ArticlesOIG Audit Reveals Diagnosis Reporting Problems Affecting Risk Adjustment Scoring
The Office of the Inspector General (OIG) recently published their Spring 2023 Semiannual Report to Congress. This report contained some diagnoses reporting issues that all providers need to be aware of. They focused on several groups of diagnoses that they considered “High-Risk” for being miscoded. Several states were included in the report and the types of errors for all can be generally grouped into several categories.
Identifying the Components of a High-Risk Evaluation and Management Service
How comfortable are you with selecting a high-level Evaluation and Management service and how often do you see high-risk E/M codes reported? In 2023, the CPT coding guidelines for E/M coding changed drastically, moving from a 3-key component scoring system to determining the final code using either time or medical decision making (MDM), but accurately scoring and having confidence in the selection of a high-level E/M service remains challenging.
Imminent Telehealth Changes After the COVID-19 Public Health Emergency (PHE) Ends
Between 2020 and 2023, an incredible amount of 1135 waivers were implemented due to the COVID-19 public health emergency (PHE). Now, with the announcement of the end of the PHE this year, how careful must we be to ensure we understand the which of the waivers will return to pre-PHE status and which will remain permanently changed? Let's take a look at some of the telehealth waivers we enjoyed during this time and how they will change either this year, or at the end of 2024.
Post PHE Changes to Coverage of Continuous Glucose Monitoring (CGM) Devices
With the announcement of the end of the COVID-19 public health emergency, many of the waivers and flexibilities will begin to go back to a pre-PHE status, one of which will affect tens of millions of patients in the United States. Continuous glucose monitors are an essential tool in successfully monitoring and reducing the complications associated with diabetes. However, this year, the process for accessing coverage through Medicare to obtain a CGM will soon require jumping through a few more regulatory hoops.
Problem Lists vs. Reality: Improving Risk Adjustment Coding Accuracy for Medicare Advantage Plans
Accurate risk adjustment coding is crucial for Medicare Advantage plans to receive appropriate funding and provide quality care to their members. However, problem lists, which are often incomplete or inaccurate, can pose significant challenges. This article presents possible targeted strategies in addressing the "problem" of problem lists, such as utilization of claims data, clinical documentation improvement, and provider education.
The Role of Risk Adjustment Models in Medicare and Medicaid Reimbursement
Risk adjustment models are used by Medicare and Medicaid programs to classify patients based on the severity of their health conditions to determine the reimbursement for payers. Different types of models are used, such as HHS-HCCs, CMS-HCCs, RX-HCCs, and ESRD-HCCs, which are based on a hierarchical structure, meaning that patients are classified into categories based on the most severe condition they have. Medicaid risk adjustment models vary by state in the US, some states use their own models, while others use models developed by the CMS. These models take into account both diagnoses and procedures, and adjust the payment rates for healthcare providers based on the complexity of the care they provide.
Leveraging Hierarchical Condition Category (HCC) Coding to Improve Overall Healthcare
Diagnosis code usage is a major component of optimizing HCCs to improve overall healthcare. Readers will gain insight into how accurate diagnosis code usage and selection impacts reimbursement and overall healthcare.
Fatten Up Your BMI Coding Skills
Accurately reporting body mass index (BMI) codes has become important with many of the payers reimbursing provider organizations up to ten dollars per chart for reporting 3008F with a documented BMI code. However, as is almost always the case, it isn't a simple scenario of collecting, documenting, and reporting the patient's BMI but rather hitting the mark on all of the criteria that goes along with it and understanding how to identify morbid obesity based on coding guidelines in the ICD-10-CM code set and specific payer policies.
Four Ways Your Organization Can Benefit from Gathering and Reporting Social Determinants of Health Data
Providers who actively engage in collecting and reporting social determinants of health (SDoH) open avenues of identifying and treating their patients' population health trends. Pairing chronic conditions that are difficult to control with identified SDoH circumstances such as transportation or electricity insecurity, can help identify those patients who may wish to be healthier, but who are dealing with circumstances that prevent compliance, such as transportation or access to electricity, for instance.
