4/8/ HCC RISK ADJUSTMENT TRAINING DAY 1 APRIL 9, Program Introduction. By Compliant Coding Systems

Transcription

1 2016 HCC RISK ADJUSTMENT TRAINING By DAY 1 APRIL 9, :00 PM EDT 11:00 AM CDT 10:00 AM MDT 9:00 AM PDT Program Introduction 1

2 Program Introduction A skilled HCC Coder should be able to: Explain the concept of Risk Adjustment Demonstrate understanding of Medicare Risk Adjustment data collection processes Articulate with proficiency steps in the Medicare Risk Adjustment payment review and dispensation process Master Medicare Risk Adjustment Guidelines for Diagnosis Validation and Reporting Apply Coding Guidelines and Resources for data accuracy Identify and overcome HCC coding and documentation pitfalls Demonstrate proficiency in analyzing medical record documentation and identifying different source documentation Recognize industry and CMS standards for quality and accuracy Program Introduction Learning Objectives: Prepare participants for success on the AAPC CRC Certification Exam Assure understanding and proficiency in the application of ICD-9 and ICD-10 Coding Guidelines Assure that participants understand Risk Adjustment Terminology and Concepts Assure understanding of Medicare Risk Adjustment and Hierarchical Condition Category (HCC) coding including all program guidelines and documentation standards Assure participants understand, with proficiency, the Domains of Diagnosis Coding, Compliance, Risk Adjustment Models, Documentation Improvement, and Quality Care in Risk Adjustment Prepare participants to meet productivity and accuracy goals in HCC Coding in both ICD-9 and ICD-10 Prepare participants to rise from an HCC Coder to Subject Matter Expert on Risk Adjustment Risk Adjustment Overview What is Risk Adjustment? Based on health status, it adjusts some financial component of the cost of healthcare coverage What and How depends on the coverage 2

3 Risk Adjustment Overview What is Risk Adjustment? Adjusts payments based on expected health care costs (Predictive Modeling) Promotes access and reduces adverse selection (disproportionately attracting high risk or sick people that are expensive to insure) Incorporates demographic and disease factors Uses diagnoses and predictive cost modeling to account for cost of care for covered populations Risk Adjustment Overview What is Predictive Modeling? Predictive modeling uses data analysis to create a statistical model of future behavior. In healthcare, using data on factors such as utilization, cost, frequency, outcomes, disease progression, and more can predict many things including cost of care, resource allocation, ratios, and more. By analyzing complex data relationships, mathematical weights can be attributed to health conditions. Examples Data analysis can determine a relative increase in resources a condition may require - Compared to the average person, a diabetic may require 15% more economic resources Can determine the impact of providing more resources on outcomes - By providing increased resources, complications or progression of disease may be reduced resulting in lower incidence of more costly outcomes by providing appropriate treatment therapies and quality of care 3

4 Risk Adjustment Overview What is Predictive Modeling? Risk Adjustment Overview What is Risk Adjustment? The main component: Documented Conditions abstracted to Diagnosis Codes (ICD codes) Diagnoses are collected and their specificity drives risk score or categorization The worse, or more serious a condition, or diagnosis, the higher the risk scoring Risk Scores either affect incoming payment or the future financial forecasting for each patient Risk Adjustment Overview Benefits of Risk Adjustment Enables changes to address quality of care for chronic illnesses Identifies Disease Management opportunities Identifies Quality of Care opportunities Identifies markers for Utilization 4

5 Diagnosis based programs: Chronic Illness and Disability Payment Systems (CDPS) -Medicaid Hierarchical Co-Existing Conditions (HCC-C) -Medicare Clinical Risk Grouping (CRG) Medicaid Prescription based programs: MedicaidRx (UCSD) RxGroups (DxCG) Hierarchical Co-Existing Conditions (HCC-D) Model Type Payment From Payment To Risk Score Level Factored Medicare CMS MAP Beneficiary Medicaid State MMCO Population Commercial Plan Plan Population Some Models Are Based On Tiers of Severity (Categorical) Some Models Based On Distinct Categories With Hierarchical Subcategories (Additive) Some Models Only Consider Chronic Conditions Some Models Include Acute and Chronic Conditions Some Models Provide For Prescription Drugs, Some Do Not What is CDPS Chronic Illness and Disability Payment System Medicaid programs use to make health-based capitated payments for TANF and disabled Medicaid beneficiaries. CDPS code is provided under license and free of charge to qualified public agencies, educational institutions, and researchers 5

