Why Plans Should Focus on Accurate Documentation Capture for Health Risk Assessments (HRA’s), for 2014

The HAUTE HCC Blog with TMI:  Free HCC Resources and TIPS For 2014 – dedicated to HCC Coding and Risk Adjustment for Medicare Advantage Plans

By Holly Cassano, CPC, AAPC ICD 10CM Certified, Director of Coding Education and Compliance for Tactical Management Inc., (TMI)

Part 1

In November 2013 The Centers for Medicare and Medicaid (CMS), stated that their intention to gather information on enrollee “Health Risk Assessments” or HRAs was a “go”.  This announcement sent shockwaves throughout the Medicare Advantage (MA), Plan Community, as HRA’s, are a common doorway for MA Plans to glean Hierarchical Condition Category (HCC), Codes, for submission and payment to CMS.

The purpose of risk adjustment is to measure health status that is related to plan liability. It is not clear to CMS that if during the course of an HRA and subsequent identification of one or more HCCs, if the MA Plans liability is directly correlated to a provision of treatment for those chronic conditions that have been identified during that same HRA.

Why CMS is Concerned

HRAs are often performed in beneficiaries’ homes and are typically conducted by Non-Physician Practitioners (NPPs), contracted by the MA Plan, independent of the MA Plan’s active provider network.   CMS feels that since these “NPPs” are not part of the beneficiaries’ primary care providers, there could be potential “risk for fraud and abuse” or “HCC Creep” during the data collection on these types of visits.

HRAs involve a myriad of processes for data collection for reporting and reimbursement that include the following:

•     Collecting Diagnostic Information

•     Reviewing Medications

•     Assessing Functional Status

•    Identifying Opportunities for Case Management

CMS feels that since these processes are a part of the HRA, there is a propensity for erroneous claims since MA Plans appear to be utilizing these types of visits as the lead source of data collection.  CMS also feels that that there is a link between HRAs and the recent influx of increased risk scores and marked differences in coding patterns comparatively between Medicare Advantage and normal Fee for Service CMS.

CMS’s Original Proposal in November 2013 with New HRA Requirements

The Risk Assessment field must contain one of the following values:

1)      Diagnosis code comes from a clinical setting.

2)      Diagnosis code comes from a non-clinical setting and originates in a visit where all requirements specified at 42 CFR 410.15(a) for a First Annual Wellness Visit or Subsequent Annual Wellness Visit were met.

3)      Diagnosis code comes from a non-clinical setting and originates in a visit where all requirements specified at 42 CFR 410.15(a) for a First Annual Wellness Visit or Subsequent Annual Wellness Visit were not met.

Clearly these new requirements were cause for confusion among MA Plans and they requested clarification from CMS on the following:

Q1: What is a “non-clinical setting”?

A1:  The patient’s home is the only non-clinical setting CMS is referring to (or any risk adjustable visit not provided in patients’ home.)

Q2:  Are Annual Wellness Visits the only services covered by Flags/Values ‘B’ and ‘C’?

A2:  Please review 42 CFR 410.15 (a), Initial Preventive Physical Exams, the “welcome to Medicare physical is included (with any risk adjustable visit – CPT code G0402, G0438 or G0439 and not provided in the patients’ home).

Q3:  Do the providers’ credentials have anything to do with use of the flags?

A3:  A providers’ credential has no weight with flag assignment (any risk adjustable visit, which is not CPT Code – G0402, G0438 or G0439 and is provided in the patient’s home).

Q4:  Does use of any of these flags indicate that the service will not be risk adjusted?

A4:  Currently, until further notice, the use of any flag will not affect risk adjustment.  (A final policy will be published in the 2015 Advance Notice in February, 2014).

Light at the End of the HRA Tunnel – for now

CMS made good on its promise to publish a Final Call Letter in February of this year and on 4/7/2014,  announced  “CMS will NOT Implement, in 2015, the Proposed Policy to Exclude, for Payment Purposes, Diagnoses identified during a Home Visit That are Not Confirmed by a Subsequent Clinical Encounter”.  This came on the heels of CMS meeting with MA Vendors and MA Plans to gain further insight as to the inner workings of the HRA data collection process and overall impact to MA Plans.

CMS stated that it does support the use of HRAs for wellness, care coordination, and disease prevention and as a key tool to assist in the identification of members who are in need of care.

Final Key Changes to the Advance Notice:

•    Deferred the Collection of Flags for Enrollee Risk Assessments Until 2014 Dates of Service.

•     CMS Stated They Would Propose & Finalize a Policy on the Extent to Which Diagnoses from 2014 Enrollee Risk Assessments Would be Used to Calculate Risk Scores for Payment Year 2015 in  2015

•     2015 Payment Year will Blend the Risk Scores Calculated using the 2013 CMS-HCC And 2014 CMS-HCC Models By 67 Percent And 33 Percent, Respectively.

•     CMS will NOT Implement, in 2015, the Proposed Policy to Exclude, for Payment Purposes, Diagnoses identified during a Home Visit That are Not Confirmed by a Subsequent Clinical Encounter.

•     CMS Will use both Full Encounter Data and RAPS Data to Calculate 2015 Payment. CMS will Notify MA Plans when Full Encounter Data solely will be used

Don’t Throw Caution to the Wind – CMS will Notify MA Plans when Full Encounter Data solely will be used

CMS has stated that they remain concerned that in-home HRAs seem to mainly serve as a mode of collecting diagnoses for payment versus serving as an effective means to improve follow-up care and treatment for Plan beneficiaries.  What this means is that although there was a “stay of execution” for 2015, rest assured, CMS will implement this change to the use of data collected from an HRA, if studies continue to show that there is no follow up on the side of the Members PCP and no documentation in the medical record from a subsequent visit.

•     To learn  more about the 2015 Final Letter on Risk Adjustment from CMS, click on the following link:    http://www.cms.gov/Medicare/Health-Plans/MedicareAdvtgSpecRateStats/Downloads/Advance2015.pdf

An Ounce of Prevention as the Saying Goes – what you can do now to prepare

•     When an MA Plan is faced with a CMS Risk Adjustment Data Validation (RADV), Audit –how it happened and what led to it is irrelevant, mistakes are mistakes and correcting and preventing future ones is what CMS is concerned with.

•     Provider Education is one of the top ways to help curb errors and also alerts providers to common documentation/coding issues and serves to better help them understand ICD-9 /AHA coding conventions and Risk Adjustment.

HCC Free Zone:  Solutions to Capture Accurate Documentation for those AWV’s

There are several solutions to aid MA Plans and Providers with accurate HRA and Annual Wellness visit (AWV), data collection and one that is recognized by CMS is WellTrackMD™.   The WellTrackMD™ Annual Wellness Visit Benefit Tool, can be used in conjunction with the Mandatory HRA to help streamline the Medicare Annual Wellness Visit (AWV) process. WellTrackMD is recognized as a preventative care service by CMS that can assist with the education of seniors in regards to potentially life-threatening conditions while promoting proactive lifestyle changes.

•     To learn more about WellTrackMD’s AWV Tool and more, click on the following link:   http://www.welltrackmd.com/

Final Thoughts

Remember: 

HCC codes determine overall acuity of members within a Medicare Advantage Plan and are added to their annual Risk profile. CMS recommends reporting Active Chronic Conditions, once per year (twice is best), in order to effectively capture a members Active Health Risk Profile.

“Documentation & Education are Key to a Plan’s success!”

 

Holly

Holly Cassano, CPC, AAPC ICD 10CM Certified

Director of Coding Education and Compliance for Tactical Management Inc., (TMI)

 

Email me: hcassano@tacticalmanagement.com

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