Seven Major Changes Proposed by CMS in the 2023 Proposed Rule
As the COVID-19-related public health emergency (PHE) seems to be dying down, CMS publishes the 2023 Medicare Proposed Rule that outlines more than a dozen major changes to existing programs, including some that relate to telemedicine after the PHE is declared officially over. Of the many changes, seven (7) really stand out and make us think about how the end of the PHE may affect services such as telemedicine or new E/M encounter types.
End-Stage Renal Disease Risk Model Updates for 2023
For the first time, ESRD Medicare beneficiaries were permitted to enroll in Medicare Advantage plans beginning in 2021. Since that time, CMS has been working to revise the program to reduce costs, improve quality, and drive benefits. Effective January 1, 2025, one such change will include a definition change for "oral-only drugs." Why is Medicare changing the definition of these drugs and how will that be a driving force in advancing care models for ESRD in the future?
Are Leading Queries Prohibited by Law or Lore?
AHIMA released its CDI Practice Brief Monday. At Yom Kippur services, I found myself thinking about the question Dr. Ronald Hirsch posed to me the day before. My rabbi was talking in her sermon about the difference between halacha and minhag. Halacha is law; it is the prescriptions...
Yes, You Have What It Takes To Lead Your Practice And Your Profession
If you’ve been in any healthcare role for more than two years, you’ve seen quite a bit of change. And guess what, it’s not over. We are living and working in uncertain times. This climate requires each of us to step outside of our comfort zones to lead exactly where we stand. It’s not required of one to have a “title” to lead. What is required, however, is a willingness to trust your instincts, look for answers and rely on your team.
Are You Prepared to Avoid Repayments
Watchful care is needed when submitting claims. The Office of the Inspector General (OIG), after completing an audit on a Medicare Advantage Plan in August 2022, is now demanding repayment of claims to the tune of $3,518,465. Although the payer is contesting that amount, it is possible that they may begin demanding repayments from the providers to cover their costs of repayment.
CMS Publishes Over 1,000 New ICD-10-CM Codes Effective on October 1, 2022
Each October 1st, the newest updates to ICD-10-CM take effect. This year with more than a thousand new codes added there is a lot of information to dig into and prepare our providers for. Many of the deleted and changed code descriptions, including the endeavor to capture social determinants of health, were made to enable expansion of specific coding categories so additional details could be reported, when captured in the documentation.
CMS Encourages Medicaid MCOs and CHIP to Employ Section Waivers to Improve SDoH and Reduce Healthcare Costs
Over the past few years, at least 15 states have consistently pursued the goal of using social determinants of health (SDOH) in their overall healthcare analysis and treatment programs for patients, and CMS has taken notice. Data and outcomes obtained from these state programs have essentially provided an outline of how the government intends to pursue health equity through managed care contracts (MCOs) and Children's Health Insurance Program (CHIP). What is CMS seeing that they like so much and how might that affect future MCO contracts?
Calendar Year 2023 Medicare Advantage and Part C & D Payment Policies
Each year CMS publishes an Advance Notice of the upcoming years Medicare Advantage (MA) Capitation Rates and Part C and Part D Payment Policies and asks for comments related to it. Each of the comments are carefully reviewed and responded to and often are impactful to changes seen between the Advance Notice and final publication referred to as the Rate Announcement. With health equity as a primary focus for 2023, CMS announced some policy changes that may impact your organization.
CMS Started to Enforce Applicable Price Transparency Requirements
Beginning July 1, 2022, CMS started to enforce applicable price transparency requirements because of the Trump Administration's historic price transparency requirement in 2019 to increase competition and lower healthcare costs for all Americans.
OIG Investigates SCAN Health for Risk Adjustment Overpayments With Surprising Results
We’ve seen a number of OIG risk adjustment data validation (RADV) audits recently where the independent review contractor was simply looking for any codes the payer reported that were not supported by the documentation, in an effort to declare an overpayment was made and monies are due to be repaid. However, it was refreshing to read this RADV audit and discover that the independent review contractor actually identified HCCs the payer failed to report that, while still resulting in an overpayment, was able to reduce the overpayment by giving credit for these additional HCCs. What lessons are you learning from reading these RADV audit reports?
