HCC Risk Adjustment Coding
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CMS - Instructional Videos on Risk Adjustment (2023-07-12)
CMS-Risk Adjustment Data Validation (2017-09-27)
Medicare Managed Care Manual Chapter 7 – Risk Adjustment Learn all about risk adjustments, what supports a risk score, and more...
CMS Medical Record Reviewer Guidance 2023 variety of resources on the RADV program
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Select the title to see a summary and a link to the full article. some articles require a subscription to view.
by Jessica Hocker, CPC, CPB, CRC
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.
Mar 15th, 2023
HCC Re-Structuring Coming Soon!
by Christine Woolstenhulme, QMC QCC CMCS CPC CMRS
by Kem Tolliver, CMPE, CPC, CMOM
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.
by Aimee L. Wilcox, CPMA, CCS-P, CST, MA, MT
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.
Oct 24th, 2022
2023 Evaluation & Management Updates Free Webinar
by Aimee L. Wilcox, CPMA, CCS-P, CST, MA, MT
Congratulations on a successful 2021 implementation of the Evaluation and Management (E/M) changes! That was a big change, but now an even bigger change is headed your way for inpatient and all other E/M categories. How great is it that almost all of the E/M categories will now be scored based on medical decision making (MDM) or total provider time? Standardized scoring and one set of E/M guidelines has the potential of bringing about a change or improvement of provider fatigue due to over regulation and documentation burden.
by Ronald Hirsch, MD FACP CHCQM CHRI
Three items are discussed in this article: First, performing random audits of critical care visits billed with CPT codes 99291 and 99292 to ensure the patient was truly critically ill, which could help avoid recoupment. Secondly, time will tell if rural hospitals will switch to the rural emergency hospital designation. Lastly, a 2023 OPPS proposed rule, CMS discusses creating a new payment category, paying for software as a service.
by Aimee L. Wilcox, CPMA, CCS-P, CST, MA, MT
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.
by Aimee L. Wilcox, CPMA, CCS-P, CST, MA, MT
In just a few short months, major revisions to the remaining Evaluation and Management categories in the Current Procedural Terminology (CPT) code book will go into effect. How many of these changes will affect your organization and how ready are you for them? While the changes to the remaining E/M categories will closely resemble the 2021 changes to the E/M Office and Other Outpatient (99202-99215) codes, there are some major differences that need to be carefully reviewed, such as how E/M will change for the Emergency Department services.
Sep 18th, 2022
What is the ICD-10 Code for May-Thurner Syndrome?
by Aimee L. Wilcox, CPMA, CCS-P, CST, MA, MT
May-Thurner syndrome is not identified in the Alphabetic Index of the ICD-10-CM codebook, so what is the ICD10 code for reporting this condition? Eponymous diseases are conditions, illnesses, syndromes, disorders, or disease named after the person who either discovered it (usually a physician) or in some cases the patient who was diagnosed with the disease (think Lou Gherig's disease). When trying to identify these diseases in the Alphabetic Index you may have to do a little additional research to identify the actual name of the condition rather than the eponymous name. So what exactly is the ICD-10-CM code for May-Thurner syndrome and what other names does it go by?
by Aimee L. Wilcox, CPMA, CCS-P, CST, MA, MT
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.
by Aimee L. Wilcox, CPMA, CCS-P, CST, MA, MT
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.
by Aimee L. Wilcox, CPMA, CCS-P, CST, MA, MT
Medicare Advantage Organizations (MAOs) have gone back and forth on whether or not to use data collected from telehealth, virtual Care, and telephone (audio-only) encounters with Medicare beneficiaries for risk adjustment reporting, but the following published documents from CMS cleared that up once and for all by providing an answer to a question specifically related to this question.
by Amanda Ballif
The Centers for Medicare and Medicaid Services (CMS) is soliciting public comments on proposed changes for Medicare payments under the Physician Fee Schedule (PFS) and other Medicare Part B issues effective on January 1, 2023 and thereafter. The Calendar Year (CY) 2023 PFS proposed rule is one of several proposed rules aimed at increasing equity in health care.
by Aimee L. Wilcox, CPMA, CCS-P, CST, MA, MT
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.
by Aimee L. Wilcox, CPMA, CCS-P, CST, MA, MT
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.
by Aimee L. Wilcox, CPMA, CCS-P, CST, MA, MT
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?
Feb 15th, 2022
Are Risk Adjusted Plans Getting a Makeover?
by Aimee L. Wilcox, CPMA, CCS-P, CST, MA, MT
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.
Feb 10th, 2022
SDoH Improves Reimbursement and Risk Scores
by Aimee L. Wilcox, CPMA, CCS-P, CST, MA, MT
The new guidelines for evaluation and management (E/M) services 99202-99215 refer to social determinants of health (SDoH) on the new or revised Table of Risk. Healthcare professionals have long hoped for the ability to score these problematic patient conditions in a meaningful way, not only for reimbursement, but also for quality of care and treatment options. SDoH codes recently added to the ICD-10-CM codeset continue to impress upon us the importance of identifying and reporting these patient issues and when combined with the new table of risk for scoring the E/M service, can impact reimbursement and care.
by Aimee L. Wilcox, CPMA, CCS-P, CST, MA, MT
SUMMARY: Medicare Advantage plans saw a surge in enrollments as ESRD Medicare beneficiaries were permitted to enroll in Medicare Advantage plans for the first time in 2021. Will your organization be ready for ESRD audits?
by Aimee L. Wilcox, CPMA, CCS-P, CST, MA, MT
As the OIG has published their intent to further investigate the 9.5% of improper payments based on incorrect ICD-10-CM code assignation, they implore Managed Care Organizations (MCOs) to begin employing some of the CMS tools and data analytic programs used to help identify outliers.
Select the title to see a summary and a link to the full webinar information. some webinars require a subscription to view.
Jun 8th, 2023
Looking Closer at High Risk EM Medical Decision Making
by Aimee L. Wilcox, CPMA, CCS-P, CST, MA, MT
Thursday @ 10:15 AM PST, 11:15 AM MST, 12:15 PM CST, 1:15 PM EST Join us for a deep dive into the Evaluation & Management element of "Risk". Learn more about the differences between complications, morbidity, and mortality and how that drives coding. What does it really take for an encounter to be considered "High risk?"Jun 27th, 2019
Coding and Billing Chronic Care Management Services
by Aimee L. Wilcox, CPMA, CCS-P, CST, MA, MT
Coding and Billing Chronic Care Management Services ...Nov 9th, 2017
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