6 What is CDPS ALL ICD-10 codes 58 CDPS categories 20 major categories CDPS categories are hierarchical within major categories CDPS: 20 Major Categories 1. Cardiovascular 2. Psychiatric 3. Skeletal 4. Central Nervous System 5. Pulmonary 6. Gastrointestinal 7. Diabetes 8. Skin 9. Renal 10. Substance Abuse 11. Cancer 12. Developmental Disability 13. Genital 14. Metabolic 15. Pregnancy 16. Eye 17. Cerebrovascular 18. AIDS/HIV 19. Infectious disease Compliant Coding 20. Systems Hematological Key Components of CDPS Level of severity: Very High, High, Medium, and Low Each subcategory contributes to an overall weight of the member s individual score Medical Assistance managed care/ffs eligibility Diagnostic Category Sample Diagnoses Cardiovascular Very High Heart transplant status or complications Congestive heart failure, cardiomyopathy, Medium tricuspid and pulmonary valve disease Endocardial disease, myocardial infarction, Low angina, coronary atherosclerosis, dysrhythmias Extra Low Hypertension 6

7 CDPS Hierarchies CDPS categories are hierarchical within major categories Weights are additive across major categories Within major categories, only the most severe diagnosis counts For example, in the major category cardiovascular: CARVH includes 3 stage 1 groups and 7 diagnoses CARM includes 13 stage 1 groups and 53 diagnoses CARL includes 26 stage 1 groups and 314 diagnoses CAREL includes 2 stage 1 groups and 35 diagnoses CDPS Payment Weights are additive across major categories. Within major categories, only the most severe diagnosis counts. This allows an accounting of comorbidities, but reduces the incentive for upcoding of diagnoses For example, if a beneficiary has both diabetes and depression, both count towards the risk score. However, if a beneficiary has hypertension and heart disease, only heart disease counts In CDPS Model, risk scores of individual enrollees are calculated based on their risk (health conditions and demographics) CDPS Plan payment is calculated based on the overall risk score of the population, versus in, plan payment is calculated directly from risk scores of individual enrollees ACA Risk Adjustment Model (HHS-HCC Model) <a href=" Peterlin</a> / <a href=" You ALL Must Have Health Insurance! IT IS LAW!!! 7

8 ACA Risk Adjustment Model (HHS-HCC Model) And YOU Must Provide It!!!!! It Is Law!!!! <a href=" Sohm</a> / <a href=" ACA Risk Adjustment Model (HHS-HCC Model) The Department of Health and Human Services (HHS) created a risk adjustment model based on the HCC classification system using commercial claims data and refines HCCs to reflect those conditions expected within the commercial risk adjustment population (HHS-HCC). The Affordable Care Act establishes State-based reinsurance and risk adjustment programs (occurs between plans), and a Federal risk corridors program (Based on percentage of claims estimates exceeded, Government must compensate plans for excess over identified thresholds). The overall goal of these programs is to provide certainty and protect against adverse selection in the market while stabilizing premiums in the individual and small group markets as market reforms and Exchange begin in HHS-HCC Model The HHS-HCC risk adjustment model uses an individual s demographics and diagnoses to determine a risk score, which is a relative measure of how costly that individual is anticipated to be to the plan The HHS-HCC risk adjustment model is a concurrent model: A concurrent model uses diagnoses from a time period to predict cost in that same period whereas the CMS-HCC risk adjustment model is a prospective model: uses diagnoses from a base period to predict costs in a future period 8

9 HHS-HCC Model Patients are classified into 15 sub-models by age (adult, child, infant) and by metal level (platinum, gold, silver, bronze, or catastrophic). Adults are defined as ages 21+, children are ages 2 20, and infants are ages 0 1. Payments will be adjusted by plan metal level, geographical rating area, induced demand, and age rating so that transfers reflect health risk and not other cost differences. Infant Child Adult Platinum Platinum Platinum Gold Gold Gold Silver Silver Silver Bronze Bronze Bronze Catastrophic Catastrophic Catastrophic HHS-HCC Model The starting point for the HHS-HCCs was the Medicare CMS-HCCs. The CMS- HCCs had to be adapted into the HHS-HCCs for ACA risk adjustment for three main reasons: 1. Prediction Year The CMS-HCC risk adjustment model uses base year diagnoses and demographic information to predict the next year s spending. The HHS-HCC risk adjustment model uses current year diagnoses and demographics to predict the current year s spending HHS-HCC Model 2. Population The CMS-HCCs were developed using data from the aged (age 65) and disabled (age < 65) Medicare populations. HCCs were reexamined to better reflect salient medical conditions and cost patterns for adult, child, and infant subpopulations in the commercial population. 3. Type of Spending The CMS-HCCs are configured to predict non-drug medical spending. The HHS-HCCs predict the sum of medical and drug spending. Also, the CMS-HCCs predict Medicare provider payments while the HHS-HCCs predict commercial insurance payments 9