Medicare Advantage (MA) Benchmarking Policies Are Headed for Change
More than 43% of Medicare beneficiaries are not enrolled in Medicare Advantage plans, which were established to control costs and improve quality. However, as noted in the March MedPac Report Executive Summary of 2021, these plans average an estimated 104% of Medicare Fee-For-Service (FFS) spending. How does CMS plan to manage Medicare Advantage plans now?
Sometimes it's the Little Coding Conundrums That Keep Us Concerned
We all experience coding situations that make us stop and rethink our coding path. Do we have the most current information on this situation? Does the payer contract change the way we must report the service? Are we missing something? Each of us experience simple to complex coding issues in our work and sometimes it is just nice to collaborate and discuss them openly to see how they may be resolved. Have you ever questioned the proper use of major depressive disorder codes versus the newly added (2021) depression, unspecified code? Take a look at what the OIG said about these codes and how the payer responded.
How Extensions to the COVID-19 Public Health Emergency Affect Healthcare Reimbursement
Providers need to begin preparations for how to handle a return to pre-COVID-19 public health emergency (PHE) policies. As the saying goes, "you can't put the rabbit back in the hat." Some COVID-19 PHE policies are so well liked it will be very difficult for the government to return to pre-COVID-19 policies. For now, we have at least the promise of a 60-day notice to all governors precipitating the end of the PHE.
Do You Know What Code is Used to Report Long-Haul COVID-19 Conditions?
A new code was added to the ICD-10-CM official code set with an effective date of October 1, 2022 for reporting post-COVID-19 sequela. We have all heard about people having odd conditions following COVID-19, well now there is a code available for reporting all of these anomalies, but are you familiar with the code and the rules for reporting it?
CMS Claims Risk Adjustment Overpayments Commonly Include 10 Specific Diseases
There are many lessons that can be learned from a single OIG audit report. In this recently-published OIG report, several of the most common documentation and coding errors are pointed out in relation to reporting HCCs for risk adjusted plans. Take a few minutes to review the report and see if improvements within your own organization can be made from what you learn.
How Would Your Organization Defend This Auditing Accusation?
The Office of Inspector General (OIG) is always working on audits in a pursuit of accurate reporting and reimbursement. A recently published OIG audit report can provide great information on how to protect providers and risk adjustment payers from serious financial losses by showing exactly what the OIG is looking for and how the payer (or provider) may have defended their coding choices. In this article, you will see how the OIG audited the HCC for major depressive disorder and what Anthem did to defend its reporting.
Opportunities to Identify Risk Adjustable Chronic Conditions Expands in 2022
Medicare made changes to the rules governing concurrently reporting transitional care management services and chronic care management services during the same calendar month. How might this help providers identify chronic conditions that risk adjust?
Medicare FFS Beneficiaries Average 2 or More Chronic Conditions
Medicare Advantage plans were created in an effort to improve patient health outcomes, quality of healthcare services, and reduce costs by managing chronic health conditions better than traditional Medicare plans. According to a CMS-published report from 2018, the average Medicare FFS beneficiary suffers from at least two chronic health conditions with a per capita cost of $2,067. Can you guess how many suffer from six or more chronic conditions?
ESRD Hemodialysis Hits Home with the New ETC Model
In 2021, two major ESRD programs became effective, essentially preparing to transform not only risk adjusted services, but also at-home dialysis, health equity among beneficiaries needing transplant services, and improved access to donor kidneys.
Take-Aways from the Medicare Part C and the Star Ratings 2023 Advanced Notice of Changes
Each year changes are made in many facets of risk adjustment calculations and processes. For the upcoming calendar year 2023, there are many changes coming, including announcements about the potential for risk-adjusting social determinants of health (SDoH) codes. A summary of some of the most significant changes are included for your review.
Are Risk Adjusted Plans Getting a Makeover?
The Centers for Medicare and Medicaid Services Innovation Center (CMMI) is responsible for developing, implementing, and evaluating the risks associated with healthcare payment models such as Medicare Advantage (a risk adjustment payment model). Recent investigation outcomes have shown payers are consistently reporting services not supported by documentation in an effort to increase revenue. As such, big changes to the CMMI health care payment models, including risk adjusted models, may be headed our way in 2023.