Hi, everyone. Welcome to the webinar. We will get started shortly. I apologize. We've had some technical difficulties on our end. So if you just give us just a minute as folks are falling into the webcast now that we've opened it, we will get started. All right, I'm going to go ahead and get us kicked off. My name is Nicole Knight, and I'm the Executive Vice President of Revenue Cycle Solutions and Care Transformation with MedAxiom. I am hopefully going to be joined today by Linda Gates Striebe. Linda is also a consultant with MedAxiom. She works with us and is also the Director of Quality Assurance at the Ascension Medical Group in Indiana. Many of you know Linda. She's been a part of MedAxiom for a long time, and I'm happy that she's joined us and is with us now on a regular basis. All right. So today we're going to cover risk adjustment, HCC coding, and documentation insights. They are going to keep me posted on if Linda is done with her technical difficulties and is able to join us, so hopefully she will join us soon. So from your Zoom control panel, there is a Q&A button where you can type in your questions related to the topic today, and we will answer those at the end of the webcast, or we will provide those after the webcast as well. Just a reminder, in order to claim your CEUs and access your certificate, you do have to go to your Academy login. This webinar is approved for 1.5 CEUs, and your certificates are all housed here for any webinar that you individually registered for. So you have to remember, if you're listening in a big group, that you do have to individually register for the webcast in order to be able to get your CEU credits. It is a requirement of the AAPC that you individually register for the webcast in order to get your CEU certificate. All right. Usually these are out there within one to two business days. Sometimes you can give us a five-day window, but usually I believe those are automatically put out there now, and again, when you've got to go back and retrieve all those CEUs, those are kept under your MyAcademy, so you'll be able to access them. All right. So today we're going to cover understanding risk adjustment in HTCs, why and how does this apply to me, leveraging accurate coding and documentation, and then metrics for success. So in looking at these first couple of slides, making the jump of fee-for-service to value. We often talk about that in our world, and it's always that magical, mythical creature of, are we ever going to be outweighing value versus that fee-for-service world? And when you look at where this started at with the Affordable Care Act, or if it started with our SGR and our growth rate, was it the chicken before the egg? So really presenting the most accurate picture of that patient population and care is vital, and we'll talk about today why that has become even more vital to that. All right. Sorry for my pauses, guys. I'm trying to get Linda on the telephone now. Hey, Linda, it's Nicole. I have you live on the webcast, so we're going to do it this way. You know what? It's always good to have even a plan D or so. I know. Boy, we are being tested today for sure. There is no doubt. Julie, if you could give me a thumbs up in the chat that you can hear Linda okay, that would be great. So I was just covering, Linda, the fee-for-service versus value, and talking about the chicken before the egg and where we were at and really painting that accurate picture of the patient population. When we get to our next slide, you're going to see where we talk about the growth in our Medicare Advantage plans. We are getting a couple of inquiries about the handout. There is a link in the chat. I'm sorry. I missed saying that on my intro. It is in the chat. It's a link you can copy and paste there. So, Linda, when we look at this slide and we talk about the growth across our Medicare Advantage plans and what that shows, you want to comment on that for the team? Yeah. Yeah. And following the rule of try to be prepared, I did have these slides printed out. We can just go with this. I was really surprised that the Medicare Advantage has now reached 48%. I mean, that seems pretty big, you know, at 48%. And what's interesting, if you go to the website where this report is published, this chart is just type in this title, it's about maybe a 30-page report, and it shows also how that penetration rate differs per state. And as I'm sure many of you are aware, you are well over the 50 and 60% mark. So I think the point of that is that this HCC wrap is absolutely not going to go away. And we've really got to get better at this before it becomes the predominant way of payment. I was pretty surprised. Yeah, I agree. I think we're continuing to see that. All right, let's move on to our next. So I couldn't resist putting a slide in here about CHAT-GPT. It seems to be what is the biggest buzz, and most of many of the meetings I've attended, if you watch the news, there is something about CHAT-GPT somewhere. So just some basic definitions when we talk about risk adjustment, and CHAT-GPT is pretty accurate on this when it talks about that it's a method used by the healthcare and insurance industries that's relative to the risk and needs of individuals or population. It's a statistical technique that aims to account for differences. And this is what they use when comparing healthcare cost or outcomes. So cost is that relative word we talk about, and how is that measured? And that's what we're going to cover in detail. HCCs play a critical role in that risk adjustment, and they help to ensure, it says, fair and accurate reimbursement. However, we know that that's based on what we code on our claims and what's supported in our documentation ultimately. When we talk about the Medicare Advantage plans and how the CMS-HCC model works, companies bid and are awarded contracts as approved by Medicare to run the Advantage replacement plan. Medicare pays these plans for the members who enroll, and payment per member is adjusted based on their expected costs. So the Advantage plan provides those Medicare-covered benefits to their members through the plan, and may also have extra benefits that traditional Medicare may not cover. So risk adjustment is that method used by CMS to approximate that expected cost for that Medicare Advantage plan's enrollees' care for that year. When we look at how it's calculated, so it's calculated based on a couple of factors, demographic characteristics such as age, sex, if they're disabled, if they're dual eligible for Medicare and Medicaid, or if they're single eligible. Their health status is then added to those demographic characteristics that are associated with that HCC model. We get a risk score, and what this ultimately illustrates is the higher the risk score is, represents a greater-than-average disease burden for that particular enrollee. A lower risk score should represent a healthier population. However, what we found is that that can be falsely represented due to inadequate documentation and coding, or gaps in the process for capturing diagnosis. What are HCC's hierarchical condition codes and risk adjustment factors? Well, we know that this is made up of our ICD-10 codes, which there's over 70,000. There's 86 HCC categories, and then there's 9,500-plus HCC ICD-10 codes that cross over. So how do you figure out all this mapping, and what's it utilized for as it's calculated? That RAF, and we'll refer to it as RAF, is that risk adjustment factor score that's additive. Linda's going to talk about what's additive, what we mean by that. Those diagnoses are summed to the total RAF score. The average risk factor is 1.0. It's determined every calendar year, so every patient starts off well on January 1st. So what happens to us at that point? Well, we have to re-document. We have to ensure that we're supporting all of those diagnoses on the claim to paint that picture. The RAF score is predictive and sets those cost benchmarks. Linda, take us through understanding the RAF and HCC basics. When we look at that patient RAF score, as Nicole explained, what we're trying to do is take into consideration