ICD-10 and Risk Adjustment

ICD-10 and Risk Adjustment

HCC coding, documentation and audit preparation

Tonya Owens Coding Quality Educator

Confidential and proprietary ? for internal use only

Premera is an Independent Licensee of the Blue Cross Blue Shield Association

Meet the presenter

Tonya Owens is a Coding Quality Educator at Premera BlueCross. She received her CPC, CEMC, CPMA, and CRC certificates from the American Academy of Professional Coders, with over 10 years' experience in the healthcare field coding and auditing multi-specialty professional services, outpatient surgeries, labs, and pro-fee. Tonya enjoys assisting providers in identifying risks, opportunities, and clinical documentation improvement. Experiences also include an extensive knowledge in AR revenue cycle and HCC coding and risk adjustment auditing.

Confidential and proprietary ? for internal use only

Premera is an Independent Licensee of the Blue Cross Blue Shield Association

Webinar objectives

? By the end of the session, you will:

Understand Risk Adjustment (RA) Know general RA guidelines Understand the significance of RA to you and your practice Know how to document thoroughly Be able to code completely and accurately using ICD-10-CM

Confidential and proprietary ? for internal use only

Premera is an Independent Licensee of the Blue Cross Blue Shield Association

Risk adjustment and general guidelines

Confidential and proprietary ? for internal use only

Premera is an Independent Licensee of the Blue Cross Blue Shield Association

Testing ... 1, 2, 3 ...

How familiar are you with

risk adjustment?

Confidential and proprietary ? for internal use only

Premera is an Independent Licensee of the Blue Cross Blue Shield Association

Defining risk adjustment

Risk adjustment is a methodology of adjusting estimated or perceived risks as they relate to diagnosis

codes of patients.

Confidential and proprietary ? for internal use only

Premera is an Independent Licensee of the Blue Cross Blue Shield Association

Calculating risk scores

ICD10

ICD10 Label

HCC

E0821 Diabetes mellitus due to

20

underlying condition with

diabetic nephropathy

HCC

HCC Label

E0822 Diabetes mellitus due to

20

underlying condition with

11 Colorectal, Breast (Age < 50), Kidney, and Other Cancers

12 Breast (Age 50+) and Prostate Cancer, Benign/Uncertain Brain Tumors, and Other Cancers and Tumors

13

Thyroid Cancer, Melanoma, Neurofibromatosis, and Other Cancers and Tumors 18 Pancreas Transplant Status/Complications

diabetic chronic kidney

disease

E0829 Diabetes mellitus due to

20

underlying condition with

other diabetic kidney

complication

E08311 Diabetes mellitus due to

20

underlying condition with

unspecified diabetic

retinopathy with macular

19 Diabetes with Acute Complications

edema

E08319 Diabetes mellitus due to

20

20 Diabetes with Chronic Complications 21

Diabetes without complications 23 Protein ? Calorie Malnutrition

underlying condition with unspecified diabetic retinopathy without macular edema

E08321 Diabetes mellitus due to

20

Hierarchical Condition Category

underlying condition with mild non-proliferative

(HCC) classification system

diabetic retinopathy with macular edema

Confidential and proprietary ? for internal use only

Premera is an Independent Licensee of the Blue Cross Blue Shield Association

HCC hierarchy trump list

Some HCCs hold more "value" than others...

If this HCC is found... 8 9 10 11 54 57 70

2015 Disease Group Label

Metastatic Cancer and Acute Leukemia Lung and Other Severe Cancers Lymphoma and Other Cancers Colorectal, Bladder, and other Cancers Drug/Alcohol Psychosis Schizophrenia Quadriplegia

Confidential and proprietary ? for internal use only

Premera is an Independent Licensee of the Blue Cross Blue Shield Association

... Then drop these HCCs: 9,10,11,12 10,11,12 11,12 12 55 58 71,72,103,104,169

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