Coding, Documentation and Attribution: How This Impacts the Deployment of Your Team Members

1. Coding, Documentation and Attribution: How This Impacts the Deployment of Your Team Members Linda Gates-Striby CCS-P, ACS-CA Director, Corporate Compliance St. Vincent Medical Group Indianapolis, Indiana Ty J. Gluckman, MD, FACC, FAHA Medical Director, Clinical Transformation Providence Heart and Vascular Institute Portland, Oregon

2. Disclosures Linda Gates-Striby, CCS-P, ACS-CA Nothing to disclose

3. Disclosures Tyler J. Gluckman, MD, FACC Consultant Fees/Honoraria Boehringer Ingelheim

4. Incident-To Billing • Way of billing outpatient services (most commonly in a physician’s office) by non-physician practitioners (e.g., PAs, NPs) • It was developed by Medicare; such rules may not apply to other payers • Billed under the physician’s NPI if conditions are met • “Incident-to” services must be part of the patient’s normal course of treatment, during which a physician personally performed an initial service and remains actively involved in the treatment (NOT a new problem) • You do not have to be physically present in the treatment room while the service is being provided, but you must be present in the immediate office suite to render assistance if needed https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/downloads/se0441.pdf

5. Shared/Split Billing • Way of billing Evaluation and Management (E/M) visits that are “shared” or “split” between a physician and a non-physician practitioner (e.g., PAs, NPs) • If documentation requirements are met, the visit can be billed under the physician’s PIN (100% of the fee schedule), as opposed to the PA’s/NP’s PIN (85%) • The PA/NP must be from the same group practice and the same specialty • The physician and PA/NP must both perform and document their face-to-face encounter with the patient • The portion of the E/M service performed and documented by both the physician and PA/NP must be substantive, which includes part or all of the history, exam, or medical decision https://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/downloads/r178cp.pdf

6. Shared/Split Billing—What’s Not Adequate • “I have personally seen and examined the patient independently, reviewed the (PA’s/NP’s) history, exam, and medical decision making and agree with the assessment and plan as written” signed by the physician • “Patient seen” signed by the physician • “Seen and examined” signed by the physician • “Seen, examined and agree with above” signed by the physician • “As above” signed by the physician • Signature alone by the physician • Documentation by the PA/NP stating “The patient was seen and examined by myself and Dr. ____________, who agrees with the plan.” signed by the physician http://medicaleconomics.modernmedicine.com/medical-economics/content/tags/coding/are-you-documenting-sharedsplit-visits-correctly-1

7. If You Have Seen One Form of Attribution . . . Attribution depends on who provides the “Plurality of Primary Care Services”. Medicare uses a two-step process for determining which patients are tied to a provider and who will constitute the spending-per-beneficiary and claims-based-quality-measure denominators. Medicare is now aligning the methods used in ACO patient attribution with the VBPM patient attribution – this is intended to create consistency between Medicare’s Value-Based Payment initiatives. CMS Attribution Basics Good News for 2017! In 2017 CMS is also reviewing APPs in the equation for “Plurality of Services” Team-based Care

8. Medicare’s 2-Step Approach Step 1 Step 1: Beneficiaries are assigned to the primary care provider (whether physician, NP, PA, or CNS) who provided the “plurality of primary care services” to the patient, as measured by allowed charges (i.e., E & M visits). But what if they were not seeing a PCP? Step 2: Beneficiaries are assigned to the practice whose non-primary care providers (i.e., specialists) provided the “plurality of primary care services” to the patient, as measured by allowed charges – again – E & M visits. But wait . . . there’s more. “Primary Care Services” may include services that a specialist provides, but which are unrelated to the conditions and events that Medicare is tracking. Step 2

