ACOs & The Importance of Risk Adjustment Coding in MSSP

ACOs Risk Adjustment Coding IN Medicare Shared Savings Program MSSP

CMS released its final Medicare Shared Savings Program rule, called “Pathways for Success” for ACOs. The new rule is designed to help establish a path toward risk.

CMS = Centers for Medicare & Medicaid Services || MSSP = Medicare Shared Savings Program || ACO = Accountable Care Organization

 

MSSP lays out a clear transition to risk, and allows ACOs to start at different points, depending on where they are as an organization. Also, it extends the agreement period from 3 to 5 years, which provides more time to measure performance against the benchmark. This creates a Basic and Enhanced track option en route to risk. (See Image A below)

 

Image A Basic & Enhanced Tracks

Basic & Enhanced Tracks
Basic & Enhanced Tracks

 

There are several best practices an ACO can adopt to help succeed within the new model. Many ACOs are now looking toward Risk Adjustment which not only allows highlighting of high-risk patient populations, but will also provides a more accurate way of predicting cost and determining reimbursement.

 

The adoption of HCC risk adjustment best practices has been recognized by Medicare Advantage plans for several years. In contrast, ACOs who participate in Medicare Shared Savings Program (MSSP) have opted away from any type of program, as they felt it had little effect on their benchmark. This is often due to an ACOs past experience within the MSSP.  However, the new changes open many doors to those who may have shied away from risk in the past, for reasons such as:

 

  • Benchmarks were based 100% on an ACO’s historical success.
  • No adjustments were made on the true risk score of the beneficiary, thus no penalty for similar low risk scores year over year.
  • False/inaccurate predictions of condition profiles of beneficiaries.
  • Re-enrolled beneficiaries given a demographic adjustment only, making it very difficult for an ACO to improve coding and increase benchmarks.

 

Given the new Pathways to Success Rule, ACO groups are being shown risk adjustment in a different light. There are no more restrictions on RAF changes for the historical beneficiary. Instead, there is a 3% limit on the total increase from historical to performance year.

 

ACOs continue to lag in adoption of HCC coding practices. From the most recent 2019 Shared Savings PUF file, 49% of groups have seen a drop in RAF from benchmark year 3 (BY3) to Performance Year (PY1). RAF scores on these groups dropped from 1.0149 within BY3 to .9819 in PY1 on average, showing a -3.25% drop (see below in Image B). As a result, ACOs could have faced a significant uphill battle over the next few performance years as they attempt to true up their future benchmarks. This is one significant issue addressed by MSSP.

 

Image B: RAF Decrease PUF file 2019 ACO MSSP

 

Coding improvements are capped at 3%, however, with this drop (shown above) from BY3 to PY1, RAF improvement can actually be significantly above the allowed 3% to offset the drop of -3.25%. Therefore, now is the time for ACOs to begin adopting HCC Risk Adjustment best practices to help in this effort. 

 

By adopting best practices within HCC coding, you can ensure that your medical group has the highest specificity of diagnoses, ensuring quality of care and compliance.

 

What exactly are these best practices that can be adopted?

 

  • Educating Providers
  • Making correct preparations prior to encounter
  • Documentation of all chronic conditions that are current
  • Ensuring a clean clinical workflow to display conditions for clinicians
  • Post-encounter review for quality assurance

 

As value-based care is being adopted on a wider scale, the old model of Fee for Service payment is slowly dwindling. More time is being spent with a patient to treat all chronic conditions at the encounter is becoming best practice.

 

One of the major issues that medical groups contend with is the ability to use all relevant data to create an aligned clinical workflow that helps the physician recapture, diagnose, and reject any conditions which are inaccurate. A melee of data is combined in the form of claims data, RX data, member eligibility, historical diagnosis, and utilization. The ability to organize this data into actionable insights, clinical suggestions, and quality opportunities is a huge task for any ACO. 

 

Here at DoctusTech, we can offer a solution to this issue…..

 

Click below to see how we solve for this at DoctusTech .

 

Need better RAF scores and recapture rates in your practice? Demo the DoctusTech integrated tools, and learn how to make your value-based care contracts more profitable. Schedule a demo today.

 

Demo the tools that make HCC coding easy

5 Strategies for a Highly Effective HCC Coding Program

If you’re a physician group engaging in value-based care arrangements: coding and documentation accuracy should be your top priorities.

 
Inaction on your part will result in immediate loss of revenue and exposure to heavy audit penalties.

