Risk adjustment coding
- 1. # our igital ransformation artner RISK A DJUSTMEN T CODIN G
- 2. 2 // Coding Services: Key Differentiators History Our team of professional coders have hands-on expertise in following areas: 100+ AAPC & AHIMA certified coders with minimum 4 years of experience Team of experienced coders working onsite and remotely Coding w.r.t. NCCI (National Correct Coding Initiatives) and LCD (Local coverage decision and medical policies) guidelines 12 - 24 hrs Coding TAT with a commitment of “no later than 48hrs” for sudden volume spikes Expertise in Common Procedure Coding System (HCPCS), CPT, ICD10 & Modifiers Handling all major EMR software like Allscripts EHR, Sevocity, Eclinical works, EPIC, GE Centricity etc. Above 98% coding accuracy, beating acceptable industry standards (95% accuracy) R Systems offers both short-term and permanent remote medical coding services to organizations across the globe. Our high- end services expedites the coding process, while ensuring optimal reimbursement of all cases in compliance with CMS policies and coding guidelines. Evaluation and Management Coding Screening Examination Preventive Services Annual Examination Well Child Care Mental Health Chronic Care Management FQHC/RHC Coding Dental CodingSubstance Abuse HCC/RAC Coding
- 3. 3 // R Systems Advantages
- 4. // Hierarchical Condition Categories Disease groups, organized into body systems or similar disease processes, and are referred to as HCCs. The CMS- and HHS-HCC models include both diseases and demographic factors, called coefficients. There are sets of coefficients for: • New enrolees • Members in the community • Members in long-term care institutions Enrolees with end-stage renal disease The HCCs used for Medicare and commercial risk adjustment are different. The models are cumulative; a patient may be assigned to more than one category. Some HCCs will trump other related conditions (only one HCC in a category may be assigned).
- 5. // Risk Adjustment - Periodicity • Concurrently, or while a year is underway • Financial needs for 2019 are based on the conditions treated in 2019. • Commercial Risk Adjustment uses this framework • It favors the commercial population which has lower incidences of chronic, persistent conditions • Prospective basis, that is, at the start of a given plan year • Data from a past year can be used to project current year payments. • Medicare has a Prospective Design: Financial needs for 2019 are based on conditions treated in 2018 • Retrospectively, after a plan year is over • Data reviewed and possibly changed at the end of the year • Used for Member Identification and Stratification • This is our coding season RISK ADJUSTMENT CAN BE UNDERTAKEN IN THREE DIFFERENT TIME PERIODS:
- 6. // Characteristics of CMS-HCC Model
- 7. // Coding and Documentation ICD-10 diagnosis coding rules can be counterintuitive to clinical practice. The pneumonic “TAMPER” is used frequently in risk adjustment coding to represent the criteria for capturing a diagnosis code on a particular date of service. • Treatment • Assessment • Monitoring or Medicate • Plan • Evaluate • Referral Risk adjustment diagnoses must be captured from the notes of an approved provider type. • MD, DO, ARNP, LCSW, Clinical Psychologist, ophthalmologist, etc.
- 8. // Coding and Documentation • Clinical documentation from inpatient hospital, outpatient hospital and face-to-face office visits is acceptable for coding and reporting under risk adjustment. • Examples of unacceptable documentation sources for risk adjustment coding/reporting include: • Super bills • Referral forms • Encounter forms • Patient-only reported conditions • Non face-to-face encounter notes • Stand alone patient problem list
- 9. // Common Error Complete and accurate coding of the most common conditions can have a significant impact on risk capture due to their prevalence . A few of the prevalent conditions that are often not monitored, evaluated, assessed or treated and coded on an annual basis are: • Asthma • Osteoporosis • Hearing loss • Psychiatric diagnosis: e.g. major depression, bipolar disorder • Vascular conditions: cardiac or cerebral. • These conditions can have a significant impact on risk capture due to their prevalence Many high risk patients with multiple conditions are often seen by a specialist for the most severe or symptomatic condition. However, analysis shows significant coding gaps for these relatively rare conditions, which often require specialty care, may be lost to care for other conditions: • Extremely or Very Low Birth weight Neonates • Respirator Dependence, Tracheotomy status • Haemophilia, Cystic Fibrosis • Bone Marrow and Solid Organ Transplant • Severe Head Trauma • Protein-Calorie Malnutrition