Risk Adjustment Coding and Reimbursement Guidelines

Format: On-Demand Webinar

Presenter: Amy Bailey, CHC, CPC, COC, CPC-I, CCS-P 

Duration: 60 minutes

Course Description:

The Medicare Advantage (MA) risk adjustment reimbursement program is one of the top compliance risks for healthcare providers. There has been significant enforcement activity from multiple agencies including: the U.S. Department of Justice (DOJ), U.S. Department of Health & Human Services Office of Inspector General (OIG), and the Centers for Medicare & Medicaid Services (CMS). Inspector General Christi Grimm stated earlier this year that risk adjustment coding one of OIG’s top two priorities after identifying $6.5 billion in improper risk-adjusted payments in just one year. In fact, in June 2023, the OIG announced through their Work Plan they will be initiating nationwide audits of risk adjustment coding.

It is important to understand the mechanics of risk adjustment reimbursement to fully appreciate the risks and the source of those risks. CMS makes monthly payments to MA organizations based on the anticipated cost of providing Medicare benefits. These “risk adjustment payments” take into consideration a number of factors including: patient demographics, age, gender, and health status. One of the other main drivers of risk adjustment payments are the diagnosis (ICD-10) codes submitted by providers to the MA plan. Certain ICD-10 diagnosis codes are categorized as HCC conditions and are eligible for increased risk adjustment reimbursement. The accuracy of the ICD-10 information submitted by a healthcare provider has a direct impact on the risk adjustment reimbursement. Submitting ICD-10 codes that are not supported may result in overpayments. Conversely, failure to accurately capture and report conditions that are appropriately documented may result in lost reimbursement to the organization.

In the past, the healthcare provider community has typically considered risk adjustment reimbursement and enforcement thereof as a MA plan responsibility. Providers have not fully appreciated their role and responsibility in assuring accurate payments. However, providers have also been subject to risk adjustment enforcement actions including False Claims Act (FCA) settlements related to their submission of HCC conditions. In fact, one of the largest providers FCA settlements resulted in a $90 million overpayment. The provider was also required to enter into a stringent corporate integrity agreement (CIA) specifically focused on HCC reporting.

Given the current government focus surrounding risk adjustment reimbursement and proper reporting of HCC conditions, coupled with extremely high error rates, there could not be a better time for compliance professionals to add HCC coding to their internal compliance work plan. We will discuss the fundamentals of risk adjustment reimbursement, explore operational considerations, examine recent settlements and enforcement actions, and provide recommendations to achieve success and mitigate compliance risk associated with your HCC program.         

Learning Objectives:

• Understand key concepts of risk adjustment coding
• Review operational considerations and impact of risk adjustment coding
• Examine recent government settlements
• Discuss auditing and monitoring recommendations

Areas Covered in the Session:

• Background of Risk Adjustment Coding
  • Medicare Advantage Payment
  • Risk Adjustment Coding and Hierarchical Condition Coding (HCC)
  • ICD-10, HCC Conditions and Eligibility for Increased Risk Adjustment Payments
  • Increased Reimbursement for Complex Patient Encounters
  • ICD-10 Codes Improper and Missed Reporting Impacts
  • Documentation
  • CMS & OIG Focus on Compliance Risk and Fraud
  • Official ICD-10 Guidelines and Instructions
  • Medicare Advantage Risk Adjustment Data Validation Final Rule
• Operational Considerations & Impact
  • Competing Priorities & Risks
  • Quality of care and malpractice concerns vs. HCC capture
  • Risk of overpayments vs. HCC under-reporting
  • Payer contract risk vs. Cost and Resources
  • EHR Controls and Access Rights vs. Patient Flow
  • Clinical documentation improvement
  • Data analytics
  • Revenue cycle
  • Compliance
  • Physician leadership
• Recent Settlements & Enforcement
  • HCC Coding as an OIG work plan item
    • Multiple HCC audit
  • ICD-10 Codes as “High Risk” for HCC reporting Errors
    • Acute stroke
    • Acute heart attack
    • Embolism
    • Major depressive disorder
    • Vascular claudication
  • Reporting
    • Past medical conditions as current
    • Conditions not documented as definitive diagnoses (e.g., probably, suspected, possible)
    • Conditions which were documented as definitively ruled-out
    • Conditions as “severe” when the documentation specified the condition as “mild"
    • Current conditions for which the documentation did not reflect any active treatment or impact care
    • Conditions not documented in the medical record
• Auditing & Monitoring
  • Routine auditing of risk adjustment coding
  • Conduct documentation and coding reviews of MA beneficiary
  • Conditions flagged as high risk by OIG
  • Documentation criteria to to support the ICD-10 (HCC) reported
  • ICD-10 codes assigned to the highest level of specificity
  • Capturing all conditions during encounter
  • Documented assessment and plan for each presenting problem
  • Required accuracy rates for both documentation and code assignment
  • Defining an Error
  • Results communicated to provider and coders
• Summary & Recommendations
  • Take a critical look at your HCC process
  • Review your documentation and coding policies. Do you have HCC specific policies?
  • Audit for accuracy
  • Compare your audit findings to your MA plan provider reports
  • Educate providers, coding and administrative staff

Suggested Attendees:

• Compliance professionals
• Clinical staff, including physicians, APPs and ancillary staff
• Health information management professionals
• Clinical documentation improvement professionals
• Quality improvement professionals 
• Providers
• Coders
• Clinic managers
• Denial management staff
• Accounts payable staff
• Auditors 
• Office Managers
• Denial resolution teams
• Insurance payers
• Payment policymakers
• Billing Staff
• Coding Staff
• Physician and Non-physician Practitioners
• Insurance Company Claims Reviewers 

About the Presenter:

Amy Bailey, CHC, CPC, COC, CPC-I, CCS-P, has over 25 years of healthcare experience and specializes in regulatory compliance for documentation, coding, medical necessity and billing. Amy has extensive experience working with publicly traded healthcare companies, large hospital systems, law firms and physician group practices. Amy frequently handles routine compliance matters, as well as assists providers subject to allegations of improper billing and also provides IRO services. Amy is certified in healthcare compliance and is also a certified coder for both physician and hospital coding and an approved coding instructor for the American Academy of Professional Coders. She has taken many leadership roles in the industry, including serving as an Auditing and Monitoring Tools Editorial Board Member for the Healthcare Compliance Association and is also a former Regional Governor and Examination Committee Chair of the American College of Medical Coding Specialists. Amy has published articles featured in Compliance Today, Journal of Healthcare Compliance and Health Lawyers Weekly and is a co-author of the American Health Lawyers Compliance Manual. She has also been selected as a speaker for groups including the American Health Lawyers Association, American Academy of Professional Coders, Healthcare Compliance Association, Georgia Hospital Association, Idaho Medical Group Management Association and the Idaho Association of Home Care. 

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