 
Whether you’re building a program from scratch or already have a program in place, the top five strategies for a successful program include:

 

Clinician Education — One-hour seminars or “codes of the month” emails don’t work.

Concurrent Chart Audits — This is more than checking boxes in the EMR to drag and drop chronic conditions into the progress note.

Point-of-care Clinical Guidance — Contrary to popular belief, we doctors don’t know everything! We make mistakes, and we don’t always have time.

Data Analytics — It’s painful and sometimes daunting, but it doesn’t have to be. Focus on a few critical points below to help drive an effective program.

Accountability — It’s a team effort. No single person should be held liable to be commended for the results.

 

Photo by RODNAE Productions from Pexels

 

Let’s dive deeper.

CLINICAL EDUCATION:

Clinicians, on average, retain 15% of any educational seminar you send them to after residency. Even with 15% knowledge retention, there is a consistent regression to the mean after eight weeks. Out of sight, out mind!

No one size fits all, but we know the Socratic method of teaching, consistent education, and regular feedback result in sustained behavior change amongst clinicians.

Socratic method —

Stop teaching at doctors and start objectively testing their knowledge. Try clinical vignettes in small group settings. Problem-based learning is how most medical education is practiced today, and yet, coding education has not caught up. Customize training to your clinician skill sets and practice patterns to improve buy-in.

 

Consistent education —

Training is done once a quarter or via email will consistently fall flat. Clinicians have a lot going on, and to cement, any new information must be presented to them multiple times and in various ways. This doesn’t have to be time-consuming but does need to remain consistent.

 

Regular feedback —

We, clinicians, don’t like to be wrong and always strive to be better. So customized feedback on documentation accuracy and opportunities for improvement are critical. Moving away from clinic-based or team-based results. Make sure each of your clinicians knows their strengths and weakness as it compares to the group.

 

Clinicians, on average, retain 15% of any educational seminar you send them to.

CONCURRENT CHART AUDITS:

This will assist you to impact in 2 ways: A) Ensure compliant documentation B) Adjudicating any claims submitted.

 

A typical clinical documentation improvement program ensures correction of over-and-under coding before billing. Typically institutions “hold” a bill for two business days to make any corrections. During this period, the provider can be asked to clarify inaccurate documentation and adjudicate the superbill to ensure proper 1:1 matching with progress notes to billable codes. Much of this is currently handled at the payor level for smaller physician groups.

 

As you start to take on more risk as a physician practice, you’ll need a consistent strategy across all your payor contracts. While vendors are currently using a heavily manual process, emerging technology from Doctus will help you do this at the point of care with our A.I. This will drop your OpEx, decrease your risk during RAD-V audits, and give you a more accurate line of sight to your risk scores.

 

POINT OF CARE CLINICAL SUPPORT:

Doctors were not trained as coders, and coders were not trained as doctors. The basic premise of accurate documentation is and should be clinical. Clinicians need to take better histories, perform more accurate physical exams, and synthesize data to make clinical diagnoses. No coder or AI can replace and find these diagnoses as the data is inherently flawed with significant gaps.

 

Doctus can help doctors ask better questions, perform accurate exams, and present clinical guidelines to lets doctors practice medicine. This will inherently improve your RAF accuracy and create physician buy-in better than any Natural Language Processing or A.I. alone. Unfortunately, EMRs are limited by their data sets. They operate only off the information inputted, so if your PCP doesn’t have the complete clinical picture from your hospital systems and your specialists inputted into the EMR, the clinical decision support in your EMR will be lacking.

 

Photo by energepic.com from Pexels

 

DATA ANALYTICS:

No pilot would fly a plane without an operational dashboard, so why do we allow the same for such a critical part of our value-based care business? No excuses, no delays. The ability to aggregate data from outside your EMR, deliver individual physician report cards on HCC documentation, and having visibility to patient annual wellness visits (AWVs) for everyone on the team is critical. If your team doesn’t have bandwidth, vendor it out. Time is critical, and the ROI is clear.

 

Remember, if the data is not easy to fetch and easy to understand, no one will use it. This does not need to be an expensive endeavor. Make sure you have visibility to the following data points by an individual physician.