the overall picture of that patient's health. That's what we're doing with our diagnosis coding is just kind of painting that picture. A 65-year-old living at home, still out working in the yard, is very different than a 95-year-old who's multiple disease states and bedridden in a nursing home. When we talk about that average RAF, they're saying that that score is 1.0. Then we take that with the demographic, plus now we start adding that diagnosis coding. As the patient adds more chronic conditions, we would anticipate that it's going to take more health care dollars to address their conditions. As you'll see, that's additive. Medicare starts paying these plans another $900 for each .1 that that patient gets. So that RAF score gets added up, and that turns into kind of the budget, I guess. We're looking for what does Medicare expect to spend on this patient. You add all these together, they get all these different chronic conditions, and say, okay, under these circumstances, we're going to plan that by the end of the year, this patient's going to need $40,000 worth of resources. So that's what the plan will get. It's kind of like the old HMO days, where you have that budget, you get a set amount, and then now the plan has to pay for all expenses. So it's the RAF score that's going to build all of those. So how do those build? Well, that's where the HCC comes into play. It's a hierarchy of coding. So the model is accumulative, meaning that you have diseases in the circulatory system, diabetes, diseases, COPD. You have all these different disease states, each one of which is a different category. So within that category, you're going to get the highest score in any individual category, and I'll show you here in just a second how that works with arrhythmias. But what's important about this, and that's where about towards the end of the year, I think you've probably all received reports from record requests and such by September, October, where they're asking for copyrights of records because they know this patient had a condition built last year that hasn't been built yet this year. And that's what we mean, where it has to be captured on a claim every 12 months. If it's not built, it's like the condition just, poof, went away, and they're not going to get the reimbursement for that for next year's expenses. And, Nicole, if you want to go to the next slide, when we talk about additive and or overwrite, we have both that are actually going on. So some HCC codes are going to overwrite others, and I've listed a couple of examples there for you on the left-hand side where you see, okay, you've got diabetes with acute complications versus diabetes with chronic. Now, that's one of those that the acute is going to overwrite the chronic. Same thing, if you first reported over on the right-hand side that only one diagnosis code per category, so maybe the patient has angina in February and maybe unstable angina in May or June, but by September, they actually had that acute MI. Well, you're not going to get the HCCs for each of those disease states because the acute MI is the highest, so you would drop the other two. Now, as you see there on the left, we dropped the diabetes with acute complications, but the patient on either side, the left or the right, if they have multiple sclerosis, that's a whole other body system. COPD, that's another body system. Acute renal failure, that's another condition. So for those patients, you would add each one of those, that HCC category 17, 111, 135, and then the most significant in the other disease states. So if you go to the next slide, you can see here, and this listing, we'll show you here in a second where you can get this kind of detail, but we click on the disease category, the HCC category, of a specified heart arrhythmias, and you can see here all these different arrhythmias that are listed, and what you don't see here is, you know, basically just a PAC or something like that. That doesn't meet the criteria of that chronic condition that's expected to lead to multiple visits and healthcare needs, but chronic atrial fibrillation, well, gosh, that's your might. Same thing with the persistent AFib. You can see the AFlutter, reentry ventricular. All of those go to the same HCC category, so they all carry the same weight. Now, what if we had a patient that had both the sick sinus syndrome as well as occasional atrial fibrillation? They're not going to get the weight of that particular HCC category more than once, so even though the patient might have a couple of different conditions within this category 96, they're only going to get the score of that 96 and that one weight. Next slide. And, Nicole, did you want to speak to the risk adjustment there? Yeah, so in the risk adjustment, we talked about the different, like the 77,000 plus ICD-10 codes. Well, this breaks it down, the characteristics of that model for CMS. So we're particularly focused on CMS, and we'll talk about a couple other example models, but for this presentation, really focused on that. So when you look at those multiple chronic diseases as HCCs, that's the base payment for each member. That influenced the cost for chronic diseases. It has those disease interactions, so when we're looking at documentation and we're talking about disease interactions, what does that mean? So what do they have, congestive heart failure and renal failure? Do they have coronary artery disease and diabetes? How is that related? What are our sources? So they'll consider all diagnosis from inpatient, outpatient hospital data and physician data, and the nature of that is to use to predict that next year, whether it's a new enrollee or an existing enrollee. So there's some principles that we share here. Obviously, when you look at this, you want it to be clinically meaningful, which, you know, when you have these lists of diagnosis in your problem list, and you're pulling those over each time, are they relative to the visit? And we'll talk about what has to be documented in order to support that. It also, I think the other one that I found interesting on these principles was providers should not be penalized for recording additional diagnosis. The principle has two consequences for modeling. No condition category should carry a negative payment rate. So a condition that is ranked higher, like Linda said, should have at least a larger payment rate as a lower rate. But regardless, if it doesn't have a weight, if it's relative to that patient, it should be documented those additional diagnoses that are taken into consideration for their medical treatment and care. Now, Linda, this is the funnel slide you created with the demographics and the risk adjustment. Did you want to add anything to that on this particular one? Yeah, I think it's just another way of looking at it. And hopefully you've grasped that concept before we move on, because this is really, you know, the really at the crux of everything, that you're gonna automatically be given that demographic information. There's nothing we do there. The plan and Medicare know that. So everyone's gonna start at that. And then you go throughout the year. Any claims submitted, you know, that's coming from a physician office or anything like that throughout the year by every specialty all goes through this funnel. And they either risk adjust or they don't. They either go to that higher hierarchy and then drop out another. And you can see just as the example here, as soon as we bill CHF, and then maybe somebody else bills morbid obesity, someone else bills angina and or one doctor on one claim, those are all gonna add up the old MIs or PBCs that doesn't add up. But we'll talk a little bit about, you know, what this is gonna mean so that it gets that total score. So it's just another way of looking at it. Yeah, and Linda, you said a very good point. And I see a couple of things in the chat about this is all claims. It's not just E&M, right? It's everything, procedures, or is it just E&M? No, it is everything. And we'll show you where you can go to get the list of the diagnosis codes and what category they're in. And on