Blog and Helpful Articles

A Moment of Silence for the Sunsetting MRA Program – Part 1

Since the CMS-HCC risk adjustment payment paradigm took effect in 2003, our company has seen considerable changes, but this year takes the cake, as they say.  Frankly, a moment (or really, a week) of silence would be appropriate to mourn the sunsetting of the current MRA program.  Seriously.

Every year, the Centers for Medicare and Medicaid Services (CMS) publishes a long document detailing payment changes for Medicare Advantage plans and this year, CMS finalized the 2024 Risk Adjustment Model.  In a nutshell, CMS overhauled the program, which was still being impacted by ICD-9 in the classification of codes into HCCs (hierarchical condition categories) and in certain aspects of the payment calculations.  This is all in CMS’s continuing quest to have MA coding more closely mirror that of fee-for service (FFS) Medicare.  Read this article for a brief explanation of the differences in these two styles of payment. 

Clinical revisions were made to the HCC model because of “discretionary coding variations” that were deemed to be less reliable predictors of future medical costs.  This means that a large number of routinely coded conditions in a traditional primary care practice are being removed from the model.  The number of ICD-10 codes mapping to HCCs will decrease from 9,797 to 7,770.  For a summary and list of conditions being phased out of the model, read Part 2 of this article series by clicking here.

Some of the remaining conditions have been re-mapped because of newly created HCCs or the splitting of existing HCCs.  The 2024 HCC model will now include 115 categories, up from 86 in the 2020 model.  Those of us who can rattle off HCCs and their hierarchies in our sleep will have our brain cells taxed as we adapt to yet another new normal. (LOL)

Finally, the coefficients for diabetes, which spans three HCCs ranging from no to acute to chronic complications, have been recalibrated to be the same.  From a practical standpoint, this means that there is no difference in payment for diabetes, regardless of any complication, although some of the complications themselves may still prompt additional payment. The world of CHF changed slightly with the potential for payment impact in the future. For now, CHF codes have been reassigned to three HCCs: acute on chronic, acute, and chronic.  Their placement in a hierarchy portends payment differentials where the (more frequent) chronic conditions will have lower coefficients and thus, payments. But let’s not borrow trouble right now.

The one ray of sunshine is that the 2024 model will be phased in over time. For 2024, CMS will calculate risk scores by blending 67% of the coefficients from the 2020 model and 33% of the 2024 model.   This means that for conditions exiting the current CMS-HCC model, plans will receive only 2/3 payment. In 2025, the blend will shift to 33% calculated with the 2020 model and 67% using the 2024 model, with 100% reliance on the 2024 model in 2026.

On what should providers focus right now and moving into 2025 to minimize losses?  We cover that in Part 3 of this article series, which you can read by clicking here.

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MRA & FFS Normalization

This post is parenthetical to the series entitled, A Moment of Silence for the Sunsetting MRA Program.

Although Medicare Advantage (MA) and the traditional Medicare program cover the same patients (called members in the former and beneficiaries in the latter), the operation of both payment systems is as different as night and day.  The idea behind Medicare Advantage, or Medicare Part C, is that it’s an alternative to traditional Medicare and shifts the financial risk of medical care for those beneficiaries to a third party (the Humanas, AvMeds, etc.) and away from the federal government.

We’re going to limit our discussion to physician care for this explanation.

The Medicare program pays physicians via fee-for-service, which is literally a fee for every service performed.  The payment for each service is determined by the CPT (Current Procedural Terminology) code® as listed on the Medicare Physician Fee Schedule based on the county where the services are rendered.  Take, for example, CPT code 99213, a low-level evaluation and management visit; payments range by region from $66.49 (FL-99) and $68.82 (FL-03) to $71.85 (FL-04).

The Medicare program bases payment on medical necessity, so providers link diagnosis codes [from the International Classification of Diseases, 10th Edition (ICD-10)] to the CPT code(s) when they submit a claim.  Each CPT codes needs only one ICD-10 code to be processed for payment, although more than one may be reported by the biller.

