PDF Risk Adjustment Coding, HEDIS, and Documentation

[Pages:50]Risk Adjustment Coding, HEDIS, and Documentation

Provider Education Training

42/1001/28018

Objectives for Today

Discuss the Risk Adjustment methodology Understand how complete and accurate documentation

and coding supports good patient care Tying in Quality and HEDIS measures Tips for accurate and complete documentation and coding

of common conditions Review Case Studies

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What is Risk Adjustment?

? Risk Adjustment is the mechanism by which government programs adjust the revenue to health plans based on the health status of the covered population(s).

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Confidential and Proprietary Information

Benefits of Risk Adjustment

Sufficient funding

Minimize incentives

Optimizing

Quality and Efficiency

Disease management

Identifying Special needs

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Risk Score calculation

Medical Record Review Rx Claims

Other Supplemental Data Files

Dx from Supp. Data

Source

Dx from Claims

Eligibility

Hospital Claims Provider Claims

In-Home Assessments

Confidential and Proprietary Information

Risk Score

Note: Not all claims are valid for risk adjustment purposes.

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Risk Adjustment Models

Medicaid

1997

? ACG, DxCG, CDPS+Rx, MRx, etc (States decide)

Medicare

2004

? CMS-HCC (Part C) and Rx-HCC (Part D)

? Aggregated and Budget Neutral

? Individualized and Additive

? Concurrent or Prospective Payments

? Prospective Payments

Marketplace 2014

? HHS-HCC (Federal), Various State Models as approved by HHS

? Aggregated and Budget Neutral

? Concurrent Payments

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Risk Adjustment Models

? Disease groups contain major diseases and are broadly organized into body systems ? HCCs (Hierarchical Condition Categories) Medicare ? HHS-HCC (Health & Human Service's Hierarchical Condition

Categories) Marketplace

? CDPS+Rx (Chronic Illness and Disability Payment System) Medicaid ? HCCs allow for payment for only the most severe or complicated

illness within a category ? Each HCC has an associated risk weight

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2017 PY Medicare Advantage Risk Adjustment Model

> 70,000+ ICD-10 Diagnosis Codes

805 Disease groups

189 Condition Categories

79 HCCs

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