Best Practices for RA Compliance

By Laura Brink, RHIT, CRC, AAPC Services Senior Auditor

Value-Based Care (VBC) is changing the landscape of both patient outcomes and revenue streams. At the same time, the obstacles in reporting for various payment models remain constant with these changes. Each payment year brings new updates — from data and processes to the payment methodologies that require review and revisions. Add in documentation and coding requirements, administrative burden, and risk of revenue loss and the notion of a Medicare Adjustment Data Validation (RADV) audit can become a concern. However, tackling this compliance burden in VBC can be made simpler with best practices and experts helping you hit the mark each payment year.

When reporting for Medicare Risk Adjustment, maintaining awareness of code changes for various models each October is essential for accurate data submission. Understanding of code and guideline changes, paired with a focused audit, ensures a smooth transition in concurrent coding reviews and retrospective reviews down the line.

This year’s guidelines further address the push for capturing specificity, not only in coding to the correct number of characters, but also to the highest specificity documented in the medical record. This change is also reflected in this year’s ICD-10-CM code release, providing a greater level of detail in reporting diagnoses.

2022 ICD-10-CM HCC Updates

*RxHCC Model

· C56.3 - Added: Malignant neoplasm of bilateral ovaries

· C79.63 - Added: Secondary malignant neoplasm of bilateral ovaries

· C84.7A - Added: Anaplastic large cell lymphoma, ALK-negative, breast

· D55.2 - Deleted and replaced by:

· D55.21 - Anemia due to pyruvate kinase deficiency

· D55.29 - Anemia due to other disorders of glycolytic enzymes

· D89.44 - Added: Hereditary alpha tryptasemia

· E78.244 - Added: Niemann-Pick disease type A/B

· F32.A*- Added: Depression, unspecified

· F78* - Deleted and replaced by:

· F78.A1* - SYNGAP1-related intellectual disability

· F78.A9* - Other genetic related intellectual disability

· G04.82 - Added: Acute flaccid myelitis

· K22.8* - Deleted and replaced by:

· K22.89* - Other specified disease of esophagus

· M31.1 – Deleted and replaced by:

· M31.10 - Thrombotic microangiopathy, unspecified

· M31.11 - Hematopoietic stem cell transplantation-associated thrombotic microangiopathy

· M31.19 - Other thrombotic microangiopathy

· M35.00-M35.04, M35.09, M35.0A – Revised descriptor: Sicca syndrome to Sjogren syndrome

· M35.05-M35.08, M35.0A-M35.0C – Added: Sjogren syndrome codes

· M45.A0-M45.A8, M45.AB - Added: Non-radiographic axial spondyloarthritis codes

· R45.88 – Added: Nonsuicidal self-harm

· S06.A0XA, S06.A0XS – Added: Traumatic brain compression without herniation

· S06.A1XA, S06.A1XS – Added: Traumatic brain compression with herniation, sequela

· T40.712A, T40.712S – Added: Poisoning by cannabis, intentional self-harm

· T40.722A, T40.722S – Added: Poisoning by synthetic cannabinoids, intentional self-harm

· T40.7X2A, T40.7X2S – Deleted: Poisoning by cannabis (derivatives), intentional self-harm

Best Practices in Risk

As the industry proceeds to transition from Fee-for-Service (FFS) to more VBC programs, the benefits of accurate documentation and diagnoses code capture should not be overlooked. Quality measures and payments for programs like Medicare Advantage Risk Adjustment depend on diagnoses accuracy.

For example, the OIG found inaccurate reporting of acute strokes, resulting in $14.4 million in overpayment in the 2015-2016 payment year to Medicare Advantage Organizations (MAOs) alone. This is a widespread outpatient coding error that is just one example of misused codes that should be addressed in audits, whether done internally or through a third-party vendor.

Reaching compliance goals to avoid reporting mistakes doesn’t have to come with an administrative burden. There are a variety of best practices and solutions to do the heavy lifting for you. At AAPC Services, we conducted a case study using data spanning 5 years, with over 200,000 audits, addressing the advantages of a compliance-founded Audit, Educate, Reaudit process. The case study found that ICD-10-CM accuracy came in at a low 83%. However, after applying this targeted audit process, the average accuracy went up 10% for diagnoses reporting. Supplementing this audit process with focused reports of pertinent findings and education to foster improved accuracy is just one way to save providers’ valuable time and energy.

Implementing a sound audit process, in combination with industry best practices and solutions, can improve reporting compliance while ensuring money is not left on the table. To assist in quality reporting, consider the following to help alleviate workloads:

Identify Risk Areas by Model and Specialties

· Is one practice or provider performing better than others? Consider appointing a provider as a champion to assist in education to improve engagement.

Revise Audit and Query Processes

· Present only what is necessary in audit reports to reduce administrative burden.

· Review and update query processes to prevent physician fatigue.

· Using discretion, templates, and standardized comments is key to effective queries.

Update Problem Lists

· Implement processes for coders and/or staff to review records and problem lists prior to Annual Wellness Visits (AWV).

· Address the reviewed problem list and HCCs for the year in one sweep.

· Don’t forget the MEAT (Monitor, Evaluate Assessed/Addressed)! Make the most of the visit and capture the patients’ risk completely the first time.

Update Code Descriptors

· Coders cannot use a standalone ICD-10-CM code. Additionally, when the description is incorrect it can map to a different code, leading to potential revenue loss.

Identify Top 10 Misused Codes

· Spotlight a coding concept for one error that can be more broadly applied to prevent overwhelming providers. Ex. Apply concepts for acute strokes codes in the outpatient setting to MIs and PE/DVTs.

Introduce Third-Party Vendors

· Determine what options are available to your practice and provide the greatest impact in recovering potential lost opportunities in your Risk Adjustment Factor (RAF) scores.

· Support from software companies like ForeSee Medical reduce admin work, while maintaining compliance with integrated discovery and decision support at the point of care.

· Audits services provide a variety of specialty and focused audits, in combination with education, to ensure accurate risk capture solutions.

Implementation of best practices for RA compliance and risk reduction is dependent on the quality of support from coders, auditors, and vendors. Uncovering new opportunities and closing gaps in patient care outcomes with process improvements is easy with a team of experts to boost RAF scores. Through experienced certified auditors and technology-employed algorithms and machine-learned natural language processing, keeping up with the changes in VBC is more customizable than ever — so physician effort stays centered on patient care.

---

About the Author

Laura Brink, RHIT, CRC began her career as an outpatient medical coder and auditor. Following her work in outpatient services, she moved to specializing in HCC Risk Adjustment performing provider and coder auditing with experience working in multiple models such as HCC, RxHCC, ACO, and QHP. Additionally, she assisted in provider education and training to ensure accurate risk scores utilizing query processes.

About AAPC Services

AAPC has the largest network of billing, coding, auditing, and practice management professionals in the world. And they offer the industry’s best software and solutions to support healthcare organizations with training, accreditation, and revenue cycle optimization. To learn how AAPC can improve your revenue cycle, visit us here.