that very same link on the CMS webpage, you can get a list of what types of claims go in. Now things like a lab and things like radiology, those don't go in there. But I was really surprised and I really didn't even learn that till last year to see things like a cardiac tab and our interventions, those are listed. So, you know, how can you as a coder personally help improve your physician's coding? You know, you might be the one that can take it up to that next level of specificity on something that you're reading and coding based on the documentation. So we're gonna talk a little bit about what needs to be in that documentation. But yes, I mean, we need our physicians to do everything they can to be as specific as possible on their E&M codes, but it is not limited to E&Ms only. Right, right. And then what we're doing this year is really calculating the payments that would be predicted for those enrollees for next year, right? So we're kind of already behind. Yeah, and you know, and as we talked about, your score as a practice or as an organization or even the individual physicians, I hear that a lot. You know, well, why do I care? This just gets the insurance company more money, right? Well, no, it helps ensure that adequate resources are planned for and used. But right back to that first slide, was it the chicken or the egg? You know, someone makes a determination on the quality of your care that takes into consideration the cost. If you cost 10 times more than somebody else, well, then they're looking at it as, you must not be doing a very good job. So we need to set those realistic expectations. All right, moving to our next slide. Linda, this is the process review. So this kind of talks about, I think we talked a little bit about this around that face-to-face qualifying visit, anything to add here? I think we kind of covered this one as much as all the questions coming in and just from what we've talked about. Yeah, I think, you know, that's kind of everything in a nutshell there. All right. So this takes us to the Congress report, Linda. What can you tell us about that Congress report? You know what? Maybe I'm a geek, but I was fascinated by this darn thing. And you can go, you can just type in CMS report to Congress risk adjustment, it's titled there. And they've only published two of these, one in 2017, and this is the second one of 2021. It goes through, you know, kind of explaining what Nicole and I are talking about and it, you know, how it's built and all these different factors. And then it talks about all these actuarial terms. I mean, we're all risk adjusted, our life insurance, our car insurance. Well, it talks about how they do this with costs. And when you get to page, oh, about 50 or so of this, that's where these tables come in. So look at this table. This is, to me, this just blows my mind. You look at these different categories, it gives you the category, then the name, the sample size. So how many people are in here? But look at these next two numbers. This is what they actually spent in this year. So you can see it's the 2019 model. This is what they spent on that sample of patients versus what they predicted that they would send. I mean, the accuracy here, I mean, that just blows my mind. You know, how they do the math that they do and have figured out these weights and it allows them to be that darn accurate with their predictions in the different disease states. And this accuracy rate wasn't unique to these cardiology numbers. It really kind of spread all across. Personally, I found it fascinating. Also, and you may see some things from CMS coming around, there was a lot of information about some proposals coming down for 24 around HCC, not just HCCs, but overall weights and star ratings, just around that whole concept. And I think, you know, it's proposed right now, but again, it's coming back to the forefront. And I think we all need to pay attention to where we're at. This is where you can go on the CMS website for to download what Linda and I are talking about from those tables. You can easily search that diagnosis code Excel sheet by just hitting find and typing in the diagnosis without a period, and it'll take you to an HCC category. And you can also download that list of those face-to-face services procedures that really codes on claims that are eligible. So that'll give you an idea of what things are included in that. And those lists are there for you to download. This next chart is just a sample of that. And you can see this is the diagnosis codes, it says are valid for calendar year 22 and 23. When you look at these models, this is the most recent one and what HCC that they map to. And it tells you about the payment year and those types of things. So this is strictly for that CMS HCC model, but it's not the only model. You've probably heard of, you know, US News and World Report rankings. They use somewhat of the same based on data and they call that an APR DRG, or you may see some that it's used through that 3M. Medicaid risk adjustment programs, there are different state Medicades and they have their own acronyms that they use. Also HHS, you'll see from the Affordable Care Act health plan premiums, they utilize that. And then our commercial carriers have variability in this area. Linda and I talked as we were putting together this presentation about many of our carriers were getting letters for information around diagnosis codes from, that came from like 2020 that they're sending us letters on this year that it was built on a claim, but not supported in documentation and just several report card type things that we'll show some examples of. So Linda, you wanna take us through the common HCCs in cardiology and give us some insight into that. Yeah, what I tried to do was give you the HCC values, number one, because those are hard to find. You have to really go on a hunt to find where they're valued and we're working from the 2020 value. So that is the current one for 23 as well. And just take the categories that cardiology often sees. We know we have a lot of diabetic patients. We may not get a lot of acute because that's like the ketoacidosis and those types of situations, but the chronic complications or without chronic complications, you can see the varying weights here. And it kind of goes to reason as you look at those weights, congestive heart failure patient, you can see that weight is pretty high. But we know we have a lot of CHF patients who we see in the office once every couple of months, so we're doing lots of things to try to keep them out of the hospital. And of course, when a patient has an MI or other unstable angina, we maybe need to do something more. You can see, as you go down, atherosclerosis of extremities, we looked at the arrhythmias, vascular disease with complications. And a couple here, the transplant status, if you're in a transplant program, you certainly don't wanna miss an opportunity to code that each year. I mean, it's not like the patients, once you've had a heart transplant, you've always had a heart transplant. Same thing with the amputation. Once you've lost your great toe to diabetes plus a peripheral cardiovascular circulatory issue, it's not gonna grow back, but we have to code it every year. So I wanted to just give you an idea. I mean, that's a pretty manageable list, really. And then, of course, just kind of included some of these other ones, the malnutrition and endocrine and cancer and substance abuse, COPD. I mean, it's not like those are the only ones we're gonna see, but it's certainly the most common and ones to familiarize yourself and some of the physicians with. And if you wanna go to the next slide, Nicole, what I tried to do was just scroll through those lists of codes and just kind of give you a little summary here of the types of things that we're very likely to see that fall up underneath each of those categories. You'll see, you know, for the respiratory failure and morbid obesity is a big one. You know, we may document that patient's BMI, but do the doctors actually code it as morbid obesity that has an HCC weight? And that's an exercise