CMS-HCC risk adjustment model

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THE HCCS OF HCCS 
United Healthcare, organized and implemented a
company wide upcoding scheme, which United called
Project 7.
United implemented it as an attempt to
significantly improve its overall operating
income by close to 100 million
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PRIMARY CARE AND DONT CARE WHY YOU SHOULD
Lets say you are a Primary Care Doctor, with a
few providers in your practice.  You participate
in several MA Plans and you receive a letter with
a list of your patients from the MA Plan asking
you to verify some conditions/diagnoses that
their coders/auditors/software, etc., noticed
might be current Chronic Conditions.
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RISK ADJUSTMENT REIMBURSEMENT DATA DRIVEN
The HCC codes must be captured every 12 months
for CMS to reimburse the MA plan, and if the HCC
codes are captured outside of that scope of 12
months (for example, 12 months and 4 days), it
will then generate a 6-month revenue gap for that
MA plan
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DATA AND ME THE PROVIDER
Good documentation begins at the time of the
patients face-to-face encounter with the
physician.
It means the physician documents the clinical
findings in the medical record, and the medical
record is used to determine ICD-10-CM codes.
The pertinent information from the patient
encounter is submitted to the MA organization for
payment.
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THE RA GUIDING PRINCIPLE AND YOUR MEDICAL RECORDS
Coded according to the ICD-10-CM Guidelines for
Coding and Reporting assigned based on dates of
service within the data collection period.
Submitted to the MA organization from an
appropriate risk adjustment provider type and an
appropriate risk adjustment physician data source
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THE WHO/WHAT/WHEN OF
MEAT    Was the condition Monitored, Evaluated,
Assessed or Treated?
MONITORSigns, Symptoms, Disease Progression,
Disease Regression
EVALUATETest Results, Medication Effectiveness,
Response To Treatment
ASSESS/ADDRESSOrdering Tests, Discussion, Review
Records, Counseling
TREATMedications, Therapies, Other Modalities
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TOP TEN RADV DOCUMENTATION FAILS
Failing to capture HCCs at least once every 12
months.
Failure to ensure the medical record contains a
legible signature with credential. For example,
determine whether such as the electronic health
record was unauthenticated (not electronically
signed).
Failure to ensure the diagnosis codes being
billed and the actual medical record
documentation match.
Failure to document according to the M.E.A.T.
principles. Diagnoses need to be monitored,
evaluated, assessed/addressed, and treated.
Failing to annually document status Z codes and
chronic conditions.
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Failing to use a linking statement or document a
causal relationship for manifestation codes.
Failing to add any diagnosed HCCs or RxHCCs
(prescription drug HCCs) to both the chronic
problem list and the acute assessment.
Failing to evaluate each of the HCCs/RxHCCs on a
semiannual basis for updates.
Failing to review all specialist documentation
related to cardiology, master discharge
summaries, radiology, specialty correspondence,
pulmonary, echocardiograms, and x-rays,
laboratory results, and previous encounters.
Failing to submit more than the standard four
ICD-10-CM codes (CMS allows up to 12, check with
your EMR and clearinghouses on what they can
accept)
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