Risk Adjustment Coding And Hcc Guide 2019

The Risk Adjustment Coding and HCC Guide brings together hard-to-find information about risk adjustment (RA) coding and hierarchical condition categories (HCCs) in a new comprehensive resource that explains this complex reimbursement methodology. Now your organization will have a guide that provides both the big picture and the fine detail needed to document, code, and report essential information so that accurate risk levels are assigned and appropriate reimbursement received.

Risk Adjustment and Hierarchical Condition Category (HCC) coding is a payment model mandated by the Centers for Medicare and Medicaid Services (CMS) in 1997. Implemented in 2003, this model identifies individuals with serious or chronic illness and assigns a risk factor score to the person based upon a combination of the individual's health conditions and demographic details. The individual's health conditions are identified via International Classification of Diseases - 10 (ICD -10) diagnoses that are submitted by providers on incoming claims. There are more than 9000 ICD-10 codes that map to 79 HCC codes in the Risk Adjustment model. CMS requires documentation in the person's medical record by a qualified health care provider to support the submitted diagnosis. Documentation must support the presence of the condition and indicate the provider's assessment and/or plan for management of the condition. This must occur at least once each calendar year in order for CMS to recognize the individual continues to have the condition. The Centers for Medicare and Medicaid Services (CMS) Risk Adjustment Model includes nearly 80 HCC categories of chronic illnesses with thousands of diagnosis codes. Beginning HCC coders need solid instruction on HCC coding to properly map codes and ensure the organization receives the reimbursement payments. This webinar educates the audience on HCC coding and discusses popular risk adjustment coding guidelines. It identifies what makes a document valid for submission, including which sources of documentation should or should not be used. Attendees will have the opportunity to review common mistakes, like a lack of specificity in provider documentation. Often overlooked conditions, which are frequently undocumented by the provider, are also explained. The presenter will give a brief demonstration on how to determine if a condition is reimbursed or not, as well as a case study showing how to apply the theories learned. Through clarification of codes and specific examples, the speaker underscores the importance of provider documentation and its impact on reimbursement. This session is a great overall introduction for beginners and the perfect refresher course for those who have already begun and want to enhance their knowledge in the field. Objectives Learn about HCC coding and risk adjustment coding guidelines. Demonstrate how mapping tools help to properly identify HCCs. Understand the importance of provider documentation and its impact on reimbursement. Risk adjustment in the CMS- HCC model characteristics is based on multiple factors, which are analyzed and reduced to offer the right risk management plan for a patient. The factors that influence risk adjustment includes: Hierarchy of diseases: Ensuring that diagnoses are included in the appropriate disease groups and are in accordance with the necessary hierarchy. Disease Interactions: The additional factors that recognize and assess the severity of multiple conditions. Demographic Variables: These focus on the demographic of the patient's living conditions and demographics. Diagnostic Sources: CMS recognizes diagnoses from a hospital's inpatient, outpatient and physician settings only. Prospective model: The diagnoses based on last year are used to extrapolate the possible payments for the next year. Multiple conditions A patient can have multiple HCC categories assigned to them based on their medical conditions. In some cases, specific conditions can override others, when documenting. This is based on the strict hierarchy of the coding procedures. HCCs are captured once a year, every year in order for the CMS to reimburse payments to the Medicare Advantage. However, diagnoses from previous years are used to establish capitation payments to the Medicare Advantage plan.