you can do is just kind of to run a diagnosis report and look at your top diagnoses and how many of them fall into these. And, you know, if you see obesity unspecified and only a handful of morbidly obese, well, then there's some education to be done with the clinicians. So you can see the different types of things that fall into this category. Angina, it just stands to reason, you've got the atherosclerosis, and of course we know that's coded by the type, native bypass transplant, but with spasm and or with angina pectrus. And then the next slide, here's where you see some of those heart arrhythmias as well as all the other things. So these are two really good slides to kind of keep handy and maybe share with your clinicians as well, because it'll help, you know, kind of prompt them to think about it. And if you go on to the next slide, you know, if we need to remind them of the types of things that they need to document so that we can code to the greatest degree of specificity, this is what we need to see for those categories. So I just took some of the primary ones and you know that, you know, we can't code it if we're missing some of these things. So these are just the types of things. This is another good one to share with your clinicians. Great. And Linda, do you know if there's anything, you know, we talk all the time with our providers about, you know, they'll say chest pain, the patient has coronary artery disease, they don't necessarily document angina. Is there anything or requirements that outline if it's angina versus chest pain, is there anything particular in black or white, or is that just based on the clinician and what they documented as? That clinician needs to document it. We are, as we've mentioned, you know, when you see some of these payers will send you back reports and, you know, they'll review the coding and, you know, these MA plans, they want you to code as accurately as possible. And they want the maximum money that they can get for these patients. And some have been a bit aggressive. Some who may have tried to take chest pain and turn it into unstable angina based on the description, even though the physician didn't call it that, ultimately may end up having to refund that. So it's really important that your physician call it exactly what they see it using their best clinical decision-making and documentation to support exactly what they want to call it. Agree. I will say, you know, that one of the things that is helpful if they say, you know, patient's chronic angina stable on current medications. I mean, that is a really nice thing to say that could get them the angina if they have something that is controlling that angina. Correct. And I think what we've seen in some of those reviews, we talked about from MA plans that I've seen are just what you said. They'll review the documentation and it may have been coded CAD with angina, but there's no documentation of angina or any treatment that they're on for angina. So I think definitely calling it out. And if it's chest pain versus angina from a clinician standpoint, really giving that to your coders because we can't assume for sure. Absolutely. Right. So that brings us to some keys to success, Linda. Yeah. And, you know, I think this is also a good one to share with your clinicians. You know, we don't want them to say, you know, patient has a history of diabetes. You know, if they have it, they have it. You know, to say that patient has type two diabetes since, you know, 2010, or not a history of CHF on meds and LASIK, but compensated CHF stable on. And we love those connecting terms. You know, these connecting terms are, they know this and in their minds as clinicians, they may be, well, of course it's due to that. But from a coding perspective, we want to see it. That, you know, their chronic kidney disease is due to, you know, the hypertension or secondary to, or associated with. We love those connecting terms. And just letting them see this list too, can often, you know, make them think about, oh, you know what? I probably could say that. So it's another good one to share with your clinicians. Right. And do you remember when, Linda? Do I ever? And I wish, you know, I was thinking it would be fun at this point, if there was a way we could say, all right, who can be the first one to type in the number? What was the ICD-9 for CHS? And I bet you a bunch of you in a nanosecond said 428. Because we had all those memorized, you know? And then along came ICD-10, where coronary artery disease went from a six inch list, if we were to lay a tape measure on a list of codes, to six feet. And then cerebral vascular disease went from 3.7 feet to 19 feet. And I think that's what we're illustrating there on that piece of paper. And the same thing with diabetes, 1.8 feet to 6.8 feet. So, you know, just thinking about, you know, helping your clinicians get to that level of specificity. You know, we know most systems now, they're not gonna scroll through a list that's as long as that paper represents. There are terms that when they go to search the diagnosis code, there's certain terms they can add that will narrow that down and present fewer options to them and let them be more specific. Those of you who just started out in this coding in the ICD-10 world, it may not seem like a big deal to you, but man, that was a tough conversion. But at least we're there now. So, you know, why do we care? That's one of the first things that I often hear from the physician themselves. You know, as these Medicare Advantage programs grow, and that's where we started with showing that, hey, they're now at 48% nationwide. And in many states, much longer, much, much larger than that. We are most likely to have contracts that do have that quality and cost incentive. And that's where we're being reviewed for our quote value. And so in the way that shared savings contracts typically work is we have our defined patient population, you know, our Medicare replacement plan, then there's a funded shared savings pool. If we hit our quality goals, rarely do these contracts reward you with any kind of financial incentive if you don't first meet your quality goals. But if you do that, then you have a chance. And that's where that, you know, pay for value versus fee for service comes in. And that transition that we're in, you get some extra incentive back. Now, you know, how that's designed and all the other details, you know, take into consideration the attribution, you know, how is that patient assigned? Are they assigned to the doctor who sees them the most often? Are they assigned to the doctor who had the biggest dollar claims, which sometimes is our cardiology and lots of benefit designs. But it's important that the physicians understand that this gives us, we are in that transition year. And if we're not setting the expectation with appropriate funding and diagnosis codes, then we're just not gonna look well when we go to a value view. Nicole, you wanna talk a little bit about some of these payer peer comparison? Yes, yes. So this was pulled from some of our commercial payers. There's a link here to this article. I found it very interesting. And the big thing to call out here, it kind of gives this step approach of what does complex care, chronic conditions, the acute episodes and primary care, what does it look like? What are some of the payment models and what's the risk bearing? What I thought was interesting is just like always, cardiology generally always wins, right? In our world, we always like to think so. When you look at the definitions of these, how many of us can relate this to cardiovascular conditions? Time limited clinical states with defined treatment courses. We have some of that. Typically high volume and variable with a high spin. And they give the examples as joint replacement surgery or colonoscopy. But where we're at is in these other two more, chronic conditions that are managed over prolonged periods of time with no expected near term resolutions. And those typically drive a very high need at a very high cost. So those are how they define in this particular peer example, how