Risk Adjustment Documentation and Coding

Author: Sheri Poe Bernard
Publisher: American Medical Association Press
ISBN: 9781622027330
Format: PDF, Mobi
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Risk-adjustment practices consider chronic diseases as predictors of future healthcare needs and expenses. Detailed documentation and compliant diagnosis coding are critical for proper risk adjustment. Risk Adjustment Documentation & Coding provides: * Risk adjustment parameters to improve documentation related to severity of illness and chronic diseases. * Code abstraction designed to improve diagnostic coding accuracy without causing financial harm to the practice or health facility. The impact of risk adjustment coding--also called hierarchical condition category (HCC) coding--on a practice should not be underestimated: * More than 75 million Americans are enrolled in risk-adjusted insurance plans. This population represents more than 20% of those insured in the United States. * Insurance risk pools under the Affordable Care Act include risk adjustment. * CMS has proposed expanding audits on risk adjustment coding. Meticulous diagnostic documentation and coding is key to accurate risk-adjustment reporting. This book will help align the industry though an objective compilation and presentation of risk adjustment documentation and coding issues, guidance, and federal resources. Features and Benefits * Five chapters delivering an overview of risk adjustment, common administrative errors, best practices, topical review of clinical documentation improvement and coding for risk adjustment alphabetized by HCC group, and guidance for development of internal risk adjustment coding policies. * Six appendices offering mappings, tabular information, and training tools for coders and physicians that include an alphanumeric mapping of ICD-10-CM codes to HCCs and RxHCCs and information about Health and Human Services HCCs versus Medicare Advantage HCCs. * Learning and design features: - Vocabulary terms highlighted within the text and conveniently defined at the bottom of the page. - "Advice/Alert Notes" that highlight important advice from the ICD-10-CM Guidelines for Coding and Reporting. - "Key Coding Concepts" that offer the advice published in ICD-10-CM Coding Clinic for ICD-10-CM and ICD-10-PCS. - "Sidebars" that detail measurements pertinent to risk adjustment seen in physician documentation, eg., cancer staging, disability status, or GFRs. - "Coding Tips" that guide coders to the right answers (using terminology and ICD-10-CM Index and Tabular entries) or provide cautionary notes about conflicts in the official ICD-10-CM guidance. - "Clinical Examples" that underscore key documentation issues for risk adjustment. - Clinical coding examples that provide snippets or full encounter notes and codes to illustrate key issues for the HCC or RxHCC. - "Documentation tips" highlight recommendations to physicians regarding what should be included in the medical record or how ICD-10-CM may classify specific terms. - "Examples" that explain difficult concepts and promote understanding of those concepts as they relate to a section. - "FYI" call outs that provide quick facts. * Extensive end-of-chapter "Evaluate Your Understanding" sections that include multiple-choice questions, true-or-false questions, and Internet-based exercises. * Downloadable slide presentations for each chapter that cover key content and concepts. * Exclusive content for academic educators: A test bank containing 100 questions and a mock risk-adjustment certification exam with 150 questions

