Tag: codng

3 ways health systems can improve care and earn additional income

By Vatica Health | June 10, 2021 | Provider

After an extremely challenging year for healthcare systems, there are now opportunities to improve financial and clinical performance as the country begins to normalize.

In 2020, hospitals and health systems lost at least $323 billion and physicians were stretched to the breaking point. Unfortunately, the burden does not seem to be lightening for primary care physicians. Approximately 40% still feel the same level of strain due to COVID-19 that they felt a year ago. Finding additional ways to generate much-needed revenue, positively impact care, and reengage with patients is more critical now than ever before.

Preventive care services

It’s no secret that patients missed out on preventive care services due to the pandemic. Over the past year, 31% of patients in the United States delayed care and more than 50% of seniors canceled existing appointments. It is imperative to get back on track with preventive and routine care, especially for patients with chronic conditions.

Your physicians and staff should be proactively reaching out to patients, particularly Medicare patients, to schedule appropriate preventive care visits, such as Annual Wellness Visits, immunizations, and various cancer screenings.  Scheduling a preventive care visit is a win-win for the patient and the physician. For the patient, it’s typically a no-cost visit that aids in the early detection and prevention of diseases, reduces the exacerbation of existing chronic conditions, and improves overall health and quality of life. For the physician, it’s a great opportunity to reengage with patients, create new revenue streams, and improve outcomes, which is especially important for improving performance under value-based care arrangements.

Health plan incentives

Health plans are eager to collaborate with physicians to achieve coding and quality of care goals. They need data and insights into their members and are willing to incentivize your organization to get it. Many payers offer programs that are free to your physicians and also pay incentives to capture real-time diagnostic coding that enables them to accurately risk-adjust their members. Some of these programs even help take the burden off of physicians and their staff by partnering with organizations that do the majority of the work, and they simplify the workflow by combining coding with preventive care services such as Annual Wellness Visits.

The timing for this could not be better. There is an emerging trend among health plans to shift from home assessments to PCP-centric prospective programs to better risk-stratify their members and address gaps in care. Given the established relationships patients have with their PCPs, prospective programs are often the most effective method for addressing gaps in care and ensuring alignment between medical record documentation and coding to the highest degree of specificity. Prospective programs permit real-time alerts of previously diagnosed conditions as well as those that are suspected. This ability to impact outcomes at the point of care is powerful.

VBC performance

Value-based care is designed to incentivize providers to improve outcomes in a cost-efficient manner. In other words, payment and quality of care are inextricably linked. The combination of driving higher utilization of key preventive care services and improving the accuracy of coding supercharges value-based care performance.  

Unfortunately, many physicians lack the tools, resources, and experience to thrive in the value-based care model. Diagnostic coding and quality reporting are labor-intensive tasks and are predicated on a complex set of rules. In addition, EMRs are not equipped with all the necessary functionality and may not contain relevant health plan data, which results in an incomplete patient picture and suboptimal outcomes. Fortunately, there are solutions that include computer-assisted diagnostic coding technology, enhanced quality measure reporting, and clinical decision support at the point of care — all of which enable PCPs to improve outcomes and their financial performance under value-based care arrangements.

As we continue to move toward a new normal, physicians are beginning to see more patients for routine in-office visits, making this the perfect opportunity for patients and physicians to start reaping the numerous benefits derived from a refocus on preventive care and partnering with health plans on in-office programs to improve diagnostic coding and documentation.

Unlocking value-based care performance with improved coding and documentation

By Vatica Health | May 24, 2021 | Provider, Risk Adjustment, Value-Based Care

The transition to value-based care is underway, but many PCPs lack the tools, resources, and expertise to thrive in these new arrangements. For physicians, an essential element of success is being able to accurately assess and report a patient’s clinical needs so that value-based payments will align with the necessary care delivered to that individual. Unfortunately, diagnostic coding with appropriate specificity and quality reporting is labor-intensive and is predicated on a complex set of rules, which frequently become a stumbling block for practices.  This dynamic creates a powerful inertia, which can be overcome by understanding the ramifications of inaction and the availability of effective solutions.

Why is documentation so important?

Provider organizations—through their documentation—tell their patients’ stories using the ‘language’ of ICD-10-CM diagnosis codes. Robust documentation and coding provide a comprehensive view of the patient, driving better and more cost-effective care. If documentation is incomplete, patients may not get the necessary care and practices can incur significant shortfalls in revenue.  As a result, high quality coding and documentation is no longer just a good practice, but an indispensable element of value-based care success.  

 The Financial Impact of Accurate Documentation & Code Capture

The example below illustrates how no or partial coding by a physician can result in $15,000 difference in payment under the CMS-HCC model based on whether the provider captures these four diagnoses with maximum specificity: Type 2 diabetes mellitus with a manifestation of stage IV chronic kidney disease, long-term insulin use, and chronic obstructive pulmonary disease.

Improving Coding and Documentation Without Burdening Physicians

According to a 2021 national survey conducted by Medscape that included more than 12,000 physicians across 29 different specialties, 42% of physicians report feeling burned out.

Interestingly, 79% of physicians said this burnout started before the current COVID-19 pandemic with the majority (58%) citing ‘too many bureaucratic tasks’ as the number one reason.  This presents a challenging dilemma as business leaders for health systems and physician practices have to balance the reality of physician burnout with the necessity of improved documentation and coding.

