Attendees spend two days learning about risk adjustment in a value-based healthcare system.
Following Day 1 of Riskcon, Day 2 of AAPC’s two-day boutique conference convened virtually with medical billers, coders, auditors, and other healthcare business professionals — all eager to learn how to take the risk out of risk adjustment.
The first challenge was to learn the lingo! There were acronyms being thrown out every which way: VBC, SDOH, RADV, HCC, and many more. What do these acronyms stand for and what do they mean? Attendees came out of this conference with answers and a clear path for where to take their newfound education.
It’s All About Population Health
The day began with a “Population Health Panel” hosted by Marianne Durling, MHA, RHIA, CCS, CDIP, CPC, CPCO, CIC, AAPC Approved Instructor, and Amy Pritchett, CPC, CDEO, CPMA, CRC, CPC-I, CANPC, CASCC, CEDC, AAPC Fellow. Social determinants of health (SDOH) — and the new ICD-10-CM codes releasing October 1 — were a main topic of discussion during this session.
Capturing SDOH on the medical claim paints a clear picture of patients. In the medical record “I look for homelessness, under-dosing due to financial hardship, English as a second language, elderly living alone, and so on,” said Pritchett, senior consultant at Pinnacle.
How Do We Code Social Determinants of Health?
Kathleen Tierny, CPC, CPC-P, CPMA, CRC, CPC-I, CEDC, CEMC, CGSC, COGC, CBCS, CMAA, CICS, CHI, CEHRS, CPhT, answered that question in detail in her session, “Successful Capture and Coding of Social Determinants of Health.” SDOH, Tierney explained, cover the conditions in which people live, work, and play. It includes environmental conditions like food, transportation, housing, social support, exposure to violence, employment, education and literacy, legal circumstances, and exposure to risk factors like dust, radiation, and toxic agents.
All of these things can create health disparities — the difference in health status between different populations — and cost an estimated $93 billion in excess medical care costs and $42 billion in lost productivity per year. The current COVID-19 pandemic is only exacerbating this situation, Tierney noted.
This is all the more reasons to collect SDOH data, which practices can capture in a variety of ways, including using screening tools such as PRAPARE, the AAFP form, the AHC-HRSN form (CMS), or even a practice-specific tool. The data is then added to the medical record and captured with the relevant ICD-10-CM codes (Z55-Z56).
Practices can use the data to build resources addressing specific local SDOH issues, while health systems can use it to identify specific social needs of their populations to provide better medical care. And under the Medicare Advantage risk adjustment model, the Centers for Medicare & Medicaid Services (CMS) compensate payers for covering dual Medicare and Medicaid enrollees with chronic conditions and SDOH.
Problems capturing the data may be great, however. Patients are reluctant to divulge deeply personal information, and they can be dishonest about it for various reasons. Providers, too, may be reluctant to spend time capturing the information. And on a larger level, there are limited guidelines on how to gather and release SDOH data.
Perhaps that’s why more than 500 attendees chose to attend the afternoon session “Provider Engagement and Education” by Sherrie Anderson, CPC, CPPM, CRC, CPC-I, AAPC Fellow, on the most effective ways of communicating with providers on documentation best practices. She began by explaining the importance of engagement, challenges faced, and strategies to employ. Anderson highlighted the many benefits of engagement, which include enhanced patient care, better quality, higher efficiency, lower costs, and increased retention, to name a few.
Communication is key to building trusting relationships with providers, she explained, pointing out that she finds face-to-face interactions to be more productive than discussions via email or instant message. The chat was buzzing as attendees enthusiastically shared their own experiences and tips on ways to collaborate and work towards improving the accuracy and quality of documentation.
What is Risk Adjustment?
SDOH is just a small component of value-based care. At the crux of risk adjustment is comprehensive clinical documentation and accurate and complete medical coding. In “Learning From Retrospective Programs and Applying to Prospective Programs,” Donna Malone, CPC, CRC, CPC-I, AHCCA, RAP, succinctly illustrated the importance of physician documentation and its link to accurate reporting of hierarchical condition categories (HCC). As she demonstrated the financial impact of HCC coding, she reminded everyone: “Everything we do attaches to a human being.” Malone went on to explain pre- and post-visit processes for ensuring payers receive complete and accurate diagnostic data.