Medicare Risk Adjustment and Hierarchical Condition Category HCC

Author: V. G
Publisher:
ISBN: 9781719832458
Format: PDF, Kindle
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Risk Adjustment and Hierarchical Condition Category (HCC) coding is a payment model mandated by the Centers for Medicare and Medicaid Services (CMS) in 1997. Implemented in 2003, this model identifies individuals with serious or chronic illness and assigns a risk factor score to the person based upon a combination of the individual's health conditions and demographic details. The individual's health conditions are identified via International Classification of Diseases - 10 (ICD -10) diagnoses that are submitted by providers on incoming claims. There are more than 9000 ICD-10 codes that map to 79 HCC codes in the Risk Adjustment model. CMS requires documentation in the person's medical record by a qualified health care provider to support the submitted diagnosis. Documentation must support the presence of the condition and indicate the provider's assessment and/or plan for management of the condition. This must occur at least once each calendar year in order for CMS to recognize the individual continues to have the condition. The Centers for Medicare and Medicaid Services (CMS) Risk Adjustment Model includes nearly 80 HCC categories of chronic illnesses with thousands of diagnosis codes. Beginning HCC coders need solid instruction on HCC coding to properly map codes and ensure the organization receives the reimbursement payments. This webinar educates the audience on HCC coding and discusses popular risk adjustment coding guidelines. It identifies what makes a document valid for submission, including which sources of documentation should or should not be used. Attendees will have the opportunity to review common mistakes, like a lack of specificity in provider documentation. Often overlooked conditions, which are frequently undocumented by the provider, are also explained. The presenter will give a brief demonstration on how to determine if a condition is reimbursed or not, as well as a case study showing how to apply the theories learned. Through clarification of codes and specific examples, the speaker underscores the importance of provider documentation and its impact on reimbursement. This session is a great overall introduction for beginners and the perfect refresher course for those who have already begun and want to enhance their knowledge in the field. Objectives Learn about HCC coding and risk adjustment coding guidelines. Demonstrate how mapping tools help to properly identify HCCs. Understand the importance of provider documentation and its impact on reimbursement. Risk adjustment in the CMS- HCC model characteristics is based on multiple factors, which are analyzed and reduced to offer the right risk management plan for a patient. The factors that influence risk adjustment includes: Hierarchy of diseases: Ensuring that diagnoses are included in the appropriate disease groups and are in accordance with the necessary hierarchy. Disease Interactions: The additional factors that recognize and assess the severity of multiple conditions. Demographic Variables: These focus on the demographic of the patient's living conditions and demographics. Diagnostic Sources: CMS recognizes diagnoses from a hospital's inpatient, outpatient and physician settings only. Prospective model: The diagnoses based on last year are used to extrapolate the possible payments for the next year. Multiple conditions A patient can have multiple HCC categories assigned to them based on their medical conditions. In some cases, specific conditions can override others, when documenting. This is based on the strict hierarchy of the coding procedures. HCCs are captured once a year, every year in order for the CMS to reimburse payments to the Medicare Advantage. However, diagnoses from previous years are used to establish capitation payments to the Medicare Advantage plan.

Medicare Risk Adjustment Coding Guidelines

Author: The Coders Choice LLC
Publisher:
ISBN: 9781718101289
Format: PDF, Mobi
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The purpose for the Centers for Medicare and Medicaid Services (CMS) to conduct Risk Adjustment Factors is to pay plans for the risk of the beneficiaries they enroll, instead of calculating an average amount of Medicare/Medicare Advantage beneficiaries. By doing so, CMS is able to make appropriate and accurate payments for enrollees with differences in expected costs. Lastly, the risk adjustment allows CMS to use standardized bids as base payments to plans.CMS risk adjusts certain plan payments, such as Part C payments made to Medicare Advantage (MA) plans and Program for All Inclusive Care for The Elderly (PACE) organizations, and Part D payments made to Part D sponsors, including Medicare Advantage-Prescription Drug plans (MA-PDs) and standalone Prescription Drug Plans (PDPs).Below is a high-level checklist of plan requirements with detailed information regarding risk adjustment data collection, submission, reporting, and validation: "Ensure the accuracy and integrity of risk adjustment data submitted to CMS. All diagnosis codes submitted must be documented in the medical record and must be documented as a result of a face-to-face visit. Implement procedures to ensure that diagnoses are from acceptable data source. The only acceptable data sources are hospital inpatient facilities, hospital outpatient facilities, and physicians.Submit the required data elements from acceptable data sources according to the coding guidelines.Submit all required diagnoses codes for each beneficiary and submit unique diagnoses once during the risk adjustment data-reporting period. Submitters must filter diagnosis data to eliminate the submission of duplicate diagnosis clutters.The plan sponsor determines that any diagnosis codes have been erroneously submitted, the plan sponsor is responsible for deleting the submitted diagnosis codes as soon as possible.Receive and reconcile CMS Risk Adjustment Reports in a timely manner. Plan sponsors must track their submission and deletion of diagnosis codes on an ongoing basis.Once CMS calculates the final risk scores for a payment year, plan sponsors can only request a recalculation of payment upon discovering the submission of erroneous diagnosis codes that CMS used to calculate a final risk score for a previous payment year and that had a material impact on the final payment. Plan sponsors must inform CMS immediately upon such a finding."

Population Health

Author: George Mayzell, MD, MBA
Publisher: CRC Press
ISBN: 1498705561
Format: PDF, Kindle
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As healthcare moves from volume to value, payment models and delivery systems will need to change their focus from the individual patient to a population orientation. This will move our economic model from that of a "sick system" to a system of care focused on prevention, boosting patient engagement, and reducing medical expenditures. This new focus will shift traditional financial accountability from the payer model to provider directed models. Population Health: An Implementation Guide to Improve Outcomes and Lower Costs covers not only the rationale for this transition, but also outlines successful practice models that are built to thrive in these new market dynamics. Besides the philosophical and the cultural aspects of these new models, it details the implementation and strategic initiatives required to succeed in today’s value- and population-oriented healthcare environment. Describing what population health is, the book explains why it represents an opportunity for healthcare delivery systems, public health agencies, community-based organizations, and other entities to work together to improve health outcomes in the communities they serve. The book clarifies how the new models will impact healthcare providers, how to manage populations, and how to handle the risk factors involved. It details new delivery models, such as primary care and medical neighborhoods, and outlines the value proposition of screening and prevention in assigned populations.

