FIFTY SHADES OF HCC’S – LOOKING INSIDE THE RISK ADJUSTMENT “RED ROOM AND HOW THE DAWN OF ICD 10 WILL CHANGE THE GAME” — by Holly Cassano, CPC, CRC, ICD-10-CM Certified CEO FORENSIC HEALTHCARE Partners
Here we all sit, poised for what October 1st, 2015 will bring, with a variance of emotions, ranging from anticipation and excitement for some and sheer panic and terror for the rest, on the eve of what is going to be either the US Healthcare Apocalypse or the Greatest Moment in US Healthcare history, depending on how each person or entity has prepared for the “Dawning of ICD 10”. I can hear the opening music to 2001, A Space Odyssey now and then I can see the image of early man beating his chest and then watching life unfold in triumph, or tragedy, as the human race evolved. Healthcare is on the brink of the same idyllic moment and ICD 10, will be the absolute game changer for all of us in healthcare today.
FACT: 1 IN 4 MEDICAL PRACTICES WILL CLOSE IN THE FIRST YEAR OF ICD 10, DUE TO INABILITY TO MAINTAIN CASH FLOW
Will your practice be able to survive if one to three of your top ten payers, pends all your claims for documentation requests for one to six months? That is the question that everyone should be asking themselves now, if you haven’t already.
So, with all of the apocalyptic warnings out there, I thought to myself, let me pair this with one of the years most anticipated and top box office grossers, Fifty Shades of Grey and mix the rising popularity of Risk Adjustment and HCC’s and see how it all will shake out in 2016. Too much to handle, I say “go big or go home” because ICD 10 and Risk Adjustment, are where the US Healthcare industry is trending for the future in both Medicare and Commercial lines of service.
I don’t know about you, but this past year seems to be “The Year of Introduction to Risk Adjustment, for many folks in healthcare, even though it has been in existence since the days of Medicare Plus Choice (remember that?). I feel like I should say “to infinity and beyond”, when I talk about the beginnings of Risk Adjustment these days, as many people are under the impression that it has only been around for about five years or so.
MY INTRODUCTION TO RISK ADJUSTMENT – THE FIRST SHADE OF GREY
CMS made the decision to dissolve the Medicare Plus Choice program and to emerge anew, with the Risk Adjustment program, about a decade ago, 2006. My first foray into Risk Adjustment really was in early 2010, when a friend of mine started doing some moonlighting from her day job at Cleveland Clinic Florida, where we both worked in the RCM department and she stated working on MRA coding/auditing.
She would run things by me from time to time for a second opinion on the work she was submitting to the company she was working for and it was pretty interesting to me. So when I moved to Central Florida, five years ago, it made sense to go work for a Medicare Advantage Plan to me, so I could learn firsthand, more about this seemingly new area of healthcare.
So I did exactly that and started working as a Field Clinical Documentation Improvement Representative for my MA Plan, February, 2011.
My first day of training in Miami, had me being handed the 2008 CMS Risk Adjustment Participants Guide (RAPS), and being told to “familiarize myself with it, as this was my new bible”. I listened thankfully and poured over the somewhat large publication.
It was pretty much trial by fire after two days of quasi-training in Miami and then I was cut loose in Central Florida to try to work some magic with the Plan’s ever lowering Risk Adjustment Factor scores (RAF) and network of providers in that area. For about 9 months I was the only Certified Coder in my area and quickly learned that face to face provider communication, would be my best course of action and work on improving RAF scores in the area, for starters.
ON FIRE AND UNINHIBITED – SHADES OF GREY, 2 – 40
So, over the past four years, I have honed my skills as a SME and have written on the topic and presented at national conferences on the topic and even authored with other SME’s, a course in Risk Adjustment. It is one of the areas of healthcare that people know me for. It has allowed me to work with many fine individuals, some colleagues of mine and allowed me to really spread my wings and fly in this field. I am very thankful for all those opportunities. So, when I was approached by the AAPC to see if I was interested on being a part of the Steering Committee to help them develop the new Risk Adjustment Credential, The CRC, I was all in. I was one of about seven other SME’s in Risk Adjustment that participated on the board, over the course of about four months.
It was while I was on that committee that it occurred to me, there are quite a few differences of opinions on Risk Adjustment Compliance and Best Practices and which Model of Risk Adjustment, is most frequently in use around the country.
I suddenly felt like maybe I didn’t understand Risk Adjustment completely and that my go to SME’s like Stacey Hernandez of SCAN Health Plan in California and Kameron Gifford of Empirical Risk Management (ERM), Hewitt Moten (great man and SME, whom the industry lost earlier this year), Alicia Scott of CCO and of course my 2008 CMS RAPS Bible, were also off track in this area.
There are quite a few other SME’s in Risk Adjustment, but it just felt like my familiar CMS HCC Model was less important in the overall landscape of things and that other Risk Adjustment Models, had moved to the front of the line.
APPROACHING THE RED ROOM – SHADES OF GREY, 40-49
As 2015 came in with a roar, I knew this year would be a game changer for many like myself in all areas of healthcare, but especially Risk Adjustment. ICD 10, is the new player in everyone’s game and will be no stranger to Risk Adjustment.
Some may ask why and I say, well, first of all, what is the core centric that Risk Adjustment is based on? The answer of course is Chronic Disease Management, which is based on capturing those diagnosis codes that encompass those Chronic Diseases, get the picture? ICD 10CM, in particular, will change the landscape for those in the Risk Adjustment game and hopefully, you have been more of the “Ant” character, versus the “Cricket” character in this scenario and are well prepared.
