ICD-10 and Risk Adjustment - Premera Blue Cross
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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