Transcript Humana Medical Risk Adjustment Presentation

MRA Overview
Yasmin
McLaughlin,CPC
SER Manager
For internal use only
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What is MRA?
• The Medicare Risk Adjustment payment system uses clinical
coding information (HCCs) to calculate risk premiums for
Medicare Advantage plans enrollees
• MRA activity is the key process to ensure accurate payment
from CMS for Humana Medicare Advantage enrollees based
on the CMS-HCC payment model
• The primary focus of the MRA department is to obtain
accurate healthcare information from providers in order to
maintain accurate payment levels through chart reviews and
provider education
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Humana’s MRA Team
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Market Team’s work with Providers
• Review Medical Records
• Provide feedback to providers regarding
documentation.
• Coding Seminars are conducted to help
practices in their coding efforts.
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Providers must be engaged in MRA
Goal = Properly Reflect the Member’s Health Status
• Fully Assess All Chronic Conditions
…every six months
• Thoroughly Document in the Chart ALL conditions evaluated
each visit
• Code to the Highest Level of Specificity (fully utilize the ICD-9
Diagnosis Coding System)
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Ok, I understand the elements…
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Medicare’s guidelines state:
“Code all documented conditions which coexist at the time of the visit that require or
affect patient care or treatment”
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Best Practices for Excellent Documentation
Document at least once a year:
 Chronic Conditions (CHF, COPD, DM)
 Active Status conditions (amputations, colostomy)
 Pertinent past conditions (Old MI)
 All conditions that require medication
 Conditions that affect the patient’s day to day life.
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Best Practices for Excellent Documentation
BE SPECIFIC
(when applicable)
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“Major Depression”, not “depression”
“Chronic bronchitis”, not “bronchitis”
“Atrial Fibrillation”, not “cardiac dysrhythmia”
“Malnutrition”, not “loss of weight”
“History of MI”, not “CAD”
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Documentation
• Be complete and legible—it has to be readable to someone else.
• Include patient name, DOB and date of service on every page.
• Note chief complaint (CC), reason for visit, assessment, and plan
of care.
• Specify basis for ordering ancillary/diagnostic services
• Indicate appropriate health risk factors.
• Indicate past and present diagnoses if still of any medical
significance.
• Show patient’s progress or lack of progress.
• Substantiate service rendered.
• Sign the progress note with full name and credentials.
• Problem list should be up-to-date and include onset AND end
dates.
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Documentation Tips
• Always document the status of each diagnosis
using specific and descriptive words to document
the problem.
• Use the word history to mean that the condition
no longer exists, not the medical history of the
patient includes these conditions.
• All medications listed should have the reason
they are taking it listed also.
• Always use an approved abbreviations list!
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“Why is thorough and specific documentation so
important?”
If it isn’t documented, it hasn’t been
done.
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Medicare
Risk Adjustment
 Wrap Up
 Questions
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