Wiki Seeking Regs Against Incentiving Coding for Risk Adjustment

[vazquecj]

Hello All,
I am anxiously searching for regulations detailing the need to avoid incentivizing vendors who are assigning ICD-9 codes; to find HCC-triggers for Risk Adjustment. Said differently, I have come across a situation where a vendor charges for every identification of a revenue-triggering diagnosis in the charts.
I can't place the source, but I remember reading that vendors cannot be incentivized by codes like these and must treat them all the same less they begin to mis-code for the sake of revenue enhancement.

Thanks for anyone and everyone's help.
-Vazquecj

 

[ajs]

Hello All,
I am anxiously searching for regulations detailing the need to avoid incentivizing vendors who are assigning ICD-9 codes; to find HCC-triggers for Risk Adjustment. Said differently, I have come across a situation where a vendor charges for every identification of a revenue-triggering diagnosis in the charts.
I can't place the source, but I remember reading that vendors cannot be incentivized by codes like these and must treat them all the same less they begin to mis-code for the sake of revenue enhancement.

Thanks for anyone and everyone's help.
-Vazquecj

I have not seen an actual regulation regarding this, but the CMS guideline for risk adjustment is that any chronic or acute condition that qualifies under the HCC codes must be documented and evalutated at least one time each year to be included for risk adjustment. CMS clears out all the codes on the MedAdvantage patients risk adjustment at the beginning of every year, so in order to count those codes for the new year and get the proper risk adjustment, we teach the physicians to briefly evaluate each condition.

Example: patient had an MI (myocardial infarction) in 2000. The physician in the course of evaluting the heart on this patient would document "old MI stable now no new symptoms" and assign dx code 412 which risk adjusts under HCC category code 83.

The Medicare Advantage plans receive money from CMS to pay claims to their contracted physicians based on the total RAF (risk adjustment factor) scores of all the patients in their plan. The more chronic or acute conditions a patient has, the higher the RAF score which means more dollars available to pay the doctors for treating the patients. We do not get any incentive from this, just money to pay physicians, usually at a higher rate than they would get from traditional Medicare. Hopefully this will keep fewer physicians from dropping out of Medicare altogether!