9. Who are You Accountable For?

10. Metrics are Patient-Centered

11. Hierarchical Condition Category (HCC) Codes • HCC codes underlie the methodology CMS uses to determine capitated payments for Medicare Advantage (MA) or other Medicare programs. • The codes allow payments to be risk-adjusted based on patient complexity • The methodology uses a 12-month diagnostic coding history to predict future utilization and risk and creates a risk adjustment factor (RAF) score reflecting the patient’s complexity. • 30% of beneficiaries are now in MA, tripling in size over the last 10 years. • Prepares providers for a future with increased risk-based contracts. • Useful for calibrating panel size, productivity, and access. https://www.advisory.com/research/medical-group-strategy-council/practice-notes/2015/august/why-getting-smart-on-hccs-matters-for-more-than-just-medicare-advantage

12. What Do We Mean by Risk Adjustment Factor (RAF) • Used to access the clinical complexity of a patient and predict the burden of illness for individuals and populations • Acts as a multiplier when calculating CMS payments in a year • Factors into bidding and payment of MA plans • Focuses on identification, management, and treatment of chronic conditions

13. Characteristics of CMS’ HCC Model 79 HCCs For multiple chronic conditions Disease interactions Used to adjust payment plans Characteristics of CMS HCC Model Considers enrollee’s general age/health/demographics Uses diagnostic sources Prospective In nature Allows for planning of resources Maps to over 3,000 ICD-10 codes. Claims-based

14. Importance of Accurate Coding of Severity of Illness Don’t Miss Chronic Conditions • DM & complications • Heart failure • COPD • Atrial fibrillation • Morbid obesity • HTN with complications (HTN alone does not have a RAF score) • Major depression • Peripheral vascular disease • Malnutrition

15. Sample Encounter and the Cumulative Impact Sample Patient - Mickey M HPI • Mickey comes in for a follow up of his HF. He also has DM and CRF, stage IV. A/P • Chronic systolic HF – Currently stable, to continue current dose of furosemide • Type II DM with stage IV CKD – Stable, scheduled to see nephrologist in 2 weeks This patient has 3 HCC categories, all three codes risk adjust and would represent an cumulative “scoring”. This patient’s RAF score would be .960 If the anticipated monthly cost was $850 this now adds $850 x .960 = $816/month Financial Metrics HCC/RAF Scoring

16. What Does Coding Correctly Mean? Mickey M—What if he also had a skin ulcer?

17. What Do Your Providers Understand? • How many codes can you submit on a claim? • Do your providers understand the importance of accurately representing the patient’s multiple conditions and their severity? • 2017 claims data will be used in the 2019 implementation ICD-10 Revenue Risks

18. Comorbidity/Complication (CC) and Major CC (MCC) Codes • CC/MCC codes play an important role in hospital reimbursement through assignment of the correct MS-Diagnosis Related Group (MS-DRG) code https://www.advisory.com/research/financial-leadership-council/at-the-margins/2015/06/the-good-and-bad-news-with-severity-tier-cc-mcc-changes-in-icd-10

19. Comorbidity/Complication (CC) and Major CC (MCC) Codes • CC/MCC codes play an important role through risk adjustment of quality measures, including length of stay, readmission rate, and risk of death AMI Episode Payment Bundle • Patients who receive medical therapy but no revascularization (MS-DRGs 280-282) and includes discharges for Percutaneous Coronary Intervention (PCI) (MS-DRGs 246-251) • CMS will adjust payment based on the DRG and composite quality score* *Defined by the 30-day, all cause, risk-standardized mortality post AMI (40%), excess days in acute care [emergency department visits, observation stays, and hospital readmissions] per 100 discharges (40%), and the HCAHPS score for all patients (20%) https://www.advisory.com/research/medical-group-strategy-council/practice-notes/2015/august/why-getting-smart-on-hccs-matters-for-more-than-just-medicare-advantage

20. CMS Risk Adjustment for AMI 30-Day Mortality Measure Hierarchical Logistic Regression Model Coefficients: • Age • Comorbid disease • Indicators of patient frailty Source: • Inpatient data • Outpatient data • Physician Medicare administrative claims data 12 month look back + index admission

21. Documentation Drill Down Example—Renal Failure (CC 131) The presence of a code from a CMS-identified CC will incrementally increase the risk of the expected outcome

22. Accurate Severity of Illness = Accurate Expected Outcome

23. Questions