 

    • Patient panel
    • Suspect vs. chronic diagnosis by patient
    • Complete vs. incomplete AWVs
    • % conditions addressed by a physician at each visit
    • Documentation accuracy

 

ACCOUNTABILITY:

Whether you plan to use a stick or a carrot approach to accurate documentation, the strategy needs to be intentional and meaningful. The entire team plays a role in an effective program, and accordingly, the strategies you deploy should touch each individual team member in a meaningful way. Rewards do not need to be financial, and the motivation here is it drives better clinical care. The emphasis in the following areas are compliant and effective:

    • Documentation accuracy
    • % AWVs scheduled
    • Regular engagement with any coding tools

 

DoctusTech’s proprietary A.I. can be embedded into your EMR or on your mobile phone to help you complete steps 1,2,3,4 very effectively. All you have to do is be ready to hold your team accountable.

Schedule a demo today & let us show you how.

— Doctus Team

What is HCC Coding? Risk Adjustment Models in Value-Based Care

What is HCC Coding?

HCC coding stands for hierarchical condition category coding.
It is a risk-adjustment coding model exclusively designed for estimating future healthcare costs for patients. The process of HCCs medical coding started in 2004, but it recently gained popularity due to payment models shifting from fee-for-service (FFS) to value-based care (VBC) arrangements.

What is HCC Coding and Risk Adjustment?


Fig 1.
Out of 70,000+ ICD10 codes, approximately 9,500 ICD10s map to a hierarchical condition category. Each HCC ICD10 is subsequently bucketed into 86 individual “condition categories.”

What is HCC Coding and Risk Adjustment?


Fig 2.
Each of the 9,500 HCC codes are put into one of 86 condition categories. Each condition category carries a specific RAF. No matter how many ICD10 conditions a patient has in the same category, they will only be assigned the RAF score one time.

 

Medicare assigns a risk score known as a risk adjustment factor (RAF) to each of the 86 individual condition categories. RAF scores of patient populations are subsequently used by Medicare and other payors to predict the cost of care, which influences reimbursements.

For the remainder of this article, we will explore the rationale behind HCC coding and why all providers (even those NOT in a value-based care arrangement) should care.

Why should doctors care about HCC coding?

HCC coding is the cornerstone of most value-based care arrangements. Today, “value-based care” is used synonymously with Medicare Advantage, but in the near future, we believe all forms of reimbursement will be tied to some VBC arrangement.

 

HCC coding falls under the broader term of risk adjustment (RA) models where patient care is paid based on a prospective payment model. Specially designed RA models are used to determine risk scores for patients. In the Medicare Advantage world, these models use the demographics and HCC diagnoses of the patient to assign a risk score known as an RAF. The assumption is the sicker the patient, the higher the RAF, the more dollars it will take to care for this patient during any given year. Therefore the RAF score of any patient population will determine the prospective payment Medicare disburses.

This prospective payment model based on RAF does 2 things:

 

1. Aligns physician incentives. Currently, clinicians make money from taking care of sick patients. The sicker the patient, the more visits, tests, surgeries they have to do, and the more they are reimbursed. In this model, clinicians are incentivized to keep patients healthy and therefore require LESS tests and surgeries.

 

2. Spurs clinical innovation the right way. Right now, pharmaceuticals and medical hardware companies are all trying to find ways to treat diseases. The newer the drug or medical device, the more revenue they make. In this model, healthcare groups are incentivized to find new ways of preventing the disease progression from ever needing the latest drug or newest medical surgery equipment.

 

As Medicare and payers alike are starting to take notice of #1 and #2 above, the market is now trending towards building in value-based care drivers to all types of patients outside of Medicare Advantage. It’s unlikely a brand new risk model will be born for commercial patients. Therefore, all physicians will need to understand the risk adjustment models and the implications of documentation accuracy for reimbursement.

Conclusion

 

HCC coding is here to stay and will only grow in the years to come. While the market has heavily leveraged medical coders or third party vendors to do much of the lift thus far, V2 of Value-based Care will require all clinicians to understand and participate in it for every patient visit.

 

HCC coding’s importance is less about the impact on revenue and more about the shift towards VBC models, which have consistently shown better clinical outcomes at lower costs. In our next 2 posts, we will dive deeper into the financial implications of HCC coding, HCC coding tools,  and the clinical outcomes associated with VBC in 2021.

 

— Doctus Team

 

Sources
https://www.inovalon.com/inovalon-insights-blog/hcc-coding-improve-risk-adjustment/
https://www.asahq.org/quality-and-practice-management/managing-your-practice/timely-topics-in-payment-and-practice-management/an-introduction-to-hierarchical-condition-categories-hcc
https://www.3mhisinsideangle.com/blog-post/hcc-coding-whats-the-big-deal/
https://www.aafp.org/fpm/2016/0900/p24.html