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Welcome back to our last installment of this three-part series on specialty providers and risk adjusted payments.  Part 2 of this blog series focused on the substance of consultation notes, while today, we  evaluate our topic from the perspective of staff members who conduct chart reviews. 

Historically, an important task of the MRA staff member is to identify risk adjusted conditions.  Staffers do this by combing through the patient’s chart and identifying conditions that have not been recognized by the PCP in previous visits.  These new diagnoses may be found in laboratory or imaging studies, hospital records and specialist notes.  The big caveat is that MRA staff must be “plugged in” and not just mindlessly suggest conditions because they happen to appear on a document. 

With regard to specialists’ notes, as we introduced in Part 2 of this series, we must be mindful of who is reporting a condition, so let’s return to our beleaguered rheumatologist who’s behind on her work because we keep bothering her in this blog series LOL Let’s assume that during a discussion of past medical history, the patient mentions to the rheum that he has had seizures but is not on any seizure medication, and the rheum lists seizure disorder on the assessment. 

The MRA staffer reviews the chart, sees the rheum note and suggests seizure disorder to the PCP as a diagnosis to include in the chart “because the rheumatologist documented it.”  Don’t be too quick to deem this an exaggerated scenario that couldn’t happen in real-life.  We’ve seen this situation more times than we can count in our chart audits, second only to a greater cause of MRA confusion:  the specialist who uses a differential diagnosis to order a test.  It’s important for the MRA employee to critically evaluate the documentation about a condition before querying the PCP or suggesting the diagnosis for evaluation. In our seizure disorder example, there will likely be nothing concrete in the rheum’s note to support this medical condition, and the diagnosis should not be suggested to the PCP. Instead, the MRA staff should carefully review the chart for any evidence supporting a possible seizure disorder.

MRA chart reviewing and coding are meticulous work and great attention must be paid to the conditions “found” in the chart.  Context is everything in this type of work and medical groups should develop standards of practice for the identification of new risk adjusted conditions for reporting.

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In Part 1 of this blog, we reviewed the role of specialty providers in risk adjusted payments and their diagnoses of conditions that may fall under the CMS-HCC model.  In this installment, we’ll evaluate the substance of those consultation notes.

As we all know, an important section of the SOAP note for MRA is the assessment; this is the section where the provider synthesizes all the information he or she collects into a diagnosis for the patient.  Sometimes this process is detailed in the assessment and other times, it’s sprinkled throughout the note from sections such as the history of present illness, review of systems, examination and treatment plan.  The important thing is that the bread-crumbs that led to a diagnosis are contained in the consultation note along with a plan for treating the patient.

However, many specialist notes include other medical conditions, presumably gleaned from the patient/historian or from the PCP’s note sent to convey the patient’s medical history.  Let’s dust off our rheumatologist example from Part 1.  In this scenario, the PCP sent her last visit note along with the referral where she explains to the rheum the reason for the referral and her work-up to that point. The patient has a history of diabetes, cardiomyopathy and emphysema.  

It’s not uncommon to find non-rheumatological conditions listed in the specialist assessment.  As a reminder, items listed in the assessment must have been assessed during the visit and so unless the rheumatologist evaluated the patient’s diabetes, cardiomyopathy and emphysema during the appointment, these conditions have no place on a rheum consult note.  The only exception to this is for conditions that impact the condition being treated. 

For example, if one of the non-rheum diagnoses impacts, or is being considered in, the rheum’s assessment and treatment – say, prescribing high dose steroids in an uncontrolled diabetic – then it should be included in the note and assessed.  This means it can’t merely be listed, but the reason for including the condition in the rheum assessment must be clear.  Going back to our scenario, if the rheumatologist is recommending more frequent laboratory tests to monitor the patient’s diabetes, or a diabetes medication change for the patient, these would “tie in” the non-rheum condition to the rheum visit.  Similarly, if the existence of diabetes poses a treatment risk or affects the rheum condition, this constitutes a valid link to support diabetes being listed in the assessment, as long as this reasoning is documented. We can’t consider an instance where cardiomyopathy or emphysema would be part of a rheum assessment and so, those conditions should not be documented by the specialist because he or she is not treating them.

Finally, just as important, specialists must take care not to report on their claims ICD-10-CM codes for conditions they are not evaluating at the visit.  This habit incorrectly inflates the patient’s risk score and the plan’s/PCP’s funding and exposes them to the liability of a retroactive recoupment.

Join us for Part 3 where we wrap up our blog series by addressing the topic of specialty notes from the perspective of MRA Dept. staff. 

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Without a doubt, risk adjusted payments are geared to primary care providers (PCPs) and form the basis of Medicare Advantage plan payments and usually those of PCPs, whether directly (as in funding) or via surpluses or bonus payments.  The same isn’t true for specialists. 

But specialty providers play a hugely important role in healthcare (obviously) and for the PCPs paid under this methodology.  In some cases, PCPs rely on consultation notes from a specialty visit to identify and thereafter report a risk adjusted condition. Say, for example, the patient whose routine labs reveal findings that signal one of several possible rheumatological conditions.  The PCP may refer the patient for a rheum consult and ask the specialist to confirm a diagnosis.  In that case, the PCP would report ICD-10-CM codes for the patient’s symptoms or abnormal labs and wait for the rheum to provide the code for the exact condition after a proper work-up. The rheum’s visit note will help the PCP to assess, monitor and coordinate treatment for the condition on an ongoing basis.

For this reason, PCP offices must have an effective system for timely follow up of consultation notes from specialists who have seen their patients.  Instead, many offices wait until the patient returns to the PCP to obtain any consult notes (we call this “the mad scramble”) or they “hold hostage” the referral for a follow-up specialty visit until the note from the prior visit is received.  This becomes a game of catch-up and can result in delays in care or member complaints to the plan for referral issues.

In Part 2 of this blog, we will review the MRA value of specialists’ notes that contain proper assessment and documentation of the patient’s conditions.

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