they compare you for chronic conditions and what it looks like per payment model in some of these plans by specialty. Then of course our complex care, which is specialty led. So we could relate cardiovascular services to many of these definitions and how it impacts us with our other payers. And then looking at how we compare in our regions, in our states, in our counties, what are other cardiologists doing and what does that look like? And that is publicly available data to many of our patients. This Linda, talk about your case study group versus individual. Yeah, so if you're hearing some of this for the first time today or maybe just getting started in this, that piece that Nicole just mentioned about you're being compared to your peers. That is so important because maybe your peers have been working hard on this for 10 years and maybe they have all these other tools they're using like embedded coders and prompts and artificial intelligence that suggests, hey doc, you haven't built this this year. They may have that. So what can you do to really get a feel for where you may stand and how do you move your diet? So I'd like this grid on the left because as we've explained, as the patient is seen by the various providers throughout the year, that's gonna start rising. So you see every year, it goes back down to the bottom with that patient's demographic data and over the course of the year, it begins to build as claims come in and conditions are reported. What I like about this one, this is when we really, really started pushing this. We've been addressing it for years, but here you can see that in quarter three of 2018, we were almost where we were at quarter four of 2017. And that's not because the patients are getting sicker. It's because we're coding better and the physicians are truly comprehending and understanding this. And another way to do it is to look at each individual physician's RAF score and what you see on the right, these are some numbers from, I believe, like 2017-ish of our cardiologists. Now look at the mean RAF score per cardiologist in that column with the star, and then look at some of these others. So I'm gonna show you an example in just a minute. We took a peek at the gentleman that's sitting at 1.6094 with 407 patients attributed to them. Well, they're doing pretty good. So what are they doing differently than some of the physicians in the far right, or clinicians, I should say more appropriately, APPs count as well. And look at some of these lower scores. Why is it that we've got someone sitting at an average of 0.687 with 553? We need to know about their coding. And when you get this data, you can run that clinician's coding and look at their diagnosis codes. And say, you know what, we need to work with you on some comorbidities. And if you go to the next slide, I took some examples here. So you can see Dr. Billenbein. Now, someone told me I should have called him Billenbein. But you can see, you know, he's the one that has the high RAF score. And, you know, this is the other piece, but my patients are so much thicker than everyone else. Well, then your RAF score should show that. You know, we need good, good documentation and coding, understanding this impact, embracing it, getting good feedback. And at some point, payment may be based on this physician is a quote, higher quality or value than the next. And then you got Dr. I never heard. He didn't come to the meetings. He didn't know how important this was. So they just give, you know, they've got their favorite list of 15 codes. They just use that all the time on everybody. Could have been more specific, but didn't realize, you know, how important the specificity and coding is as we go to this new, you know, fee for value. So go to the next slide here. And let's just assume that with these three clinicians, we got, I never heard Dr. Guy pretty good and Billenbein. And let's just assume their treatment is absolutely identical. Their documentation is absolutely identical. The only thing that changes between these three with the very same patient is their coding. So look what happens. You've got, you know, everyone gets their demographics. So that's gonna be the same. And for the one encounter, they coded systolic heart failure and obesity unspecified, neither of which risk adjust. If that was the only time that patient was seen all year long, you can see the total amount that that plan would have been given to take care of that patient all year versus look in the center. Now we're being a little more specific. Now we've got the chronic systolic heart failure. We've added patient is morbidly obese with that BMI. We've got diabetes without complications and an abnormal EKG. Well, that's when that disease interaction comes to play. Simply by nature of the fact that heart failure and diabetes coexist in the same patient, we get a little bump. That's not something we have to code. It's something that happens behind the scenes. And you can see that disease interaction there. And now look at what that score went up to versus the final. Now we're adding, it's not actually diabetes without complications. It's diabetes with circulatory complications. And not only are they just circulatory complications, they've actually had their left toe amputated. And that abnormal EKG, well, that's really chronic AFib. And so that's coded as well. And now you see that we've got two interactions. There are seven interaction codes, five of which are heart failure. So kind of the moral of the story there is never miss the opportunity to code that heart failure. You know they're addressing it. You know they're thinking about it. And nine times out of 10, they're gonna have a comment about it. So this slide really helps, you know, kind of drive home the point of what a difference it can make. And you never know for sure if you're gonna see that patient again by the end of the year. So every encounter becomes more and more important to really get to that specificity and to report these comorbidities that do factor into their decision-making. So if you go to the next slide, this is the list of those interactions. And you'll see there, oops, it's four of six. I was thinking it was five or seven, my bad. Four of six do involve heart failure in some way. So like we said, you don't have to code it. This is just an extra bump. If over the course of the year, they see that the patient has both of these conditions, because that is gonna complicate one another. So if we go to the next slide, you know, when we talk about these, what we saw, like in the differences in those numbers that we reviewed earlier in our case study, truly it's those clinicians that are coding the comorbidities that really end up with those higher scores. And, you know, sometimes we'll have the clinician say, but you know what, I don't code the diabetes because I'm not treating that. They see endocrinology. Well, if the patient's having chest pain, chest pain in a patient with diabetes means something different to them because the patient is less likely to experience chest pain. So that does factor into their medical decision-making. And their note may say patient followed by endocrinology or patient stable on, you know, whatever it is they're taking. What's key is on the left-hand side where the coding guidelines tell us we should be coding everything, that coexists at the time of that encounter and affects the physician's idea and treatment. You know, if that patient's on a steroid, well then the physician may be selecting one medication over another when they come to controlling their hypertension or something. So it does impact them. So now we need a MEAT statement. And MEAT is the acronym for Monitor, Evaluate, Assess, or Treat. So you can see any one of those pieces. We don't have to have them all. Any one of these pieces is the MEAT that's going to support the fact that it factored into their medical decision-making and therefore should have been coded. So, Nicole, I'll let you give a few more examples there. Yeah, I sure wish it was a better acronym than MEAT. But, you know, it is what it is. And what I would