Risk Adjustment ABC s

Transcription

1 Medicare Advantage Risk Adjustment and Coding Academy Coding Risk Adjustment Documentation Training Risk Adjustment ABC s What is Risk Adjustment? Risk adjustment is the process by which the Medicare & (CMS) reimburses Medicare Advantage Plans, such as Empire BlueCross, based on the health status of their members. Risk adjustment was implemented to pay Medicare Advantage Plans more accurately for the predicted health cost expenditures of members by adjusting payments based on demographics (e.g., age and gender) as well as health status. History of Risk Adjustment As a part of risk adjustment implementation, CMS initially collected hospital inpatient diagnoses for determining payment to Medicare Advantage Plans. In 2000, Congress mandated a change to include ambulatory data. This change took place gradually, with full implementation in CMS selected a payment model that included diagnosis data reported from physician office, hospital inpatient, and hospital outpatient settings. This payment model is referred to as the CMS-Hierarchical Condition Category (CMS-HCC) payment model. What are Hierarchical Condition Categories (HCCs) HCCs are a hierarchy of condition categories that correlate or link to corresponding diagnosis categories. The number of HCCs and affected ICD-9-CM codes can change from year to year. In addition, the implementation of ICD-10-CM will significantly impact the number of HCCs and the number of diagnosis codes currently in effect. How Does Risk Adjustment Impact the Physician and the Member? It s important to keep in mind that the risk adjustment process also benefits you and your Y0071_12_14235_I_004_02/07/2012

2 patients. How? Increased coding accuracy helps Empire BlueCross identify patients who may benefit from disease and medical management programs. More accurate health status information can be used to match healthcare needs with the appropriate level of care. Also, by supplying Empire BlueCross with the most accurate and complete diagnosis coding and medical record documentation, you will not only help us meet our reporting obligations to CMS, which will in turn help us be the best health care plan we can possibly be. However, your assistance and commitment to risk adjustment will also help you meet your own CMS provider obligations which include the use of standard diagnosis coding standards in medical record documentation, reporting all conditions and diagnoses codes that exist on the date of an encounter and participating in CMS Medicare Recovery Audit Contractor (RAC) and Risk Adjustment Data Validation (RADV) Audits. In addition, your commitment and assistance will assist in improving the overall patient health care evaluation process, as well as improving office practice patterns and communication among the member s health care team. Why is Medical Record Documentation Important to Risk Adjustment? Medical record documentation plays a critical role in risk adjustment because accurate risk adjusted payment relies on complete medical record documentation and diagnosis coding. And this ultimately impacts the services and benefits Empire BlueCross is able to provide to its membership. Additionally, CMS requires that all applicable diagnoses codes be reported and that all diagnoses be reported to the highest level of specificity and this must be substantiated by the medical record. Toward this end, Empire BlueCross conducts medical record reviews to identify additional conditions not captured through claims or encounter data and to verify the accuracy of coding. These reviews are performed to help us make sure all required ICD-9-CM codes are duly reported to CMS. And finally, CMS requires that the medical record validate the diagnoses codes that have previously been reported by the Physician. RADV Audits A RADV Audit is a CMS audit that ensures the integrity and accuracy of risk-adjusted payment. It is the process of verifying that the diagnosis codes submitted by the Medicare Advantage health plan are supported by the medical record documentation for a member. Medicare Advantage health plans can be selected for RADV Audits annually. Health plans that are selected to participate in a RADV Audit are required to submit member medical records to validate diagnosis data previously reported to CMS. It is important for Physicians and their office staff to be aware of RADV Audits because medical record documentation may be requested by the Medicare Advantage health plan. In this instance, you will be required to assist the health plan by providing medical record documentation for members included in the audit. Y0071_12_14235_I_004_02/07/2012

3 Services provided by Empire HealthChoice HMO, Inc. and/or Empire HealthChoice Assurance, Inc., licensees of the Blue Cross and Blue Shield Association, an association of independent Blue Cross and Blue Shield plans. Y0071_12_14235_I_004_02/07/2012

