For questions, contact Mike at Mike@EnosMedicalCoding.com
For deposits, mail
ATTN: Mike Enos
Enos Medical Coding
22 Ferncliff Avenue
Warwick, RI 02886
REGISTER HERE
Enos Medical Coding is proud to announce that we have opened enrollment for Fall 2019 Professional Medical Coding Curriculum (PMCC.) Mike Enos is an AAPC certified instructor. Don't miss your opportunity to gain a first-hand understanding of the business of medicine, medical and surgical coding, pathology & laboratory coding, radiology coding, and more. In addition to live lectures and homework (including textbook reading and workbook activities) students will have practices quizzes and 2 practice exams to prepare them for certification. Take the next step in your career! Register today! (Note that your spot will not be reserved unless we receive at least your $500 deposit. The balance can be either mailed, brought to class and paid via check, or paid online via credit card or paypal.)
For questions, contact Mike at Mike@EnosMedicalCoding.com For deposits, mail ATTN: Mike Enos Enos Medical Coding 22 Ferncliff Avenue Warwick, RI 02886 REGISTER HERE With ICD-10-CM comes a new dawn in physician documentation and a much more transparent clinical footprint. Government payers, insurers, hospitals, health systems, medical groups and others will use ICD-10’s granular data to determine accurate, fair physician compensation and reimbursement. Diagnosis Coding is Vital to Fair Provider Compensation. Medical groups are signing payer contracts that adjust payment for a contract year based on quality measures, outcomes, utilization and the acuity of care for a patient population. The payor measures acuity of care by reviewing the patient’s age, gender and medical conditions. Where does the payor get the list of medical conditions? Diagnosis codes on claims! Medicare Advantage Plans base incentive payment on Risk Adjustment Factor (RAF) Scores. Diagnosis Coding is Vital to Fair Funding to Insurance Plans. The purpose of a Risk Adjustment model is to predict the future health care costs for enrollees in Medicare Advantage plans. CMS is then able to provide capitation payments to these plans. Additional funding to the plans in the form of Capitation payments help the health plans to enroll not only healthier individuals but those with chronic conditions or who are more seriously ill. HHS Payment Goals are to help drive the health care system towards greater value-based purchasing. Rather than continuing to reward volume regardless of quality of care delivered CMS is focused in improving outcomes and reducing cost. Alternative payment models include Accountable Care Organizations (ACOs), bundled payments, and advanced primary care medical homes. Specifically, they want to:
Under MACRA (Medicare Access and Chip Reauthorization Act) there is a merge of previously introduced payment incentive programs, including:
Hierarchical Condition Category Model (HCC) affects Medicare Advantage Plans (aka Medicare Part C) which have been paid under an HCC model since 2004. HCC is a risk adjustment model which identifies patients with serious acute or chronic illnesses and assigns a risk factor score to the beneficiary based on the patient’s demographics and medical history. The government contracts with for-profit insurers to manage health care for these patients, and pays insurers a yearly fee for each member they enroll. The higher the risk score, the higher the annual fee. Hierarchical Condition Category Model (HCC) Calculations Each patient is assigned a Risk Adjustment Factor (RAF) score. RAF scores are based on:
How does HCC Affect Payment? RAF scores are additive. All qualifying diagnoses are included in the RAF score. Risk factors are added to achieve total RAF scores for each patient. RAF scores are predictive, and ICD-10 codes reported this year determine payments for next year. Remember, the payment for the RAF score is from CMS to the Medicare Advantage Plan. Then Plan distributes the incentive bonus to all providers participating in the care of the patient. This payment is in addition to the contractual fee-for-service payments and is paid annually. It is important to remember that the health status is re-determined each year, therefore codes must be submitted every year to be counted. Past data is not carried forward, and the RAF for each patient is reset every year. Also, payment is made per HCC category (not per diagnosis code). A patient with 4 ICD-10 codes from category E11 for Type II Diabetes Mellitus with complications will only receive credit once for complicated Diabetes Mellitus (HCC 18), and not 4 times that value in the RAF score. How to Achieve Accurate RAF Payment The Annual Health Assessment is very important. Consider implementing a program to have a staff member call all Medicare Advantage members to schedule their Annual Wellness Visit and be sure the Risk Assessment, required screenings, and status of all chronic conditions is addressed and documented to qualify as a “reportable” diagnosis. The claim should include accurate and specific diagnosis coding. Example of How Diagnosis Codes Affect Payment A patient is seen in your office. Patient is a 64-year-old disabled female. She has Type II diabetes and Diabetic Chronic Kidney Disease. The patient also has congestive heart failure and Stage IV CKD (GFR 24 ml/min Filtration). The patient is obese with a BMI of 56, is on insulin and is paraplegic. (see table) Common HCC Categories Chronic Kidney Disease Diabetes Mellitus Hypertension Peripheral Arterial Disease (PAD) Major Depressive Disorders Stroke and Late effects of prior Stroke Chronic Conditions History of Heart Attack Renal Dialysis Status Tracheostomy Status Respirator Dependence Lower Limb Amputee Organ Transplant Status Asymptomatic HIV Status Protein Calorie Malnutrition Alcohol Dependence & Drug Dependence What supports coding for HCC? Use Current ICD-10 Codes. Effective October 1, 2017 the Centers for Medicare & Medicaid Services (CMS) and the Centers for Disease Control and Prevention (CDC) added or updated approximately 620 diagnosis codes in the 2018 ICD-10-CM coding classification.