10 HHS-HCC Model HHS-HCC has 127 HCCs and CMS-HCC has 79 HCC coefficients decrease by metal level when moving from the platinum model to the catastrophic model, but typically not by a substantial amount For example, the coefficient for HCC 130, Congestive Heart Failure decreases from for the platinum model to for the catastrophic model. HHS-HCC Model The HHS Risk Adjustment Model estimates financial risk using enrollee demographics and medical diagnoses. It then compares plans in each geographic area and market segment based on the average risk of their enrollees, in order to assess which plans will be charged and which will be issued payments Individual risk scores: based on each individual s age, sex, and diagnoses,are assigned to each enrollee. Diagnoses are grouped into a Hierarchical Condition Category (HCC) and assigned a numeric value that represents the relative expenditures a plan is likely to incur for an enrollee with a given category of medical diagnosis If an enrollee has multiple, unrelated diagnoses, both HCC values are used in calculating the individual risk score. If an adult enrollee has certain combinations of illnesses, an interaction factor is added to the person s individual risk score. HHS-HCC Model Infant Risk Adjustment Models The infant model utilizes a categorical approach in which infants are assigned a birth maturity. There are four Age 0 birth maturity categories: extremely Immature; Immature; Premature/Multiples; Term, and a single Age 1 Maturity category. Age zero infants are assigned to one of the four birth maturity categories and age one infants are assigned to the Age 1 Maturity category. There are 5 disease severity categories based on the clinical severity and associated costs of the non-maturity HCCs: Severity Level 5 (Highest Severity) to Severity Level 1 (Lowest Severity) 10

11 HHS-HCC Model Child Risk Adjustment Models Each of the five metal level models includes the same independent variables: eight agesex cells and 119 HCCs, no disease interactions The age/sex demographic coefficients have a U-shaped pattern, unlike the monotonically increasing coefficients of adults. For example, for males in the silver model, the age/sex coefficients are for age 2 4, for age 5 9, for age 10 14, and for age Female children are less expensive than male children until ages 15 20, which is perhaps when reproductive health expenses begin to become more pronounced. HHS-HCC Model Adult Risk Adjustment Models Each metal level includes the same independent variables: 18 age-sex cells, 114 HCCs,17 and 16 disease interaction terms. Predicted plan liability for each enrollee is the sum of one agesex coefficient, from zero to many HCC coefficients (individual HCCs and aggregate HCC groupings) subject to HCC hierarchies and constraints/groups, and zero or one severe illness disease interaction term. HHS-HCC Model If the enrollee is receiving subsidies to reduce their cost-sharing, an induced utilization factor would be applied to account for induced demand If an enrollee has multiple, unrelated diagnoses, both HCC values are used in calculating the individual risk score. If an adult enrollee has certain combinations of illnesses, an interaction factor is added to the person s individual risk score. If the enrollee is receiving subsidies to reduce their cost-sharing, an induced utilization factor would be applied to account for induced demand Once individual risk scores are calculated for all enrollees in the plan, these values are averaged across the plan to arrive at the plan s average risk score. 11

12 HHS-HCC Model The average risk score, which is a weighted average of all enrollees individual risk scores, represents the plan s predicted expenses. Under the HHS methodology, adjustments are made for a variety of factors, including actuarial value (i.e., the extent of patient cost-sharing in the plan), allowable rating variation, and geographic cost variation. Under risk adjustment, plans with a relatively low average risk score will make payments into the system, while plans with relatively high average risk scores will receive payments What is CRG Clinical Risk Grouping Clinically Based classification system to measure burden of illness. Based on claims data along with other data sources Comprehensive and takes into account age, income, disability, severity of illness, frequency, and other factors CRG Components Base CRG Each individual is assigned to a single base CRG that reflects the full range of diagnoses for that individual Severity-of-illness Subclass for the base CRG 4 to 6 explicit severity levels within a given category Total 1,080 CRGs 9 Health Categories 272 base CRGs 4-6 severity of illness levels 12

