Transcript Risk Adjustment Factor [RAF]

Overview:
1) Risk Adjustment
Program establish by Centers for Medicare and Medicaid Services [CMS]
GOAL: to allocate resources
to those patients who most
need them, based on each
patient’s severity of illness
Risk Adjustment Factor [RAF] score, is a metric tied to each individual member which
reflects the health status of that member and is used by CMS to calculate payment
[2 components]:
demographic (age, sex,
Medicaid status, and
disability)
Hierarchical Condition Category
(HCC) risk adjusting diagnoses
codes submitted via encounter
data claims
IDEAL SCORE: >1.00
By January 1st of each year, CMS cleans the slate for all patients and each
patient is considered “cured” of all their chronic conditions
“Very important” to evaluate each senior patient for an annual health
assessment where each medical problem is properly documented, coded and
reported via submission of encounter data
•
Three key components need to be validated by the provider(s):
 Diagnosis (es)
 Status of each chronic condition [i.e. new, stable, improved,
worsening]
 Plan [outlines the management of each chronic condition
Also one of priority STAR program clinical measures, “ ADULTS’ ACCESS
TO PREVENTIVE/AMBULATORY HEALTH SERVICES”
Requirements to be eligible for bonus incentive:
 Must meet eligibility with the IPA
 IHA/AHA form must be completed in its entirety (diagnosis, status
and plan section must be validated)
 A CMS 1500 form must accompany the IHA/AHA form (if there are
more ICD-9 CM diagnoses codes than the form can
accommodate, please follow the CMS guidelines in accordance
with 837 or 5010 requirements)
Must be billed using HCPCS codes:
 G0402 [Initial Preventive Physical Exam] aka “Welcome to
Medicare Visit”
 G0438 [Annual Wellness Visit, initial visit]
 G0439 [Annual Wellness Visit, subsequent visit]
Importance to both IPA and PCP office:

to ensure that our members are getting quality of care
and that their needs are addressed

to meet the CMS guideline of seeing the members at
least once annually

to qualify for the CMS STAR and HEDIS program
incentives – must be at least 3.5 stars
 3 KEY COMPONENTS [DSP]
 “FOREVER CONDITIONS” – CONDITIONS THAT DO NOT GO
AWAY, E.G. CHF, COPD, DM, RA, MS,
AMPUTATIONS….ETC…
 DO NOT USE “HISTORY OF” FOR CONDITIONS THAT ARE
STABLE AND CONTROLLED
 DM CODING GUIDELINES- ALWAYS USE 2 CODES
WHENEVER THERE IS A COMPLICATION
 PULMONARY/RESPIRATORY PROBLEMS – IF PT IS ON O2
– CHRONIC RESPIRATORY FAILURE, CHRONIC SMOKER –
SMOKER’S COUGH
 CVA – USE LATE EFFECTS OF..
 CHRONIC KIDNEY DISEASE – MONITOR GFR
CKD 1 GFR>90 w PROTEINURIA/MICROALBUMINURIA
CKD 2 GFR 60-89 w PROTEINURIA/MICROALBUMINUR
CKD 3 GFR 30-59
CKD 4 GFR 15-29
CKD 5 GFR <15
CKD 6 ESRD
 CANCER
 PSYCH
 MALNUTRITION
 FECAL IMPACTION VS CONSTIPATION
 SIGNATURE REQUIREMENT
 CKD I, II, III will no longer risk adjust AFTER 2013. It is
still IMPORTANT to look for and stage CKD as you
have been since it is A) excellent quality medicine to
identify and treat CKD I, II early. B) It will still support
“Diabetes with Renal Manifestation” to be Dxd and
captured. C) The CKD will still continue to risk adjust
for Pharmacy. So with the above considered, continue
as you all have been looking and diagnosing CKD at
all stages.
 OLD MI, Hx of MI will no longer risk adjust AFTER
2013, however it is A) still important to be looking for
and diagnosing it this year and B) consider ANGINA
413.9 in all patients with CAD, Hx of MI.
 HYPOXIA will no longer risk adjust AFTER 2013, meaning
it is IMPORTANT to diagnose “Chronic Respiratory Failure
518.83” (which will still risk adjust) in COPD patients with
hypoxia.
 MORBID OBESITY will RISK ADJUST in 2013. It is
important that the BMI is calculated and interpreted by the
provider if greater than or equal to 40 as Morbid Obesity.
Additionally a BMI greater than or equal to 35 with a COMORBID diagnosis of DM, CHF, HTN, Sleep Apnea or
moderate to severe DJD Knees/Hip may be diagnosed as
Morbid Obesity
 Diabetic Neuropathy will no longer risk adjust
AFTER 2013 however, just as with CKD, it is still
important to continue to screen and Dx in patients
since it will support “Diabetes with Neurologic
Manifestation”.
 Stage 1 and 2 PRESSURE ULCERS will not risk
adjust AFTER 2013 but it is obviously important to
be screening for them for early care.
Questions?
Thank you