4 Medicare Advantage Risk Adjustment and Coding Academy Coding Risk Adjustment Documentation Training Risk Adjustment ABC s What is Risk Adjustment? Risk adjustment is the process by which the Medicare & (CMS) reimburses Medicare Advantage Plans, such as Empire BlueCross BlueShield, based on the health status of their members. Risk adjustment was implemented to pay Medicare Advantage Plans more accurately for the predicted health cost expenditures of members by adjusting payments based on demographics (e.g., age and gender) as well as health status. History of Risk Adjustment As a part of risk adjustment implementation, CMS initially collected hospital inpatient diagnoses for determining payment to Medicare Advantage Plans. In 2000, Congress mandated a change to include ambulatory data. This change took place gradually, with full implementation in CMS selected a payment model that included diagnosis data reported from physician office, hospital inpatient, and hospital outpatient settings. This payment model is referred to as the CMS-Hierarchical Condition Category (CMS-HCC) payment model. What are Hierarchical Condition Categories (HCCs) HCCs are a hierarchy of condition categories that correlate or link to corresponding diagnosis categories. The number of HCCs and affected ICD-9-CM codes can change from year to year. In addition, the implementation of ICD-10-CM will significantly impact the number of HCCs and the number of diagnosis codes currently in effect. How Does Risk Adjustment Impact the Physician and the Member? It s important to keep in mind that the risk adjustment process also benefits you and your patients. How? Y0071_12_14235_I_003_02/07/2012

5 Increased coding accuracy helps Empire BlueCross BlueShield identify patients who may benefit from disease and medical management programs. More accurate health status information can be used to match healthcare needs with the appropriate level of care. Also, by supplying Empire BlueCross BlueShield with the most accurate and complete diagnosis coding and medical record documentation, you will not only help us meet our reporting obligations to CMS, which will in turn help us be the best health care plan we can possibly be. However, your assistance and commitment to risk adjustment will also help you meet your own CMS provider obligations which include the use of standard diagnosis coding standards in medical record documentation, reporting all conditions and diagnoses codes that exist on the date of an encounter and participating in CMS Medicare Recovery Audit Contractor (RAC) and Risk Adjustment Data Validation (RADV) Audits. In addition, your commitment and assistance will assist in improving the overall patient health care evaluation process, as well as improving office practice patterns and communication among the member s health care team. Why is Medical Record Documentation Important to Risk Adjustment? Medical record documentation plays a critical role in risk adjustment because accurate risk adjusted payment relies on complete medical record documentation and diagnosis coding. And this ultimately impacts the services and benefits Empire BlueCross BlueShield is able to provide to its membership. Additionally, CMS requires that all applicable diagnoses codes be reported and that all diagnoses be reported to the highest level of specificity and this must be substantiated by the medical record. Toward this end, Empire BlueCross BlueShield conducts medical record reviews to identify additional conditions not captured through claims or encounter data and to verify the accuracy of coding. These reviews are performed to help us make sure all required ICD-9-CM codes are duly reported to CMS. And finally, CMS requires that the medical record validate the diagnoses codes that have previously been reported by the Physician. RADV Audits A RADV Audit is a CMS audit that ensures the integrity and accuracy of risk-adjusted payment. It is the process of verifying that the diagnosis codes submitted by the Medicare Advantage health plan are supported by the medical record documentation for a member. Medicare Advantage health plans can be selected for RADV Audits annually. Health plans that are selected to participate in a RADV Audit are required to submit member medical records to validate diagnosis data previously reported to CMS. It is important for Physicians and their office staff to be aware of RADV Audits because medical record documentation may be requested by the Medicare Advantage health plan. In this instance, you will be required to assist the health plan by providing medical record documentation for members included in the audit. Y0071_12_14235_I_003_02/07/2012

6 Services provided by Empire HealthChoice HMO, Inc. and/or Empire HealthChoice Assurance, Inc., licensees of the Blue Cross and Blue Shield Association, an association of independent Blue Cross and Blue Shield plans. Y0071_12_14235_I_003_02/07/2012