13 CRG Severity-Of-Illness Subclass The subclass addresses individual differences relating to severity of illness 4 to 6 levels to indicate severity of each base CRG Sample CRG Payment Weights by Severity Level for Individuals with DM, CHF and COPD Severity of Illness Level Base CRG DM CHF COPD COPD & DM DM & CHF COPD & CHF DM & CHF & COPD CRG Clinical Logic 1. A disease profile and history of past medical interventions is created 2. For each organ system, the most significant chronic disease under active treatment is identified 3. For each organ system, the severity of illness level of the most significant chronic disease under active treatment is determined 4. #2 and #3 are combined to determine the overall base CRG and severity of illness level for the individual 5. The overall base CRG and severity of illness level are consolidated into three successive tiers of aggregation CRG Clinical Risk Grouping Base # of Severity CRG Health Statuses (9) CRGs Examples of Base CRG CRGs Levels (272) (1080) 9 Catastrophic 11 ESRD on Dialysis Dominant/Metastatic malignancy 22 Acute Leukemia 4 88 Dominant chronic disease in 3 or more Diabetes Mellitus, CHF and organ systems COPD Significant chronic diseases in multiple 6 61 Diabetes Mellitus and COPD 4 or 328 2, 6 organ systems 5 Significant chronic disease 107 Diabetes Mellitus 2 or Minor chronic diseases in multiple 4 1 Migraine and ADHD 4 4 organ systems 3 Single minor chronic disease 41 Migraine History of significant acute disease 6 Meningitis None 6 1 Healthy 2 Preventive Care None 2 13

14 CRG Impact on Revenue Plan Risk score computed by member distribution across Risk Groups / Weights Calculated for each premium group and region Regional Risk Score determined by premium group using distribution of all plans in that region Relative Risk Score computed for each plan using raw risk score and regional risk score in each premium group Relative Risk Score used to adjust a plan s payment The plan is not reimbursed based on individual member Risk Score CRG Payment Calculation Assume that the MMCOR PMPM Rate is $1000 Plan A: = 1.25 x 1000 = $1250 PMPM Plan B: = 0.75 x 1000 = $ 750 PMPM Now assume each plan has 5000 members. Plan A s reimbursement would be $6,250,000 (5000 x $1250) Plan B s reimbursement would be $3,750,000 (5000 x $750 The ABCD of Medicare Medicare Part A, B, C & D 14

15 The ABCD of Medicare Medicare Part A, B, C & D Part A Facilities: IP Hospital, IP SNF care, IP care in religious non-medical health care facility, home health, hospice, drugs given during an inpatient stay or drugs for symptom control or pain relief while receiving Part A covered hospice care Part B Physician services: office visits, screenings, therapies, preventive services, OP hospital, emergency care, ambulance, medical/surgical supplies and durable medical equipment, drugs and biologicals used for the treatment of End-Stage Renal Disease (ESRD), injectable and infusible drugs that aren t usually self-administered and that are given at outpatient setting, The ABCD of Medicare Medicare Part A, B, C & D Part C Medicare Advantage includes Part A and B services, coverage for extra dental, vision, hearing and preventive services and some optional supplement services (e.g. gym memberships and exercise classes). Medicare Advantage plan receives payment for each member from CMS. Payment is based on member predicted health status and demographic characteristics (HCC) Part D Pharmacy (Prescription Drug) benefits: Only through private insurance companies (MAPD or PDP). Each Medicare Prescription Drug Plan has its own list of covered drugs (formulary). Many Medicare drug plans place drugs into different "tiers" on their formularies. Drugs in each tier have a different cost. Prescription Drug plan receives payment for each member from CMS based on member predicted health status and demographic characteristics (RxHCC) (MRA Model) History of MRA 15

16 History of MRA In 2003, the CMS-HCC model was finalized as the risk adjustment payment model. The goal was to select a clinically sound risk adjustment model that improved payment accuracy while minimizing the administrative burden on MA organizations The model is a revision of the Hierarchical Condition Category model, originally developed by Health Economics Research, Inc. The CMS-HCC model functions by categorizing International Classification of Diseases, 9th Edition, Clinical Modification (ICD-9-CM) codes into separate groups of clinically related codes, (e.g., diabetes, cancer, ischemic heart disease, infections, etc.) that have similar cost implications. History of MRA In 2004, the CMS-HCC model was implemented at a 30 percent risk adjusted payment, with the remaining 70 percent represented by the demographic payment. The portion of risk adjusted payment will increase to 50 percent in 2005, to 75 percent in 2006, and finally to 100 percent in 2007 There was not blended payment transition for the Part C ESRD and Part D models. Payments under these models were implemented at 100 percent risk adjustment from the beginning. Payment Year % Demographic 30% 50% Demographic 50% % Demographic 75% % Purpose of MRA: Risk adjustment allows CMS to pay Medicare Advantage Plans (MAP s) for the risk of the beneficiaries they enroll, instead of an average amount for Medicare beneficiaries. By risk adjusting plan payments, CMS is able to make appropriate and accurate payments for enrollees with differences in expected costs. Risk scores measure individual beneficiaries relative risk and risk scores are used to adjust payments for each beneficiary s expected expenditures. 16