Healthcare Risk Adjustment and Predictive Modeling

Author: Ian G. Duncan
Publisher: ACTEX Publications
ISBN: 1566987695
Format: PDF, Mobi
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This text is listed on the Course of Reading for SOA Fellowship study in the Group & Health specialty track. Healthcare Risk Adjustment and Predictive Modeling provides a comprehensive guide to healthcare actuaries and other professionals interested in healthcare data analytics, risk adjustment and predictive modeling. The book first introduces the topic with discussions of health risk, available data, clinical identification algorithms for diagnostic grouping and the use of grouper models. The second part of the book presents the concept of data mining and some of the common approaches used by modelers. The third and final section covers a number of predictive modeling and risk adjustment case-studies, with examples from Medicaid, Medicare, disability, depression diagnosis and provider reimbursement, as well as the use of predictive modeling and risk adjustment outside the U.S. For readers who wish to experiment with their own models, the book also provides access to a test dataset.

Buck s 2019 HCPCS Level II E Book

Author: Elsevier
Publisher: Elsevier Health Sciences
ISBN: 0323582788
Format: PDF, Mobi
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Continue to code quickly, accurately, and efficiently with Buck’s 2019 HCPCS Level II. This easy-to-use reference presents the latest HCPCS codes to help you comply with coding regulations, confidently locate specific codes, manage reimbursement for supplies, report patient data, code Medicare cases, and more. This edition features Netter’s Anatomy illustrations, dental codes, and ASC (Ambulatory Surgical Center) payment and status indicators. Current Dental Terminology (CDT) codes from the American Dental Association (ADA) offer access to all dental codes in one place. Full-color illustrations enhance understanding of specific coding situations. At-a-glance code listings and distinctive symbols make it easy to quickly identify new, revised, reinstated, and deleted codes. Easy-to-use format optimizes reimbursement and assists with quick, accurate, and efficient coding. Full-color design with color tables helps you locate and identify codes with speed and accuracy. UNIQUE! Full-color Netter’s Anatomy illustrations clarify complex anatomic information. Jurisdiction symbols show the appropriate contractor to be billed for suppliers submitting claims to Medicare contractors, Part B carriers, Medicare Administrative Contractors submitting for DMEPOS services provided, and more. Special coverage alerts helps you identify when codes have special coverage instructions, are not covered or valid by Medicare, or may be paid at the carrier’s discretion. Drug code annotations identify brand name drugs as well as drugs that appear on the National Drug Class (NDC) directory and other Food and Drug Administration (FDA) approved drugs. Ambulatory Surgery Center (ASC) payment and status indicators show which codes are payable in the Hospital Outpatient Prospective Payment System to ensure accurate reporting and appropriate reimbursement. Durable medical equipment, prosthetics, orthotics, and supplies (DMEPOS) indicators address reimbursement for durable medical equipment, prosthetics, orthotics, and supplies. Age/sex edits identify codes for use only with patients of a specific age or sex. Quantity symbol indicates the maximum allowable units per day per patient in physician and outpatient hospital settings, as listed in the Medically Unlikely Edits (MUEs) for enhanced accuracy on claims. The American Hospital Association Coding Clinic® for HCPCS citations provide a reference point for information about specific codes and their usage. Physician Quality Reporting System icon identifies codes that are specific to PQRS measures. Codingupdates.com website includes quarterly updates to HCPCS codes, content updates, and the opportunity to sign up for e-mail notifications of the newest updates. NEW! Updated 2019 code set features the latest Healthcare Common Procedure Coding System codes to comply with current HCPCS standards for fast and accurate coding.

