The first day of RISKCON was a hit, leaving attendees wanting more.
The past two years have brought a whirlwind of changes that have transformed the business of healthcare, and given the growing popularity of AAPC’s virtual conferences, it seemed like the perfect time to host an event dedicated to providing an in-depth look into risk adjustment and the integral role it plays in the provision of quality care.
Yesterday marked the first day of RISKCON (Sept. 13-14), AAPC’s first virtual conference focused solely on risk adjustment theory and practice. Attendees gained insight and guidance on a myriad of topics including value-based care, creating a strong audit program, compliance best practices, establishing an effective clinical documentation improvement (CDI) program, and much more. Industry leaders shared their thoughts on these timely topics and the many changes that have occurred and are currently evolving in the healthcare arena.
Clean Data Is Key
Day one commenced with a panel discussion on technology solutions for risk adjustment. In this 680+ attended panel, Kevin Coloton, founder and CEO of Curation Health, and Khush Singh, MD, discussed how technology should help — and not hinder — risk adjustment.
A shift away from the fee-for-service (FFS) payment model is underway, Coloton explained. But while 70 percent of health systems plan to move to value-based arrangements in the next year or two, only a third think they have adequate technology infrastructure, and a whopping 60 percent say they lack critical staffing for care management.
In value-based care, success is ultimately measured by what is written in the physician note and coded for the encounter. Coloton went on to say that technology must service this workflow. Don’t worry though, the goal of utilizing technology is not to replace human intervention, but to make it more meaningful, emphasizing, “Success is clinical outcome improvement.”
For instance, technology should take away the “silly work” and enable the coder to perform core activities more efficiently. “We pull out the things that don’t matter, so they can get to the root of their expertise,” Coloton said. To unlock the value of technology, you need very clean data. In other words, if you put garbage in, you’re going to get garbage out.
Should you worry about technology replacing the human factor? No, you can breathe a sigh of relief. “We haven’t seen artificial intelligence (AI) replacing radiologists, for example, but it’s certainly assisting and helping them,” Coloton said. We are not at a point where technology is able to “replace” the human experience; in fact, we should celebrate the human element, he went on.
But technology is all in service of those clinical encounters. “If you’re working under the value-based environment, we really want to see what the patient has,” Singh agreed, “We want more than to simply get reimbursed but to help the patient who’s been sitting there, waiting.”
Back to Basics
In the first breakout session, published author Sheri Poe Bernard, CCS-P, CDEO, CPC, CRC, gave an incredibly informative presentation on risk adjustment. This session provided insight into the history and context in which risk adjustment was created and where it is going. Bernard walked attendees through the basic principles and practices utilized in risk adjustment, including a deep dive into hierarchical condition categories (HCCs) and documentation and coding guidance that must be followed.
Pro Tips for Developing an Effective Audit Program
Some attendees opted to listen to Donna Malone, CPC, CRC, AAPC Approved Instructor, delve into creating an effective risk adjustment program. Government audits in the value-based care space are on the rise, with the Office of Inspector General conducting Medicare Advantage risk adjustment data validation (Centers for Medicare and Medicaid Services (CMS) RADVs) and Commercial Exchange (Department of Health and Human Services (HHS) RADV) audits. Barriers to developing an audit program, such as not enough staff or insufficient training, must be overcome because value-based care is not going away. In fact, it’s expanding quite rapidly. She stressed the importance of accurate documentation and coding to make sure proper reporting of patient complexity to these programs.
Malone then shared some tips for developing a strong audit program:
- Include a mixed case selection based on both a random and targeted approach.
- Incorporate both administrative and documentation components.
- Target high-risk conditions such as history of/resolved versus active condition, stroke and pulmonary embolism in the office setting, conditions appropriate for mother’s chart versus baby’s chart, and fracture coding with 7th character use.
- Target unspecified and under documented conditions such as depression, chronic kidney disease (CKD), diabetes, amputations, ostomies, and HIV positive status.
- Audits should look both ways — not just one way — when you open a chart for review.
- Include ICD-10-CM coding guidance, AHA Coding Clinic, and CMS and HHS RADV protocols when developing documentation review guidance.
Something for Everyone
The afternoon brought a wealth of knowledge, starting with a presentation on HCC categories for cardiology coding by Robin Peterson, CPC, CPMA, and Autumn Hall, CPC, CPMA, CEMC, CPAR. They started by detailing why HCC coding is important, how it impacts reimbursement, and the overall goal of risk adjustment. “Documentation specificity is what it’s all about,” they explained as they went over documentation requirements, tips, and best practices. After reviewing HCC cardiology conditions and codes, they wrapped up the session with come clinical examples.
Some attendees listened to Chris Lally’s session on using natural language processing (NLP) — which “allows for clinical information to be extricated from natural language data: text or voice” — in your prospective approach to risk adjustment. He began by speaking about the retrospective review process and the challenges that arise when using this type of audit. Lally went on to discuss prospective reviews and how they are a must for a comprehensive program. He wrapped up the session talking about the importance of implementing people, processes, and technology for accurate HCC coding and how NLP and suspect analytics are key technology enablers.
Paint the Full Clinical Picture
Nowhere is specificity more important than in coding for type 2 diabetes, so why do providers still insist on documenting diabetes as uncontrolled, especially when that is no longer a classification in ICD-10-CM? That was the question, president-elect of the AAPC National Advisory Board Colleen Gianatasio CPC, CPC-P, CPMA, CRC, CPC-I, CCS, CCDS-O, posed in her presentation, “Advanced Coding: Diabetes.” She walked attendees through frequently asked questions and official guidance to help them ensure these cases are accurately and compliantly documented and coded.
The answer to avoiding this issue, according to Gianatasio, lies in provider education. But rather than overwhelming providers with information about the 300-plus ICD-10-CM diabetes codes, she recommended that coders break down the major E11 Type 2 diabetes mellitus code groups for them so that they understand how the codes function. This means acquainting providers with the use of fourth digits in the E11 codes to maximize specificity, so that they can easily identify the accurate codes for reporting diabetic complications.
Stressing to the provider that these codes justify the need for specific — and very different — treatment modalities is tremendously important, Gianatasio argued. This means avoiding the unspecified type 2 diabetes code E11.8 at all costs. And, as always, justifying each code means proper documentation. She said one way to accomplish this is though a progress note that covers the four factors outlined by the MEAT (monitoring, evaluating, assessing, treatment) acronym.
The remaining sessions of the day covered the gamut: establishing an effective CDI program, compliant provider queries, and strategies for successful payer audits, to name a few.
A Round of Applause!
Day one of RISKCON days brought extraordinary education and networking opportunities. Don’t miss day two of AAPC’s novel risk adjustment conference.