If you are more of the “Cricket” in this changing landscape, you had best get on board with the rest of us and sync up to stay in the game. I think there are many of the “Cricket” types in certain Risk Adjustment groups on social media, Facebook, Linkedin, Twitter, who truly don’t understand what is at stake, nor do they understand what is coming from CMS and commercial payers over the next few years.
These social media forums that cater to “newbie Risk Adjustment coders” are fraught with misinformation and on any given day you can find numerous “chats” where people don’t just have a difference of opinion and each person can refer back to their source documents and move on. I am talking about folks who misquote the RAPS Guidelines, folks who didn’t even know about the RAPS Guidelines, folks who misquote RADV Guidelines, folks who guess at how the AHA meant a code to be interpreted, negative chatter about both the AAPC and AHIMA and actual professionals who work for both of these governing bodies for the coding industry and on and on. These folks are the future of the healthcare system and who will take the providers through ICD 10 and beyond? Quite frankly, it is disheartening to me and some of my colleagues. These same individuals slam the AAPC and AHIMA, based on misinformation and hold an attitude of contempt for others in the field, who try to offer the right course of action or answer.
Bearing witness to all of this ongoing, has led me to develop what I like to call “THE RISK ADJUSTMENT F.S.G.R.R. (FIFTY SHADES OF GRAY – RED ROOM), RULES”, which I feel are necessary to adopt, in order to become and remain a successful and respected Risk Adjustment Coding Professional – they are as follows:
THE F.S.G.R.R. TOP TEN
- RESPECT YOUR COLLEAGUES AT ALL TIMES
- RESPECT YOUR PROVIDERS AT ALL TIMES
- EVERYONE IS ENTITLED TO AN OPINION, REMEMBER HUMILITY
- THERE IS NO CRYING IN RISK ADJUSTMENT, ICD 10 OR CODING/AUDITING
- THERE IS NO “I” IN ANY OF THE ABOVE, EXCEPT “INTEGRITY”
- THE TEAM APPROACH IS THE ROAD TO SUCCESS
- THERE IS NO ONE SME IN RISK ADJUSTMENT, THERE ARE MANY
- THE CMS HCC MODEL IS THE MAIN MODEL OF RISK ADJUSTMENT, THAT IS UTILIZED IN THE INDUSTRY, FOLLOWED BY – (NOT RANKED) CMS RxHCC Model. The 2015 payment year will continue to use the RxHCC model (33 HCCs6) used in 2014. CDPS (13 states), Medicaid Rx (4), Adjusted Clinical Groups (ACG) (3). The CDPS model is updated annually across 58 categories. Although CDPS and HCCs are different models, their structure is similar. PACE/ESRD, Individual/Small Group Marketplace.
- EDUCATE, FOSTER AND PROMOTE POSITIVITY, PROFESSIONALLY AND PERSONALLY, IN ORDER TO GROW WITH THE INDUSTRY
- ADMITTING “IT” IS THE FIRST STEP IN THE RIGHT DIRECTION
ICD 10 Certification — ICD 10 CM Proficiency Exam – VIDEO
THE FIFTIETH SHADE OF GREY
Well, if you made it this far, you are definitely in line with the “ant” mentality and you will thrive as we move forward with ICD 10 and Risk Adjustment. CMS/HHS has announced that over the next three to five years, the program will shift from Fee For Service (FFS), to Fee For Value (FFV). This is right in line with Risk Adjustment, Population Health Management, Patient Centered Medical Homes and bringing up the rear, our new friend, ICD 10!
2015 is a year that allows us to ring in two New Year’s Eve’s – the usual on 12/31/2015 and the earlier, 10/1/2015. This is truly the “dawning of the age of Aquarius” for Healthcare in the US. Risk Adjustment is a part of all this and goes hand in hand with ICD 10, in essence a perfect marriage. They both target the ongoing management of Chronic Disease Processes in certain demographics, with the overall goal of achieving better outcomes, reducing costs, allowing plans to offer better benefits and ensuring a healthier aging population, that is proactive and living longer, and stronger, not longer and impaired, draining their savings and the healthcare system.
I will leave you with the following thought, that I am sure Mr. Grey would approve of – The Key to ICD 10 and Risk Adjustment for providers and coders is to remember, “It is the quality, not the quantity of documentation, that satisfies the need for care and supports medical necessity” .
Good Luck to all in 2016 and remember, Kubrick’s theme music for 2001, was taken from a poem written in 1896, by Richard Strauss, entitled “ Also Sprach Zarathustra”, or “Thus Spoke Zarathustra” and the initial “fanfare” of this classical work of genius, is entitled “SUNRISE”, a fitting title and representative of where we are all poised on ICD 10 Eve. We are waiting for the sun to rise on the dawn of an age in Healthcare, that I feel, we are lucky to witness and with which we will most likely not experience again to this magnitude.
As always, stay compliant and code on!
Holly Cassano, CPC, CRC, ICD 10 CM Certified
CEO of FORENSIC HEALTHCARE Partners f/k/a/ ACCUCODE Consulting LLC
If you are looking to become a Certified Risk Adjustment Coder (CRC), please visit the AAPC’s website for information on sitting for the exam.
If you are looking to take a course in Risk Adjustment, I suggest any of the following curriculums: