF values are additive

• RAF score of baseline demographics is < 1

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HCC Coding Categories and Scoring

• The 79 HCC codes contained in the CMS Risk Adjustment model are matched to the

approximately 9,000 ICD-10 codes.

• HCC coding is to predict use of medical services for Medicare members in the year to

come.

• HCC diagnosis coding looks at all conditions a patient has been diagnosed with over

the past year, which places great importance on recording comorbidities.

• The coding assigns a weight to each condition. These weights, combined with

demographic factors, determine the HCC score.

• High scores mean that a patient has more complex and serious conditions and will

use more health services, resulting in higher costs in the future.

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Commonly Reported HCC Coding Diagnoses

• Chronic obstructive pulmonary disease

• Congestive heart failure

• Vascular disease

• Cancer

• Ischemic heart disease

• Specified heart arrhythmia

• Diabetes

• Ischemic or unspecified stroke

• Angina

• Rheumatoid arthritis

• Inflammatory connective tissue disease

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HCCs in Action Scenario 1

HCC reporting for an 82-year-old female:

Scenario 1: RAF base score 0.7 – Based on demographics for an 82-year-old female - age, sex, community vs.

SNF, Medicare/Medicaid eligibility

Based on an average per patient-per month payout of $1,000, baseline annual payout with comorbidity

conditions:

0.7 x $1,000 x 12 mos. = $8,400 per year


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Diagnoses per Chart

DocumentationHCC RAF

Base N/A RAF 0.7

TOTAL RAF = 0.7



Scenario 2: RAF base score 0.7 with more specific documentation of conditions and treatments

Based on an average per patient-per month payout of $1,000, baseline annual payout with comorbidity conditions:

0.821 x $1,000 x 12 mos. = $9,852 (Source: American Academy of Family Physicians)

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Diagnoses per chart

documentationHCC RAF

Base N/A RAF 0.7

DMHCC 19 Type II DM w/o

complicationsRAF 0.121

Obesity None

BME 36 (STARS) None

HTN None

Insomnia None

Major Depression, single episodeNone (severity not

documented)

Smoker None

PMH Breast C None (PMH)

TOTAL RAF = 0.821



Scenario 3: RAF base score 0.7 with even more specific documentation of conditions and treatments

Based on an average per patient-per month payout of $1,000, baseline annual payout with comorbidity conditions:

7.16 x $1,000 x 12 mos. = $85,920 (Source: American Academy of Family Physicians)

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Diagnoses per chart documentation HCC RAF

Base N/A RAF 0.7

Type II DM with diabetic CKD HCC 18 - Diabetes w/ complication RAF 0.374

+ CDK Stage 4 HC 137 RAF 0.153

Diabetic peripheral angiopathyHC 108 (HC18 DM w/comp already

assigned)RAF 0.319

Diabetic non-pressure foot ulcer, R heel HCC 161 RAF 0.628

Amputation lower extremity L 2nd toe HCC 189 RAF 0.721

Morbid Obesity

(BMI 36 + DM, HTN due to obesity) HCC 22 RAF 0.295

Hypertensive HF, chronic systolic HF HCC 85 RAF 0.365

Major Depression, single episode, mild HC 58 RAF 0.300

Sedative-hypnotic Dependence, uncomplicated HCC 55 RAF 0.370

COPD HCC 111 RAF 0.336

Metastatic CA to spine HCC 8 RAF 2.6

TOTAL RAF = 7.16


HCC best practices

1. Focus on accuracy

• Provide and complete and accurate information when billing and reporting.

• Put systems in place to capture the necessary information about your patients’

conditions and the services you provide.

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HCC best practices

2. Understand your patient population

• If you serve Medicare patients, become familiar with most common HCC

diagnoses.

• Take a look at your patients and determine who belongs in what diagnosis

category.

• Work with your administrative and clinical staff to place the right patients with

the right diagnosis.

• Keep up-to-date, accurate records.

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HCC best practices

3. Engage your patient population

• Determine schedule capacity and appointment templates to reserve time slots

going forward.

• Prioritize patients according to past risk scores and gaps in care, needed

screenings, etc.

• Engage patients to secure the initial annual face-to-face and any required

follow up

• Manage no-shows by predicting trends and reminding patients for

appointments booked out into the future.

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HCC best practices

4. Capture comorbidities

• Capture every diagnosis, not just the major ones.

• Remember “Monitor, Evaluate, Assess, or Treat” or MEAT as the justification to

code.

• Ensure provider documentation supports diagnosis capture.

• Avoid use of “unspecified” codes.

• Pay attention to mental health diagnoses, as well.

• Remember that a record can have multiple HCC codes.

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Conclusion

• Risk adjustment is here to stay. Applies to Medicare, Medicaid, Commercial

plans.

• HCC coding is critical to making risk adjustment work for patients and

practices.

• HCC coding is also critical to making sure your practice gets the

reimbursement it deserves for the quality services it provides.

• HCC coding starts with scheduling annual face to face visits between the

provider and patients

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© 2018 Formativ Health Proprietary and Confidential ©2018 Formativ Health, Proprietary and Confidential

About Formativ Health

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We are redefining the ambulatory patient and provider experience throughout the health care ecosystem

Our purpose

To transform the patient and provider experience and make health care better for both.

Our approach

We partner with physician practices, hospitals, and health systems to improve financial health, enhance the patient experience, and free up physicians to focus on what they do best – taking care of patients.

48


What Makes Us Different?

By Physicians, For PhysiciansWe are purpose-built by physicians with two decades of experience leading one of the largest health systems in the United States.

Comprehensive Patient Services We offer the most comprehensive, high-touch patient services in the ambulatory market, easing the patient’s clinical and financial journey, building patient loyalty and enabling physicians to focus on patient care.

End-to-End Technology Enabled ServicesOur services are the first to span the care continuum, from patient access through collections and beyond. We offer a portfolio of solutions that can be implemented in either modules or as an end-to-end solution, based on the provider’s needs.

Agnostic TechnologyOur services are able to work with the provider’s existing technology and do not require system replacements that create operational disruptions.

2249


End-to-End Revenue Cycle

Technology and Services Redefining revenue cycle management with

tailored solutions that span the care

continuum

Outsourcing

• Full and partial revenue cycle services outsourcing

• Agnostic Technology

• Portfolio of agnostic technology across front, middle, back of

revenue cycle

Analytics

• Analytics that leverage data to reveal strategic insights and

empower data-driven decision making

Advisory Services

• Advisory services that improve processes, increase

efficiencies and streamline operations

Education Services

• Education services that improve staff performance and

retention

Our Capabilities

High-Touch Patient Access Enhancing the patient, staff, and physician

experience while improving financial outcomes

High Touch Patient Access Center • Handle all inbound and outbound calls • Optimize administrative workflow and scheduling

Call Management• Answer all patient calls, direct “clinical calls” to a

centralized nursing group • Scheduling, insurance verification, registration, referral

management, requests

Care Coordination • Schedule post discharge care, disease and chronic care

management, overdue routine appointments • Identify gaps in care

Revenue Improvement • Manage appointment wait list, no shows, cancellations • Counsel patients on payment options, financial support

services

Quality Assurance • Record 100% calls; screen capture 20% • Review agents twice yearly; ongoing peer review and

management reviews • Generate scorecard to analyze each agent call

Staff Competency • Low attrition with existing staff • Targeting bachelor’s degree candidates • 8-week training program

Workforce Optimization • Predictive modeling for staffing based on day of week,

weather patterns, geography, type of practice, utilization rates, gaps in services/specialists needed, operational gaps

Practice Operations Managing administrative functions so that

physicians can focus on patient care

Personnel

• Accounting, human resources, benefits management,

research & benchmarking, practice governance

IT and Infrastructure

• Server maintenance, network management, EHR & PM

systems, helpdesk, data conversion, document

management, scanning

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Group Purchasing

• Group purchasing management, contracting for supplies

and pharmaceuticals

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Thank you

Questions

Thank you for joining Formativ Health1.866.725.2855

www.formativhealth.com© Formativ Health 2018

All Rights Reserved

No part of this presentation or any of its contents may be reproduced, copied, modified or adapted, without the prior written consent

unless otherwise indicated for stand-alone materials.

Contact Danielle Taimuty with any additional [email protected]

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