Providers have been counseled to code "to the highest specificity," yet are not taught how to accomplish it. Already overworked and often underpaid the Provider doesn't have time to plow through all the rules and regulations to produce the solution. Risk Adjustment Factor Made Easy hopes to cut through the jungle of red-tape, thick textbooks, and laborious internet searches to equip the Provider with quick access to the knowledge needed to be successful while providing references on topics for more exploration when desired. In this version of the Hierarchical Condition Coding (HCC) and Risk-Adjustment Factor (RAF) coding book, the busy provider will receive a simple short-cut to all the information necessary to be successful. This book is quick; easy-to-understand; focuses on common mistakes made by Providers and displays examples of proper coding with appropriate details to help the Provider describe the illnesses of their patients more effectively.HCC/RAF is designed to estimate a patient's "future" health care costs. With the changing of the payment system for Providers from "Paid for Services Rendered" to "Risk-Adjustment Value-Based Care" adherence to coding guidelines are vital to a Provider's bottom line. With the coding details listed, you will learn which codes carry high value and why the codes currently used are not increasing your risk score; thereby, lowering potential earnings. The business end of the practice often suffers because of simple coding errors. This RAF book will arm the provider with the tools necessary to ensure success in the "Value-Based Care" system. ABOUT THE AUTHOR: Barbara Jane Deaton, MSN, FNP-BC, ENP-BCBarbara holds a Master of Science in Nursing and is dually certified as a Family Nurse Practitioner and an Emergency Nurse Practitioner. She owns her own practice in North Carolina and is deeply involved in Risk Adjustment Factor Coding. She has been recognized by a major insurance agency for her understanding of the Risk Adjustment Factor and its role in the future of medicine. Her own risk score has significantly increased by implementing the rules contained in this book.Barbara has won numerous awards since entering the medical field. Among her awards are "Best Nurse Practitioner Award in Morganton, NC 2018" for Inclusion in the 2019-2020 Edition of Worldwide Leaders in Healthcare: nominated Best Nurse Practitioner Preceptor 2019 by Perdue University: Business of the Year Award in Burke County, NC Foundation Award; and the Emergency Physicians Award by the United States Commerce Association.NOTE FROM THE AUTHOR: Over the past year, as I became more interested in the Risk Adjustment Factor (RAF), I realized that much of my research portrayed RAF as complex and extremely difficult to learn. When I began putting RAF into play in my own practice, I realized that as a Family Provider, the main codes continued to reappear. The techniques developed became second nature. Gifted with the ability to translate complex medical problems into simple language for some of my uneducated patients; I became aware that this gift should be used to break down the barriers that exist with Risk Adjustment Factor Coding. This book is written in a simplified format with characterizations to help get the point across. By placing these techniques into practice, the patient's illnesses will be accurately portrayed, and the Provider's bottom line will improve

Risk-adjustment practices consider chronic diseases as predictors of future healthcare needs and expenses. Detailed documentation and compliant diagnosis coding are critical for proper risk adjustment. Risk Adjustment Documentation & Coding provides: - Risk adjustment parameters to improve documentation related to severity of illness and chronic diseases. - Code abstraction designed to improve diagnostic coding accuracy without causing financial harm to the practice or health facility. The impact of risk adjustment coding--also called hierarchical condition category (HCC) coding--on a practice should not be underestimated: - More than 75 million Americans are enrolled in risk-adjusted insurance plans. This population represents more than 20% of those insured in the United States. - Insurance risk pools under the Affordable Care Act include risk adjustment. - CMS has proposed expanding audits on risk adjustment coding. Meticulous diagnostic documentation and coding is key to accurate risk-adjustment reporting. This book will help align the industry though an objective compilation and presentation of risk adjustment documentation and coding issues, guidance, and federal resources. Features and Benefits - Five chapters delivering an overview of risk adjustment, common administrative errors, best practices, topical review of clinical documentation improvement and coding for risk adjustment alphabetized by HCC group, and guidance for development of internal risk adjustment coding policies. - Six appendices offering mappings, tabular information, and training tools for coders and physicians that include an alphanumeric mapping of ICD-10-CM codes to HCCs and RxHCCs and information about Health and Human Services HCCs versus Medicare Advantage HCCs. - Learning and design features: - Vocabulary terms highlighted within the text and conveniently defined at the bottom of the page. - "Advice/Alert Notes" that highlight important advice from the ICD-10-CM Guidelines for Coding and Reporting. - "Key Coding Concepts" that offer the advice published in ICD-10-CM Coding Clinic for ICD-10-CM and ICD-10-PCS. - "Sidebars" that detail measurements pertinent to risk adjustment seen in physician documentation, eg., cancer staging, disability status, or GFRs. - "Coding Tips" that guide coders to the right answers (using terminology and ICD-10-CM Index and Tabular entries) or provide cautionary notes about conflicts in the official ICD-10-CM guidance. - "Clinical Examples" that underscore key documentation issues for risk adjustment. - Clinical coding examples that provide snippets or full encounter notes and codes to illustrate key issues for the HCC or RxHCC. - "Documentation tips" highlight recommendations to physicians regarding what should be included in the medical record or how ICD-10-CM may classify specific terms. - "Examples" that explain difficult concepts and promote understanding of those concepts as they relate to a section. - "FYI" call outs that provide quick facts. - Extensive end-of-chapter "Evaluate Your Understanding" sections that include multiple-choice questions, true-or-false questions, and Internet-based exercises. - Downloadable slide presentations for each chapter that cover key content and concepts. - Exclusive content for academic educators: A test bank containing 100 questions and a mock risk-adjustment certification exam with 150 questions