The Medicare Advantage world is very different.  MA plans are paid a flat payment by CMS that covers all of the costs of care the member incurs.  The formula to calculate this flat payment includes factors for demographics, such as age, sex and location, but the predominant driver of the payment is the member’s medical profile as expressed in diagnoses, or ICD-10 codes.  MA payments are highly impacted by the number of medical conditions in the member’s profile, which are assigned to hierarchical condition categories (HCCs), from the CMS-HCC model. 

Conditions are mapped to an HCC when they have sufficient predictive value for future medical costs.  Although MA physicians also report a CPT code for each service, when providers are paid via capitation, the CPT code doesn’t impact the payment amount. The medical conditions do. In summary, physician payment in the traditional Medicare program is based on CPT codes with ICD-10 codes used only to prove coverage and medical necessity. Physician payment in MA is capitated and based on ICD-10 codes, and CPT codes are largely irrelevant.  Yet CMS is bent on squeezing the MA risk adjustment paradigm into the FFS framework, despite the disparate incentives and rules.

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Medical Practice Owes for COPD & Morbid Obesity False Claims

Over the years, we’ve written many a blog post on risk adjustment compliance, advising our readers on ways to work successfully with this payment paradigm.  And yet, almost every week, the Office of Inspector General (OIG) publishes notices regarding false claims liability for medical practices working with Medicare Advantage plans. Sadly, we’re not surprised.  The most recent press release concerns a practice in Philadelphia that allegedly submitted unsupported diagnosis codes. 

The codes in question are for chronic obstructive pulmonary disease (COPD) and morbid obesity (MO).   Let’s look at these conditions in more detail:

COPD is a respiratory condition affecting millions of Americans.  According to the Global Initiative for Obstructive Lung Disease (GOLD), diagnosing COPD requires spirometry test results within specific parameters.

Over the years, we’ve seen a COPD diagnosis conferred without spirometry because:

  • The patient is/was a smoker.  Yet GOLD states that although cigarette smoke is an environmental risk factor for COPD, “fewer than 50% [of heavy smokers] develop COPD during their lifetime.” Consequently, smoking history cannot be de facto evidence of the diagnosis.
  • An imaging study, such as a CT scan or chest x-ray, showed it.  COPD is not an imaging-based diagnosis although a scan may show lung changes consistent with COPD.  Per GOLD, “spirometry is required to make the diagnosis.”
  • The patient is/was a smoker and is using a bronchodilator or steroid.  First, these medications are used for myriad conditions, many of which are not risk adjusted.  Second, per CMS guidelines, the mere presence of a medication is not clinical support for a condition. 

To be sure, other pulmonary conditions also fall under the CMS-HCC model and may be diagnosed via imaging or based on signs and symptoms for a defined period of time, but not COPD.

MO is one we don’t often see mis-coded but for the PA practice, it allegedly was.  Body mass index (BMI) is the determinant of conditions such as overweight, obesity and morbid obesity.  To be clear, we’re specifically referring to the BMI documented on the note at the time of the visit.  Under ICD-9 guidelines, MO was defined as having a BMI of 40 or above; ICD-10 removed this instructional note, which has made it possible for providers to code MO for pts with a BMI between 35.0 and 39.9 as well.  However, a BMI in that range doesn’t mean MO is automatically supported.  Health plan guidelines require comorbidities (usually two) that when combined with a BMI of 35+, pose a greater risk for the patient’s health and future medical costs.