Such processes ensure your provider’s sickest patients are accounted for. Colleen Gianatasio, CPC, CPC-P, CPMA, CRC, CPC-I, CCS, CCDS-O, discussed the relevance of chronic pulmonary disease and cancer in value-based care in her session, “Advanced: Pulmonary Disease and Cancer.” She walked attendees through official guidance and what to look for in clinical documentation to help ensure accurate and compliant coding.
Make your education adaptable and keep it concise Gianatasio advised, “make it about patient care.” Instruct your providers to “think and ink” — tell the patient’s story and make sure to paint the complete clinical picture, so it can be translated into the appropriate codes. Remind them that things, such as malnutrition, depression, cachexia, and morbid obesity, need to be documented as their presence makes for a more complex patient.
What Is Value-Based Care?
In the session “Value-Based Care,” Catherine Field, from Humana, and Craig Riley, MD, from Vancouver Clinic, talked about the differences between fee-for-service and value-based payment models. Field walked attendees through Humana’s value-based evolution, stating that the insurance giant has made “significant progress” in shifting their Medicare Advantage members into value-based relationships; and this has led to positive results in performance and key indicators — star ratings have gone up and the rate of avoidable hospital admissions has declined. The key takeaway from this session was the message that providers, payers, and patients must develop trust in one another.
Trust is earned, however, which is a brilliant segue to Risk Adjustment Data Validation (RADV).
What Is RADV?
CMS uses this type of audit to ensure risk-adjusted payments to Medicare Advantage plans are based on accurate diagnosis coding and sound medical record documentation. In “The Function and Impact of RADV Audits 2021,” presenters Melissa Kirshner, MPH, CPC, CRC, CDEO, CFPC, CPI-I, AAPC Fellow, and Kelly A. Shew, RHIA, CPC, CDEO, CPB, CPCO, CRC, CPC-I, gave an overview of RADV (pronounced rad V) and the process for preparing for these audits. Kirshner emphasized the importance of audit preparation by highlighted a few recent Office of Inspector General (OIG) Work Plan items. She also reviewed provisions in the 2020 Physician Fee Schedule final rule that are affecting RADV audits now.
Shew provided a timeline for RADV activity. 2019 and 2020 audits are being conducted concurrently as a result of the various waivers put in place during the public health emergency for COVID-19. Using something such as CMS’ RADV audit checklist, practices can perform internal audits to ensure compliance.
The Job of the Risk Adjustment Coder
Ever wonder what exactly risk adjustment coders do? In the session “Available Jobs for Risk Adjustment” panelists Randi Escobedo, CRC, along with veteran coder Linda Farrington, CPC, CPMA, CRC, CPC-I, and AAPC Services Regional Director Jennifer Hill, CPC, CPMA, CRC, led a lively Q&A session with attendees. The panelists talked about how they got into risk adjustment and invited attendees to share their stories and ask questions. The chat lit up and the panelists got busy offering career advice and providing answers. Everyone walked away with the lesson that every step you take is a step in the right direction. “Be fearless,” Farrington said. They also emphasized the importance of networking. “These are your people,” said Escobedo. Take the initiative to connect with people in the field. Getting a job often comes down to who you know.
It Wasn’t All Work and No Play
Over the two days, in between breakout sessions, attendees networked via AAPC’s Conference app, talked via the chat wall, and participated in various challenges — all for points to win prizes.
At the end of Day 2, AAPC staff, presenters, and attendees joined the Virtual Happy Hour to conduct/participate in trivia questions, play games, and talk freely. Random polls would pop up onscreen such as the one that asked, “How often would you likely attend specialty virtual conferences like Riskcon?” Surprisingly, 5 percent said they would attend conference every weekend! How about a few times a year? We hope to see everyone at our next boutique conference, Auditcon, Nov. 1-2; and don’t forget you can attend conference in person at our HEALTHCON Regional, Oct. 4-6, in South Carolina, and HEALTHCON 2022 in Washington, D.C.!