Encyclopedia of Health Services Research

Author: Ross M. Mullner
Publisher: SAGE Publications
ISBN: 1452266115
Format: PDF, Docs
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Today, as never before, healthcare has the ability to enhance the quality and duration of life. At the same time, healthcare has become so costly that it can easily bankrupt governments and impoverish individuals and families. Health services research is a highly multidisciplinary field, including such areas as health administration, health economics, medical sociology, medicine, , political science, public health, and public policy. The Encyclopedia of Health Services Research is the first single reference source to capture the diversity and complexity of the field. With more than 400 entries, these two volumes investigate the relationship between the factors of cost, quality, and access to healthcare and their impact upon medical outcomes such as death, disability, disease, discomfort, and dissatisfaction with care. Key Features Examines the growing healthcare crisis facing the United States Encompasses the structure, process, and outcomes of healthcare Aims to improve the equity, efficiency, effectiveness, and safety of healthcare by influencing and developing public policies Describes healthcare systems and issues from around the globe Key Themes Access to Care Accreditation, Associations, Foundations, and Research Organizations Biographies of Current and Past Leaders Cost of Care, Economics, Finance, and Payment Mechanisms Disease, Disability, Health, and Health Behavior Government and International Healthcare Organizations Health Insurance Health Professionals and Healthcare Organizations Health Services Research Laws, Regulations, and Ethics Measurement; Data Sources and Coding; and Research Methods Outcomes of Care Policy Issues, Healthcare Reform, and International Comparisons Public Health Quality and Safety of Care Special and Vulnerable Groups The Encyclopedia is designed to be an introduction to the various topics of health services research for an audience including undergraduate students, graduate students, andgeneral readers seeking non-technical descriptions of the field and its practices. It is also useful for healthcare practitioners wishing to stay abreast of the changes and updates in the field.

Sabiston and Spencer s Surgery of the Chest E Book

Author: Frank Sellke
Publisher: Elsevier Health Sciences
ISBN: 1455700096
Format: PDF, Kindle
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Through seven successful editions, Sabiston & Spencer Surgery of the Chest has set the standard in cardiothoracic surgery references. Now, the new 8th Edition, edited by Frank W. Sellke, MD, Pedro J. del Nido, MD, and Scott J. Swanson, MD, carries on this tradition with updated coverage of today's essential clinical knowledge from leaders worldwide. Guidance divided into three major sections—Adult Cardiac Surgery, Congenital Heart Surgery, and Thoracic Surgery—lets you quickly find what you need, while new and revised chapters reflect all of the important changes within this rapidly evolving specialty. Expert Consult functionality—new to this edition—enables you to access the complete contents of the 2-volume set from anyplace with an Internet connection for convenient consultation where and when you need it. This is an ideal source for mastering all of the most important current knowledge and techniques in cardiac and thoracic surgery—whether for specialty board review or day-to-day practice. Features short, focused chapters that help you find exactly what you need. Presents the work of international contributors who offer a global view of the entire specialty. Covers thoracic surgery as well as adult and pediatric cardiac surgery for a practical and powerful single source. Includes nearly 1,100 illustrations that help to clarify key concepts. Features online access to the complete contents of the 2-volume text at expertconsult.com for convenient anytime, anywhere reference. Covers the hottest topics shaping today's practice, including the latest theory and surgical techniques for mitral valve disease, advances in the treatment of congenital heart disease, minimally invasive surgical approaches to the treatment of adult and congenital cardiac disease and thoracic disease, stent grafting for aortic disease, and cell-based therapies. Your purchase entitles you to access the web site until the next edition is published, or until the current edition is no longer offered for sale by Elsevier, whichever occurs first. Elsevier reserves the right to offer a suitable replacement product (such as a downloadable or CD-ROM-based electronic version) should access to the web site be discontinued.

Die Blockchain Revolution

Author: Don Tapscott
Publisher: Plassen Verlag
ISBN: 3864704065
Format: PDF, Docs
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Blockchain ermöglicht Peer-to-Peer-Transaktionen ohne jede Zwischenstelle wie eine Bank. Die Teilnehmer bleiben anonym und dennoch sind alle Transaktionen transparent und nachvollziehbar. Somit ist jeder Vorgang fälschungssicher. Dank Blockchain muss man sein Gegenüber nicht mehr kennen und ihm vertrauen – das Vertrauen wird durch das System als Ganzes hergestellt. Und digitale Währungen wie Bitcoins sind nur ein Anwendungsgebiet der Blockchain-Revolution. In der Blockchain kann jedes wichtige Dokument gespeichert werden: Urkunden von Universitäten, Geburts- und Heiratsurkunden und vieles mehr. Die Blockchain ist ein weltweites Register für alles. In diesem Buch zeigen die Autoren, wie sie eine fantastische neue Ära in den Bereichen Finanzen, Business, Gesundheitswesen, Erziehung und darüber hinaus möglich machen wird.