Fortunately, there are solutions that drive improved financial and clinical performance without burdening physicians and their staff. Vatica Health is one example. Vatica takes a physician-centric perspective, focusing on minimizing the amount of time and effort required of physicians. Vatica uses a combination of powerful technology along with clinical and administrative resources dedicated to practices.  Organizations participating in Vatica’s program realize incremental revenue, better outcomes, increases in the utilization of preventive health encounters (e.g., Annual Wellness Visits), and improvement in overall performance in value-based care arrangements.

Learn how to maximize revenue and results for your organization

Documentation, coding, and revenue: What every physician needs to know about HCCs and risk adjustment

By Vatica Health | March 31, 2021 | Provider, Risk Adjustment

Every patient has a story. The question is, are you—as the provider—telling the most important aspects of it, or are you missing critical details? We’re talking about the details that affect the patient’s health status and predict the resources required to care for them—two pieces of information that play a critical role in risk-adjusted payment models. Here are five questions and answers to consider.

Why does provider documentation matter for risk adjustment?

The provider—through their documentation—tells the patient’s story using the ‘language’ of ICD-10-CM diagnosis codes. Together, these codes create a narrative that includes important diagnostic information. When combined with demographic data and other details, the patient’s health status becomes clearer. Without this narrative, the story is disjointed, confusing, or lost completely. Health plans, CMS, and other treating providers can’t connect the dots when there are only a few dots to connect, or worse yet, a blank page.

If your documentation doesn’t support the ICD-10-CM codes you’ve assigned—or you omit certain codes because no documentation exists—your revenue under value-based contracts could suffer. 

Why does coding matter for risk adjustment?

If your coded data indicates subpar performance or that you haven’t met certain performance thresholds, you could be missing out on revenue. Inadequate coding (i.e., missing codes or lack of specificity) also often leads to time-consuming onerous retrospective chart retrieval and reviews as well as compliance risks.

For patients, lack of appropriate ICD-10-CM diagnosis codes can result in poor coordination of care. This is true under all payment models—not just risk-adjusted ones. That’s because documentation and coding are the primary means of communication between care teams. In addition, patients may be omitted from beneficial care management, disease intervention, and other wellness programs if the coded data associated with their records is inaccurate or incomplete. Strong documentation, combined with appropriate ICD-10-CM coding, provides a comprehensive view of the patient. This ultimately helps control the cost of care.

For the purposes of this article, we’ll focus on the Centers for Medicare & Medicaid Services’ (CMS) risk adjustment model.

Not every ICD-10-CM diagnosis code affects risk adjustment under the CMS model. That’s because this payment model excludes diagnoses that are vague/nonspecific (e.g., symptoms), discretionary in medical treatment or coding (e.g., osteoarthritis), not medically significant (e.g., muscle strain), or transitory/definitively treated (e.g., appendicitis).

In the CMS model, those conditions that do affect risk adjustment (which are roughly 10,000 out of 70,000+ diagnoses) are grouped into approximately 1,300 diagnostic groups (DXG) that are then aggregated into condition categories (CC). CCs are related clinically and with respect to cost. Hierarchies are imposed among related condition categories. This mean that a patient is coded for only the most severe manifestation among related diseases. Hence the term ‘hierarchical condition categories’ or HCC. HCCs accumulate among unrelated diseases, and the model accounts for interactions between certain conditions for which costs can be exacerbated, (e.g., diabetes and congestive heart failure).

HCCs paint a complete picture of each beneficiary’s acuity to ensure appropriate and accurate reimbursements, effectively managing costs for high-risk members and delivering high-quality care.

Check out the example below that illustrates a $15,000 difference in payment under the CMS-HCC model based on whether the provider captures these four diagnoses with maximum specificity: Type 2 diabetes mellitus with a manifestation of stage IV chronic kidney disease, long-term insulin use, and chronic obstructive pulmonary disease.

Impact of Accurate Documentation & Code Capture

What are some documentation and coding best practices for busy physicians?

Consider these tips:

  1. Perform a valid face-to-face encounter. As a result of the ongoing impact of the COVID-19 pandemic, synchronous audio and video appointments are, for the time being, acceptable for the purposes of risk adjustment.  
  2. Use the ‘MEAT’ acronym as a best practice guide for documentation:
    • Monitor: Document signs and symptoms as well as any disease progression or regression. Don’t forget to evaluate chronic conditions at least once annually. Also, avoid use of ‘history of’ if the condition remains active.
    • Evaluate: For example, document test results, medication effectiveness, and response to treatment.
    • Assess: For example document any of the following, when relevant: Ordering of tests, discussion, reviewing records, and counseling. Copying and pasting the entire problem list into the assessment and plan is unacceptable.
    • Treat: For example, document any medications ordered, therapies, or other modalities.
  3. Link diagnoses with manifestations using a linking statement or other document.
  4. Add all diagnosed conditions to both the chronic problem list and assessment.
  5. Submit all relevant ICD-10 diagnosis codes, including Z codes.
  6. Ensure the medical record includes a legible signature with name, date, and credentials.
  7. Ensure the diagnoses being billed match the actual medical record documentation.
  8. Always remember the golden rule of medical record documentation: If it’s not documented, it didn’t happen.

How can physicians minimize compliance risk and benefit from risk-adjustment programs?

One way to minimize risk and to actually increase revenue is to participate in a health plan-sponsored risk adjustment program that helps providers tell the patient’s story as accurately and completely as possible—all while minimizing the impact on staff and internal processes.