ICD-10-CM and Documentation – Use the MEAT Acronym. A condition is reportable when the condition was Monitored, Evaluated, Assessed or Treated. Do not report a diagnosis code that was not addressed during the encounter or documented in the note. Our auditors have found errors when the main note does not mention a problem, but ancillary documentation such as medication lists and referrals contains orders for those conditions. The medication list may include Prednisone 5mb PO daily for asthma, but asthma is not mentioned in the history, exam or assessment portion of the note. Referrals for consultations and tests can be found in the note (Ex: chest x-ray confirms pneumonia) without mentioning pneumonia in the assessment portion of the note. Steps to take in your Practice: Identify HCC Categories that are clinically meaningful. What chronic diseases do your sickest patients have? The HCC diagnosis categories are well defined. Meet with your clinicians and decide which specific diseases/conditions are common. The ICD-10 codes are grouped to each HCC category. There are more than 9,000 ICD-10-CM codes map to 79 HCCs in the current risk adjustment model. Diagnosis codes are excluded from mapping when they do not predict future cost or are vague or variable in diagnosis, coding or treatment. An example is symptom codes or osteoarthritis. Risk Adjustment Data Validation (RADV) are a reality when participating in an incentive program. CMS audits Medicare Advantage (MA) plans for accuracy of risk-adjustment payments and compares accuracy of coding to medical record. Medicare Advantage (MA) plans can be audited annually. MA plans audit provider records to ensure compliance. If you are selected, you will be required to submit medical records to substantiate coding. Audits may include the entire note to verify that it supports the level of service billed, medical necessity, and all codes reported. Common errors from RADV audits show that electronic medical record was not authenticated, or medical record does not have legible signature or appropriate credentials Parting Thoughts. Does your practice have a compliance program? Make it stronger by Including risk adjustment audits to validate clinical documentation. Use audit results to provide education to all clinicians and coders, and continue to audit CPT coding documentation. Continue to monitor patient visits to ensure annual reporting. Make 2018 your year to become a certified professional coder! Enos Medical Coding is happy to announce the dates for our next live CPC course. The course will run from February 10th to May 5th, and students will sit for the CPC exam on May 12th. Be one of them! Seats are limited, so visit the Education page to register and make sure you get your seat reserved. Classes will be held in the Trowbridge Building at Kent County Hospital, and free parking is available in the lot. If you have any questions, contact Mike@EnosMedicalCoding.com UPDATE: The Fall CPC course is now SOLD OUT. Thanks for all your interest! We will update the site again with our new course offerings; both live classroom training and online eLearning modules will be made available in the near future. Check back soon! The Fall Professional Medical Coding Course has been scheduled at Kent Hospital and will begin on Saturday, September 9th with a Preview Workshop to prepare students for success! The CPC exam will be proctored on Saturday December 16th. The course will be held in classroom 4B of the Trowbridge Building at Kent Hospital on Tollgate Road in Warwick, RI. Classes begin at 8am and end at 1pm. Tuition is $2,000 and includes the Course, AAPC Textbook, AAPC Membership fee and CPC Exam (2 opportunities to take the exam). A deposit of $500 is required for registration and the balance is due on or before the first day of class. CLICK HERE TO REGISTER Advance your career and attain CPC Certification. The course will cover subjects including CPT, ICD-10, HCPCS, Compliance, the Business of Medicine, Anatomy and Medical Terminology. Click on the "Education" tab for more information and to register. TRENTON, NJ—A physician who was the owner and founder of Visiting Physicians of South Jersey—a Hammonton, New Jersey provider of home-based physician services for seniors—pleaded guilty today for charging lengthy visits to elderly patients that they did not receive, U.S. Attorney Paul J. Fishman announced. Lori Reaves, 52, of Waterford Works, New Jersey, entered her guilty plea to an information charging her with one count of health care fraud before U.S. District Judge Freda L. Wolfson in Trenton federal court. During her guilty plea, Reaves admitted lying in Medicare billings about the amount of face-to-face time she spent with patients, which led to her receiving at least $511,068 in criminal profits. Reaves was the highest-billing home care provider among the more than 24,000 doctors in New Jersey from January 1, 2008 through October 14, 2011, according to court documents. “Today, Lori Reaves, a South Jersey physician, admitted intentionally overbilling Medicare and pocketing more than half a million dollars she didn’t earn,” U.S. Attorney Fishman said. “The Medicare system depends on doctors and other medical professionals truthfully billing for services they actually provide. Here, Dr. Reaves chose to lie about the major service she was providing to her homebound, elderly patients: her time.” ----------------------------------------------- Reaves routinely billed Medicare using codes that would have required her—under Medicare regulations and depending on the corresponding service—to spend between 60 and 150 minutes with a patient. Many of the claims Reaves submitted would have required her to spend a minimum of two-and-a-half hours of face-to-face time with her elderly clients, when she actually spent far less. As a result, Medicare reimbursed Reaves more than $511,068 for the fraudulent prolonged service visits Reaves claimed to have made. Reaves faces a maximum potential penalty of 10 years in prison and a fine of the greatest of $250,000 or twice the gross gain or loss caused by her offense. She will also be required to forfeit the proceeds of her crime. Sentencing is currently scheduled for July 13, 2013. Read the rest of the press release at FBI.gov |
AuthorMike and Nancy are independent consultants and coding educators. They are a mother/son team who are active in local and regional professional organizations. Archives
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