This means: 1) Your practice should have an internal policy – approved by your Medical Director – that specifies which comorbidities are recognized by your practice as meeting these criteria AND provider visit notes should specify which comorbidities the patient has.  This is part of supporting the condition with evidence.  2) Your providers must assess MO as they do any other condition.  A proper assessment is more than a short statement that the patient was provided with a diet plan.  If your patient had uncontrolled diabetes, would the provider simply say, “Take your medicine” at every visit?  Or would there be an escalation of treatment options while attempting to manage the condition? Same with MO.  3) Pay attention to BMIs because they can fluctuate at every visit. This is something that billers can assist with when they review a note prior to encounter processing in order to minimize coding errors.   

The PA medical group also allegedly improperly billed Evaluation and Management code 99214 and 99212 (incident to).  This video explains the new AMA criteria for E/M which took effect on January 1, 2021.

It’s important for providers to understand that each instance of reporting an unsupported (diagnosis or procedure) code is considered a false claim.  The US Department of Justice’s website states, The FCA provides that any person who knowingly submits, or causes to submit, false claims to the government is liable for three times the government’s damages plus a penalty that is linked to inflation. Needless to say, the financial costs can be staggering because in addition to these fines, the provider may be subject to recoupment from the plan for all unsupported codes.

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What We’re Reading: Florida Hospitals Must Soon Require Patients to Declare Immigration Status

Beginning on July 1, 2023, Fisher & Phillips reported that any hospital in Florida that accepts Medicaid will need to ask all patients whether they are a U.S. citizen, lawfully present in the country or not lawfully present.  The hospital representative must explain to the patient that his/her response will not affect patient care or result in a report to immigration authorities.

In addition, each hospital must submit a quarterly report to the state within 30 days after the end of each quarter, reporting the number of hospital admissions or ER visits and patients’ responses to the question – or whether they declined to answer.  Of note is that the reported information may not include patient names or any personal identifying information.

The Florida Agency for Health Care Administration (AHCA) will compile details from across the state and report these figures to the Governor and lawmakers on an annual basis. The report must also include information about the costs of uncompensated care and its impact on hospitals’ ability to provide services to the community.

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CMS Issues Revised ABN for Use by June 30th

The Centers for Medicare and Medicaid Services (CMS) has issued a revised advance beneficiary notice (ABN) form.  The new form has an expiration date of 1-31-26 and will be mandatory on 6-30-23. You may continue to use the ABN form with the expiration date of 6-30-23 until the renewed form (expiration date 1-31-26) becomes mandatory.

The ABN is a document given to a Medicare beneficiary (one who is in the regular Medicare program, and not a Medicare Advantage plan) when the provider believes that Medicare is not likely to cover a service. It is a service-specific document and not a blanket, sign-it-once document as part of the new patient packet.  The types of providers required to provide the beneficiary with an ABN include: physicians; hospitals; providers and suppliers paid under Part B, including laboratories; hospices; home health agencies, and a few less common provider types.

The purpose of an ABN is to transfer potential financial liability to the beneficiary.  Basically, let’s say you believe your patient needs service A – or your patient wants service A – but you’re doubtful that CMS will cover it.  Maybe the patient doesn’t meet the criteria to receive the service or it’s not a covered service but the patient wants it anyway. Prior to delivering the service, the provider explains all of this to the patient, including the fact that Medicare may not pay for it, and provides the patient with a completed ABN.  This puts the patient on notice – and he or she essentially agrees – that if CMS declines payment of the service, the patient will be responsible for paying.

A few caveats:

  • All of the patient’s questions must be answered by the provider before the patient signs the ABN; this is not one of those perfunctory “Just sign here” situations. 
  • The ABN must be provided far enough in advance so the beneficiary has time to consider his/her options and make an informed decision.  ABNs are never required in emergency or urgent care situations.
  • The completed ABN form can have no blank spaces. 
  • Once the form is complete, the beneficiary will sign the form and receive a copy. The provider must retain a copy of the signed ABN in the file.

An ABN may also be used to provide notification of financial liability for items or services that Medicare never covers. In that case, it is not necessary for the beneficiary to choose an option box or even sign the notice.