say is this is a good chart that I've used when talking to providers as well as what do you mean by that? I'm going to document the diagnosis. You know, what do I need to review? What do I need to document? Well, these are some simple words. It doesn't have to be lengthy. So when you monitor, what are you reviewing? Their signs and symptoms, their progression. Is it stable, improved, worsening? What are you evaluating? Medication effectiveness, their response to treatment, test results. Is it controlled, uncontrolled, deteriorating? If you think about this too in how they're documenting medical decision-making, this all comes into that of, do you have what you reviewed and what you documented and addressing and assessing? What did you discuss? Did you review records? That gets into your data. Did you refer them to a specialty? Just using some simple sentences or simple words to really describe that and all of the conditions that were taken into consideration for the treatment of that patient. And I think that's the key is, how can you explain this to a provider? You're not asking them to document something that they're not doing. You're asking them to document what they're doing that may come just natural and easy to the physicians. And I know we may have some physicians on the call as well, but you know, this comes natural, but getting it in the documentation is the key. And I think this helps us both from a diagnosis coding perspective and also from our medical decision-making. You don't have to document all the elements of meat. If the assessment is missing, can you still assign a code? You know what we said, you have to have at least one of the following. So for every diagnosis. So do you have at least what you reviewed or what you're looking for, what you're documenting the condition on, but that's for your diagnosis. Got to think about that medical decision-making. And I think really this came together with providers when they look at it that way. And it doesn't have to be in one particular part of the note, get asked that often too. It can be within their HPI, if you have physicians that start off with all this information. But again, you want to be sure that that information's there for those diagnosis codes. This is a frequent question about, and it comes up with this, of course, diabetes with circulatory compromise. And it is very confusing. So Linda outlined in here from the coding clinics, what they've put out around when a patient has symptoms such as PBD, ulcers, these are listed in ICD-10-AIDS examples. Absent those conditions, it's less clear, right? So if they don't have that documented with their diabetes and their circulatory, this goes through, is there a cause and effect? Well, when you look at in 2016, it was, you can assume a cause and effect between diabetes and certain diseases, such as kidneys, nerves, and circulatory systems. This is often given as a reason to support if they have CAD and diabetes as a circulatory complication. But then it goes on and talks about, if physician documentation specifies the diabetes is not the underlying cause of the condition, the condition should not be coded as a diabetic complication. Well, don't we wish it was that simple, right? If they use the term with, you could assume a causal relationship. And then it goes into, it comes down to, and I totally agree with this statement, does the provider document an association or connection of that CAD and their circulatory complication or vice versa? If so, you have a clear yes, just like many things in our environment. If not, it's gray. Absent that linkage, you can rely on either enter, and coders don't all agree in this area. And I know that's a shocker, but it's one of those things where when you're talking to your providers, having them give you something for that linkage is what I would recommend, and not having to figure all this out. Because again, when they were viewing your records external a year or two later, they may not follow one of these guidelines. They might follow the one that's gonna say it has to be clearly documented, or looking in some examples like that. And I think this comes into play in a few things that we look at when we're coding diagnosis codes. I absolutely agree. And it kind of goes back to that linkage slide that we had before. If we can get that with secondary two, due two, well, now it feels so much better. And it's just a good practice to get into to include that when that's the case. I've had physicians as well challenge that and say, well, I wouldn't make that assumption. Well, I sure don't want to as a coder either. I would much rather find that term. Right, exactly. And then this is some tricks that we've given physicians as well from when they're talking about essential hypertension. If it's hypertensive heart and kidney disease, and they have chronic kidney disease, and you know the stage that they're on dialysis, if you have that information, yes, you may not be treating coexisting or comorbidity conditions. We kind of use in those terms interchangeable. But if the physician is taking into account that that patient has chronic kidney disease, they're on dialysis, and they have hypertensive heart disease, may not be treating it, but he is taking it into account for his treatment, he's addressing it within his documentation, then that can be documenting. If they're just listing all of these chronic conditions, but there's no meat anywhere within the note, that's where we get into just having a list of that is not gonna get you there. And I think this kind of just goes down the path of, you know, if it's ischemic cardiomyopathy, if it's dilated, is it with heart failure? Is it syncope due to sick sinus syndrome when we talk about angina? If it's chest pain, call it chest pain. If it's angina, call it angina. And I think we can go down that, and you could go down your list of the common ones to kind of look at what are some considerations toward that HCC weight. What does not risk adjust? You wanna talk about that, Linda? Yeah, I think, you know, this helps, you know, we talk a lot about specificity, and, you know, the morbid severe obesity does, obesity unspecified does not. That is a great check, if you do nothing else, is to run your individual clinician's diagnosis coding and see what their ratio is there, and seeing if it makes sense to them. I know I worked with a practice, and they sent me their top codes, and I sent their doctor back, who was assigned to, you know, be the head of HCC. And we're talking a cardiology practice here, and only three of their top 10 risk adjusted. But look at that list of what does. It simply came down to old habits die hard, and they were using less specific terms. Now, of course, you know, you can't just code more than you know, and you certainly can't code more than what's documented. But that, just give us a little more specificity, and code it as such, is a really good approach to what you can do to improve. If you go to the next slide, this is an example, and I've used over dates of service, but look where this clinician was. This was one of our lady docs and and she had never heard this information and once she got the education look at her average draft scores just climbing and it's not that they got sicker it's oh okay well gosh why didn't I know this and that's exactly what we need to do is make sure that our physicians are at least aware and and help them with that and what can you do you know like we said running those diagnosis code reports look at some of the ones with uh lower scores there's lots of things people are doing uh to try to increase this as this grows even more and more and more and if any of you are in the medicare accountable care organizations you know at some point your organization may be the payer you know to where you you need to get ready now for if you join an accountable care and if you are in an aco well then you got to get ready for when you become risk you know and so it's just important that we we do this and do it to the best of our abilities now so let's go to the next slide you know what if you're thinking