Wiki HCC/RAF

Create Wiki
S

stephmescher

Networker
Messages
57
Location
Dyersvile, IA
Best answers
0
Hello,
I am really new at the HCC coding and I was wondering if someone could help me out with finding the weight that goes along with the HCC diagnosis code to calculate the RAF score? Example- DM with retinopathy- .123. Is there a table with these numbers listed that I am just overlooking? I have the 2020 HCC model downloaded but that is not giving me the numbers I need. Do I need to calculate these numbers somehow?
Hope this makes sense. Any help is appreciated.
Thanks
Steph
 
I am a new coder and I was wondering when doing HCC coding where do you look to pull codes from
 
Our practice is very conservative. We do not pull from the past medical history or the problem list. The provider must document it in the MDM portion and incorporate why/how it's pertinent to that days visit and meet some level of the MEAT or TEMPAR.

I have worked at other places that will allow you to pull from anywhere in the note.

I would recommend creating a policy within your practice on how you would like to approach it.

I think specialty also matters. We work at a Pain Management clinic and there are times that the provider is only treating the patient's knee pain, or back pain and he may not think that the patient's foot ulcer is pertinent to what he is treating.

As long as they (the provider) not the MA documents it, we bill for it. Again, it's practice specific.
 
I recently listened to an AAPC Risk Adjustment webinar about Risk Adjustment, and one of the main points the presenter discussed was "The amount of Risk your practice/company is willing to take". In terms of audits, CMS will treat you differently if you are a practice or if you are a health plan, however the main rules are the same when it comes to MEAT and TAMPER. As CMS cannot audit 100% everything you submit to them, your policies should be defined accordingly. Would you allow more "gray areas" in order to get more funding, or tighten the restrictions and requirements, but ultimately get paid less.

I work at a health plan and we routinely get audited by CMS. We have been pretty successful in having a stricter than average risk adjustment policies, when it comes to determining what is MEAT and what is TAMPER. This has especially been beneficial when CMS does their "focused" RADV audits on certain HCC ranges (neoplasms, diabetes, CKD, sepsis, etc.). Another example is when documentation shows Atrial Fibrillation, and there is a cardiac ablation repair for that condition. Then on the other hand, we are instructed to look at the whole chart to look for MEAT and TAMPER. I have been able to pick up certain codes from the Problem List, because the way the chart was written supported MEAT.

In my experience. it's a balancing act between strict policies, risk and the amount of funding you get.
 
You must log in or register to reply here.
Top