The revised ABN form in English and Spanish can be downloaded here.  The ABN instructions document can be downloaded here.

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Guilty Pleas in Fraudulent Nursing Diploma Scheme

Dozens of defendants allegedly participated in a scheme to create an “illegal licensing and employment shortcut” for nurses, according to the U.S. Attorney’s Office, Southern District of Florida.  Five individuals pled guilty to wire fraud conspiracy and admitted to working with Palm Beach School of Nursing to create and distribute fraudulent diplomas and transcripts.  These materials represented that the aspiring nursing candidates had attended the school and completed the necessary courses and clinicals to obtain their nursing diplomas when, in fact, the aspiring nurses had not completed the requirements. Each student paid the school $15,000 for the fraudulent nursing school diploma and transcripts. 

As part of your due diligence in the hiring or contracting process, it’s important to vet applicants’ materials carefully to assure they are legitimate.  For accredited agencies, competency evaluations are a required step in the hiring process and may help you identify those who are not able to deliver the standard of care your agency requires.  Lastly, it goes without saying that if you’ve hired students who “graduated” from Palm Beach School of Nursing, you should certainly take steps to determine whether their credentials are valid.

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What We’re Reading: All Florida Employers Must Use E-Verify as of July 1, 2023

The use of E-Verify has been mandatory in Florida for public employers and for private employers who contract with state and local governments or receive state incentive dollars.  A new Florida law, however, will require all private employers with at least 25 employees to use the E-Verify system during their onboarding process beginning on July 1st. 

E-Verify is an online verification portal for employers to verify the identity of a new hire and assure he or she is authorized to work in the US.  It does not replace the requirement to complete an I-9 form for all employees; it is the step that follows the I-9 completion. Additionally, the E-Verify system must be used to verify all new hires regardless if they are US citizens.

Our friends at Fisher & Phillips (F&P), a well-known employment law firm, further explain some take-aways for employers:

1. Make sure you have a plan to comply by July 1st.  Also, understand the process: if the info you enter doesn’t match the records in the database, the system will issue a tentative nonconfirmation which the employer must provide to the employee.  The worker has 10 days to resolve the mismatch or discontinue employment.

2. Employers are required to retain documentation and any verification documentation for at least three years.

3. If an employer uses the E-Verify system in good faith, F&P states that the government presumes you have not hired unauthorized workers. They suggest that if the E-V system is down at any time and you can’t complete the process for a new hire, take a screenshot each day to document the system’s unavailability or certainly, retain any official notifications you receive.

4. Employers must certify use of E-Verify each year.

5. Penalties for noncompliance go into effect on July 1, 2024, resulting in a fine of $1000 per day until the employer can provide evidence of compliance. The employer’s first violation will result in a one-year probationary status prior to potentially having its license revoked.

Finally, businesses with less than 25 employees can choose to use E-V on a voluntary basis and also conduct the annual certification. F&P states this action will bring heightened immunity protections, definitely a win-win.

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2023 Hurricane Season is Around the Corner. Ready?

According to Weather.com, Hurricane season generally begins when water temperatures reach the rough threshold of 80 degrees, which usually occurs between June 1 and Nov. 30. That’s right around the corner! Weather forecasters predict between 13 and 15 named storms for 2023, six or seven becoming hurricanes with two to three reaching Category 3 or higher. The potential El Niño effect could soften those numbers but either way, in Florida we know to prepare for rain, wind, flooding and power outages. 

That said…. How’s your emergency management plan (EMP)? 