here well this is great but i have no idea where to get these numbers i've never seen this i have no clue where we land well there's a couple of things i would say if you are part of a larger organization you know a hospital owned chances are there is a population health department now i can tell you that a lot of them are focused on primary care but that doesn't mean they can't give you your cardiology data you know the primary care focus is important because really the opportunity to to schedule that long visit and really focus on all those conditions most typically lands in that medicare annual wellness visit and you hope you catch them there but i'll show you some slides here a minute where that you know just as the cardiologist may not be too keen on coding diabetics well some of the primary cares aren't too keen on coding some of the cardiology diagnoses so if you're part of a large organization you know key is getting both in the game and that's when you really make a difference now if you're in a private practice actually even if you're in a large organization any of your medicare replacement plans they will just fall all over themselves to give you education to give you tools to give you information about how you're doing it helps them it helps your patients and they would love to help your physicians understand this and give you data on areas they see where you might be able to improve so if you if you don't have other resources you know reach out to any of your medicare replacement plans they'll be happy to help you if you run a report on your diagnosis codes we've mentioned that a couple of times even if you just do it practice-wide first and then you can later do it per clinician and just look for the differences you'll be amazed at how many people for example just are in a pattern of coding diabetes unspecified when they know darn good and well that is a type 2 diabetic and they could be more specific and that they might have something more going on so you know even if you pick I don't know five codes they're you know looking at the comorbidities which ones you know are being under reported you know look at how many times you may have billed the code COPD or how many times you build you know some of these other conditions that may not be the primary reason but are often taken into consideration when they see the patient and then we hear a lot of feedback where you know the clinicians will respond back to us saying well I thought we could only put on four you know make sure that your system is ready and capable and you have it you know functioning where you can put 15 or 20 codes on the claim I know that clinicians think I'm not going to sit here and click to one different condition okay but maybe 10 you know all the ones that you really thought about today so there's a lot of different things you can do that might get your numbers up Nicole any other comments there no I absolutely agree Linda I think that there's there's many things there I think um you know when we get into some of our tools within our medical records I think this covers the one you're currently using now I think that's helpful also yeah yeah just knowing what those tools are and I know we've got some examples here the the first one here is from Athena and one of the things that this has is what's called a gap so if you if we click on problems we can see what's been listed and then there's a little prompt there that says hey there's 13 other conditions that were built somewhere along the way last year that have not been built yet and if you look at the what those amount to that would increase that patient's HCC score by 7.44 if they still apply and it gives the opportunity to say oh gosh yeah they do have peripheral neuropathy because of their diabetes I need to add a comment on that today it's just a reminder now it's not in the in the total workflow it is one extra click and we know that our clinicians are super busy and it to us it's one more click but to them it's a few more seconds and a few more seconds and a few more seconds but we have to get ready for this conversion we have to get closer and this is truly key so you know know what tools your medical record has available and make sure that you've trained on them Nicole I think you've got a few other system examples here yeah this is one within Epic and I think this one was interesting that you know if when you look at with an HCC diagnosis to address it kind of gives you a little advisory if you have doesn't have an HCC it doesn't give you the advisory so some of these depending on your Epic and boy do I know every Epic is different they may have different things in there also if you're doing just pick list from some programs like this is from a hospital charge capture program if you have a little H with a circle by it just giving an idea of what does risk adjust and what does not and has an HCC I think this has helped physicians as well because if they have multiple ones listed and they see that you know the more specified congestive heart failure has that H and it's not just a generic then you you know you're going to choose that one so I think that that's very helpful from that standpoint um when you look at your reporting Linda does your medical record or billing system support some sort of reporting I think this was one example you have and is this your gap that you're showing here yeah I thought this was interesting um and I went into some of these just to see you know why was there such a big gap you know so you can see the patient name you can get into the chart you can go in and look at it see what's coding then I could I could look at that gap and say okay what was there that's not there any longer I found a couple patients who unfortunately had passed I found some of these were patients that had some type of a cancer and you know unless we're the ones in cardiology I mean we do see those cancer patients a lot of times we're asked to look at the heart failure that may be worsening because of the chemo that they're on and so coding that cancer is absolutely appropriate um also saw a lot of patients who only lived in Indiana when it was nice and warm which means by June they're gone they are they're the snowbirds you know they may stick around till August or September but that makes the visits that we're going to have in the next couple of months even more important because they may be snowboarding and somewhere else you know towards the end of the year when we're trying to close close gaps so you know if you have a tool like this and you can go in and see okay what did the physician address on that visit and what did they code or what did they document and not code and use it you know as a educational tool to give some feedback as this next slide this is an example of what we received from a payer that they said sent it to us and said hey we have some gaps here and I thought it was interesting as you and I think this illustrates well that you know the list from the payers is kind of an all-in this is what came in from the primary care from endocrinology from cardiology from pulmonology from infectious disease and they'll say it's not you know we haven't seen it yet this year well look at how many variations of what's going on with this patient is it unspecified a fifth unspecified a flutter is it atypical a flutter is it chronical atrial fibrillation well you know the cardiologist really could be uh the best one to maybe get that cleared up and that's another thing you know if you're in an organization where you have a shared chart it kind of becomes everyone's responsibility to try to help everyone else you know if they come in to see cardiology and if by chance all four of those conditions are listed in the problem list then gosh it would be great if the cardiologist picked the correct one or maybe this patient has both fib and flutter you never know and then you can see down below another example you know you've got all those variations of pulmonary hypertension so this is what the plans see and they want to know well what is it and and what is it that you're treating because we had