Risk adjustment is a method to offset the cost of providing health insurance for individuals--such as those with chronic health conditions--who represent a relatively high risk to insurers. Under risk adjustment, an insurer who enrolls a greater-than-average number of high-risk individuals receives compensation to make up for extra costs associated with those enrollees.In the absence of risk adjustment policies, insurers have a financial incentive to deny coverage to higher risk individuals, and to write exclusions into policies or impose unaffordable premiums for individuals with pre-existing medical conditions. Risk adjustment aims to make comprehensive insurance available to all individuals, regardless of risk, and to allow plans that insure sicker-than-average populations to charge similar average premiums as plans that insure relatively healthy populations.The risk adjustment model enacted under the Affordable Care Act (ACA, or "Obamacare") is budget neutral. Total payments to insurers do not increase. Rather, insurers covering a relatively greater number of healthy individuals must contribute to a risk adjustment pool that funds additional payments to those insurers covering a larger portion of high-risk individuals.Risk adjustment models typically use an individual's demographic data (age, sex, etc.) and diagnoses to determine a risk score. The risk score is a relative measure of the probable costs to insure the individual. To cite a simple example, an individual with diabetes will have a higher risk score (his or her predicted healthcare costs will be greater) than an otherwise statistically identical individual without diabetes. Older individuals typically have a higher risk score than younger individuals, and those individuals with a personal or family history of certain conditions may garner a higher risk score than individuals without such a history.There are several risk adjustment models. The Centers for Medicare & Medicaid Service (CMS) risk adjustment model uses the Hierarchical Condition Category (HCC) method to calculate risk scores. This method ranks diagnoses into categories that represent conditions with similar cost patterns. Higher categories represent higher predicted healthcare costs. For example, diabetes with complications is ranked "higher" (resulting in a higher risk score and thus greater expected healthcare costs) than diabetes without complications. An individual may be included in more than one HCC.Diagnoses are reported using ICD-10-CM codes Not every diagnosis will "risk adjust," or map to an HCC. Acute illness and injury are not reliably predictive of ongoing costs, as are long-term conditions such as diabetes, chronic obstructive pulmonary disease (COPD), chronic heart failure (CHF), multiple sclerosis (MS), and chronic hepatitis; however, some risk adjustment models may include severe conditions relevant to a young demographics (such as pregnancy) and congenital abnormalities.All risk adjustment models depend on complete and accurate reporting of patient data. CMS requires that a qualified healthcare provider identify all chronic conditions and severe diagnoses for each patient, to substantiate a "base year" health profile for those individuals. Documentation in the medical record must support the presence of the condition and indicate the provider's assessment and plan for management of the condition. This must occur at least once each calendar year for CMS to recognize that the individual continues to have the condition. This information is used to predict costs in the following year. As such, incorrect or non-specific diagnoses can affect not only patient care and outcomes, but also reimbursement for that care, going forward.