  • Home health agencies and nurse registries are required to maintain an EMP that meets Florida Department of Health (DOH) criteria and has been approved by that office.  Other providers, like hospitals, need to meet accreditation requirements which dictate a comprehensive EMP with contingencies for just about everything.  Most medical practices, though, have no requirement. Let’s review some important issues on which to focus our attention over the next three weeks as we count down to June 1st:
  • If you have a plan, review it.  With. A. Fine-toothed. Comb. Refresh yourself with all its aspects and what-ifs, and more importantly, re-orient all staff.  The DOH requires a mock drill so train early and then spring a drill on your staff to see how your business will fare.
  • If you’re not required to have an EMP, you can still prepare one.  If you’ve been in Florida for any length of time, you can probably anticipate the types of issues you’ll encounter over the season. (Hint: some are mentioned in paragraph one).  Think through what areas of your business or practice will be affected.
  • Do you have updated contact info (physical address, telephone and next of kin contact) for every staff member? How will you communicate with staff if phones are not usable? Work through this now and make sure you inform staff members in advance.
  • Assess your practice’s operational systems: EMR, telephones and other patient contact avenues. Can your practice operate remotely if your office is not usable, and how would that work? Do all necessary staff members have access and have you tested their access especially if they’ll be using their personal computer equipment?  Some practices restrict remote access to a small number of individuals.  How easy is it for your business to expand that list and will staff know how to do this in a pinch?
  • What about telephones?  If you use an answering service, you will probably not be affected as much as businesses that do not.  How will you answer phones in the event of an extended situation?  Do you have the needed passwords or vendor contact info to make changes to your settings, especially remotely?  Have you tested everything in advance to work through any glitches?
  • Are you able to text patients and receive texts from them through a vendor?  How will that service be impacted during an emergency?
  • Consider preparing a list of pts with significant health needs and begin a discussion with them (and/or their designated family member) before any emergency.  Should your patient evacuate for his/her safety?  Where would your patient go?  How will you ensure patients have an adequate supply of medications and oxygen during an emergency?
  • Business-wise, where is your liability insurance policy and other critical vendor information you may need to access off-site?  Consider preparing a “GO Binder” with all the information in one place.  Reproduce for management staff as needed.
  • Include a section in your binder for documenting your EMP preparation & implementation activities, preferably with dates.  If it’s easier, document in week-long chunks and summarize what was accomplished or put in place.

We all hope and pray the season is a quiet one, but let’s not put too much stock in predictions that may or may not be accurate; it’s always best to prepare for the certainty of an emergent situation.  No regulatory body can expect super-human responses from us during times of devastation, but we do need to show a good faith effort to cover all the bases and begin the season well-prepared.

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Primary Diagnosis Quiz

Let’s play a game…. I am going to list the diagnoses on the Assessment section of a specialist’s consult note in the order he listed them, and you try to guess the provider’s medical specialty:

  1. Paroxysmal atrial fibrillation
  2. Coronary artery disease
  3. Hypertension
  4. GERD
  5. Gastric polyps
  6. GI bleed
  7. Chronic kidney disease
  8. Hyperlipidemia
  9. Diabetes
  10. Hypogonadism
  11. Iron deficiency anemia

We’re going to pause our game to review two relevant topics, starting with the purpose of the assessment section of the note.  As we’ve explained in the past, the SOAP note has a specific format and the information in early progress note sections – such as the chief complaint; history of present illness; past medical, family, social history; review of systems; and examination – culminates in the medical conditions that are listed as being assessed during the visit.  To quote a former client….

She, incredulously: “You mean I have to assess the conditions I list in the assessment?”

Me: “Yes, ma’am. That’s why they call it an assessment.”

Now, let’s recall the documentation and coding rule of the primary, or first-listed, diagnosis.  This is the condition that dominates the provider encounter, is the main reason for the visit, and the issue that occupied the majority of resources at the visit.

So, by looking at the list above, you could assume this note was documented by a primary care provider, who is responsible for the first-line management of a variety of medical conditions.  But remember, I said it was a specialist’s note.  What we see above – loosely speaking – are cardiac conditions (#1, 2, 3, 8?), GI conditions (#4, 5), endocrine (#9, 10, maybe 8), nephrology (#7) and hematology (#11, which could also be under investigation by GI).  If we consider the first listed condition, you’d think – hands down – this is a cardiac or electrophysiologist note.  Would it surprise you to know this provider is a nephrologist?  My mind was certainly blown!