this billed four different ways last year and no one has billed it this year is anyone addressing it and it's a good prompt that way as well to make sure that you you are seeing and addressing these patients we go to this next chart you know we if you've not yet had a review by the payers where they look at what you said the patient had and then they audit it and say we disagree well we just got one of those reports and i can tell you a couple of things that that were takeaways there is they put really heavy emphasis on what's in the assessment and plan now here you can see you know what's in that assessment and plan that's all i copied in here but the other thing they look for is the absolute code per code match that you know i 73.9 is there and it's what was coded e 11.51 is up top and that is what was coded so making sure that it is an absolute specified diagnosis that is both documented and coded as such and looking for that meet so you know here's this is just an example we had another one that um the patient had a bmi of 35.7 and then diabetes type 2 as well as diabetes with uh peripheral neuropathy so if you know uh that piece and make sure your clinicians understand that a bmi over 35 with a comorbidity is morbid obesity and this clinician had clearly documented the bmi of 37 they clearly documented the comorbidities but they didn't use the word morbid obesity in their assessment and plan and nor did they code for it they just attested to it on the sheet that yes this patient is and then they came back and said it's not documented well the conditions were documented but the words themselves were not so just just understanding uh the importance of really being specific nicole you want to talk a little bit about why that's important yes absolutely um so we do know we've seen headlines about medicare advantage companies leverage chart reviews and risk assessments to drive payments so the oig um designed this to ensure that the health plan received appropriate risk adjustment based on their patient's health status so we've seen that and i think in the next slide um you know it goes into the oig is calling for more oversight on some of these ma insurers because we've seen some headlines where the diagnosis may have been coded but the documentation didn't support it and do you think those reviews are going to increase linda as we we've gotten out of the phe now um i think we're all prepared for many audits to start back up what is your thought on that oh yeah oh yeah i think i think uh those folks are anxious to get back to work we know that they did say that they would you know slack off they know how crazy busy we all were but yeah i think that grace period's over and we're going to see the volume significantly increase yeah and i thought this interesting graph 610 million dollars in vascular disease was disproportionately driven for payment by some of the um medicare advantage plans so again you know having that solid documentation for sure so how can we improve well i think you know depends on where you stand but in that getting started even though you may have started this you know 10 years ago it's a year it's an annual thing you know we've just have to keep trying to help our clinicians you know we want them to do their absolute best clinically and we're holding them and asking them to do all these quality metrics and all these different pieces you know but what can we give them you know something pretty manageable to maybe say okay let's get in the habit of morbid obesity let's get in the habit of you know whatever it is come up with a couple of things see if there are tools see if there are any barriers and keep in mind that on the right you know there you're being compared to your peers so what are your peers doing you know i'm curious how many of you might have an hcc coder that actually looks at the chart up front and prompts the physician hey don't forget to address this today and or looks on it on the back side hey you documented this but you didn't bill it you know a lot of us are we're just relying on whatever that clinician clicks but to really move this dial and as we move forward more and more things do come into play yeah absolutely i think this this next slide here you know this is another takeaway for you you know if you if you don't take away anything else these are certainly the conditions that make your clinicians aware if they have a patient with any of these that it's so important that they they document and add that code accordingly each time they get the opportunity you never know if you're going to see that patient again they may or may not keep their follow-up appointment yeah that next slide is one that we use with a lot of the primary care doctors and and really i've used this for cardiology as well just to say hey just take a look at this you know what what are you seeing that you may not be addressing and coding take a few and you can make a big difference so nicole i'll turn it back over to you to take us home yeah so obviously key takeaways and some good comments in the questions you know what do we think has been the most successful from an education perspective is it you know sorry about that linda i said i said we're seeing a couple of things around education so i think this number one takeaway educating your providers with simple key tips ongoing so it sticks uh and then uh also in the question you know do you think focusing it on your emr hcc gap tool i'll tell you i think you have to leverage those platforms i don't think it's one or the other is more successful i think the key for what we see is that it has to be ongoing and in small bites because most don't want just tons of this flooded to them at one time and you can't do it once every nine months you got to give it to them in small tips and then what can you do in your ehr you know so many times searching for diagnosis is painful because it's pulling that code description what can you use to help your providers even if it's still a piece of paper with some cheat sheets on it i mean if that's all you got um it definitely helps and i think it's those little things that help with that success and then that ongoing and then your provider documentation workflows i think that's an easy win to help them and then you know i put in here have we thought about queries in the ambulatory setting and how to make these effective i often get asked that because in the hospital the doctors will tell you they're queried to death in most cases so can you have some sort of query for clarification and i think you've got to do that with some providers but really focus on trends with providers not if it happens one time but what are some of the trends for those particular providers and if you're looking at their documentation regularly pretty creatures of habit and i think you'll pick up on some of those to focus on lynda is there anything else you can you'd like to add to that no i i'd absolutely agree with everything here i think you know educate educate educate and work with them on what are the barriers what does make it hard if they're having a hard time getting a specific code to come up when they type in its verbiage then as nicole mentioned give them a tool a teach a cheat sheet they can just type the code itself in and get there quicker so get your get your clinician feedback and most importantly make sure they're at least aware and now you guys are aware and you can do what you can do on some of those procedures and others to be as specific as you can versus just going with the one you have memorized absolutely well thank you so much lynda i apologize to everyone lynda too on our technical issues early on but good news is we're right on the dot at 230. if you have any other questions feel free to reach out stay tuned we'll be developing some tools that lynda and some of her team have worked on and also looking at doing some podcasts with lynda so we hope that we see you all out there and we appreciate everyone's attention today and i hope you have a good afternoon thank you thank you everyone

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