If the provider must make an assessment of the conditions listed in the assessment, how then is the kidney doctor assessing the status, disease progression/regression, treatment efficacy, etc of the first six conditions?  He’s not.  And we see this scenario all.the.time. 

While the nephrologist may need to consider the patient’s coexisting conditions for his management and treatment of the kidney disease, he is not assessing or treating those other diagnoses.  For that reason, he should use the HPI section of the note for a discussion of the impact, say, hypertension or diabetes have had on the patient’s kidneys.  Those conditions, then, would not be coded as part of the visit because they’re not being assessed or managed.  Additionally, when determining the E/M level of the visit, those non-nephro diagnoses would not factor into the AMA’s requirement for the visit code selection.

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Standards for Your MRA Department – Consider the Source

Since 2004, our company’s MRA work has undergone significant evolution, and we’ve worked on everything from isolated projects for a one-time client, to daily or annual reviews and even to serve as a client’s MRA Department.  We presented some of this information in a blog series entitled Pitfalls in Chart Reviews during Spring 2022, and in this series, we’ll flip the script and look at overall perspectives for the MRA department’s work.

Let’s start with facts – not facts with a small ‘f’ but facts, almost in all caps. What are the facts that guide the work done by your MRA dept, specifically when it comes to recognizing, suggesting and querying diagnoses?  We could regale you with stories from the trenches of conditions proposed by coders and reported by providers that have little to no basis in fact, or conditions reported because someone at some health plan said you should.

When something is rooted in fact, it can be put in writing by the sayer – with no angst.  After all, if you’re going to risk your practice’s funding by reporting a condition whose payment can be recouped years into the future, make sure your source is solid.  That doesn’t mean your source may not be wrong, or the plan or CMS may disallow the condition for other reasons, but at least you’ve done your due diligence in striving for accuracy and you can back up your actions. If the individual is reluctant to provide you with written information about the proposed code, heed the warning bell and reconsider your actions.

In terms of medical conditions, there is a great deal of lore that affects a coder’s recognition of a possible risk adjusted condition, but – as they say – consider the source.  Our company spends a great deal of time researching scholarly sources (more on that in a second) and conferring with licensed physicians to understand – as much as possible for laypeople – the hallmarks of certain conditions.  Perhaps we take this requirement to heart because our company is a vendor and we have a responsibility to our clients to back up our work with vetted information; the same is not usually true of the medical practice MRA coder, who may feel free to implement what his friend at [fill in the blank] is doing because the rep from [fill in the blank] said they could. And sometimes those blanks are big-name medical groups or plans, which could lead you to think you’re being too narrow minded or ill informed.  Before you cave to the pressure, take a look at some of our blogs on OIG cases involving “big names” who have paid back millions in recoveries to the federal government for, among other things, improper coding and reporting conditions for which there is no evidence.

Anyone can set up a website and publish misinformation, and just because it’s out there doesn’t make it true.  That’s why we stick to sources such as medical journals, medical texts, and organizations like the American Diabetes Association, Alzheimer’s Association, etc. – in other words, no dot-coms. All of our bulletins and guidance to clients list the sources we consulted because we have no problem naming names.  And after we’ve done that, we confer with clinicians to fill in gaps and operationalize the information. 

Consider re-evaluating the methodology your practice employs when hearing about “new” conditions to code, or new connections among diagnoses that happen to yield higher payments.  Put the brakes on eager coders or providers and do your research.  Discuss the information with relevant individuals in your practice, seek clinician input and establish parameters for reporting those conditions.  When a large number of your patients seem to have a condition with low prevalence in the medical literature, something’s wrong with this picture.

Join us for Part 2 of this blog series where we’ll continue our discussion on best practices for your MRA work.

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