17 Characteristics of the MRA Model: Characteristics Description SIMILAR MODEL CHARACTERISTICS (PART C AND PART D) Selected Significant Disease (SSD) Model Serious manifestations of a condition are considered rather than all levels of severity of a condition. Models are additive. Include most body systems and conditions. Prospective Model Uses diagnostic information from a base year to predict total costs for the following year. Site Neutral Models do not distinguish payment based on a site of care. Diagnostic Sources Models recognize diagnoses from hospital inpatient, hospital outpatient, and physician settings. Multiple Chronic Diseases Considered Risk adjusted payment is based on assignment of diagnoses to disease groups, also known as HCCs. Model is most heavily influenced by Medicare costs associated with chronic diseases. Disease Interactions and Hierarchies Included Interactions allow for additive factors based on chronic conditions and disabled status to increase payment accuracy. Hierarchies allow for payment based on the most serious conditions when less serious conditions also exist. Demographic Variables Models include four demographic factors: age, sex, disabled status, and original reason for entitlement. These factors are typically measured as of the data collection period. Characteristics of the MRA Model: Frailty Adjuster Part C Specific Characteristics Frailty add-on is used for PACE and certain demonstration plans with a frail elderly population in the community. Medicaid Eligibility Medicaid status for full risk enrollees is prospective and always determined based on the data collection period. Medicaid status for new enrollees is concurrent and based on Medicaid status during the payment year (during final payment). Community-Based and Long-Term Institutionalized Enrollees Distinguished ESRD CMS-HCC Model LTI Multiplier LIS Multiplier Long-term institutionalized is defined as enrollees with 90 days or greater of residence in a nursing home. Institutional model is not based on institutional factor demographic-only model. Separate models account for higher treatment costs of similarly-ill community residents. Community and institutional models both include 70 disease groups. Model addresses disparate treatment costs structures related to ESRD enrollee status. The model includes specific payments for individuals with dialysis, transplant, and functioning graft. The ESRD model includes 67 disease groups. Part D Specific Characteristics Long term institutional (LTI) factor gets assigned to the risk scores of beneficiaries with 90 days of residence or greater in a nursing home. LTI status is determined based on the data collection period. Two low income status (LIS) factors (full subsidy, and partial subsidy) one or the other gets assigned to the risk score for enrollees based on their Part D determined LIS status. LIS status is determined during the payment year. Application of MRA: The CMS-HCC model uses beneficiary demographic characteristics and prior year diagnoses to predict relative Part A and Part B Medicare fee-for-service program payments The CMS-HCC model does not incorporate Medicare Part D costs The CMS-HCC model is prospective, meaning it uses prior year information to predict costs for the subsequent year Based on documented and treated Chronic Conditions (Some severe Acute conditions are Risk Adjusted) Risk Adjustment is applied to each Medicare Beneficiary enrolled in a covered plan Unrelated diagnoses cumulatively impact Risk Scores 17

18 Application of MRA: In order to improve payment further, CMS has developed separate models for different populations who have different cost patterns than the general Medicare population. There are four CMS-HCC models used to calculate risk scores for MA plans: o Community model o Long-term institutional model o ESRD model o New enrollee model The new enrollee model is different than the other models in that it is not disease based Different MRA Models Enrollee Type Aged & Disabled ESRD Dialysis ESRD Transplant Status Functioning Graft Model Full-Risk Community Model Full-Risk Long-term Institutionalized Model New Enrollee Model Full-risk Dialysis Model New Enrollee Dialysis Model Special Payment Factors Full-Risk Community Model Full Risk Long-term Institutionalized Model New Enrollees - apply aged/disabled model Components of MRA Model CMS uses diagnoses from Medicare fee-for-service and/or from RAPS for determining the HCCs for each enrollee. Medicare fee-for-service data are utilized for risk adjusted payment when an enrollee joins an MA organization (or PACE/demonstration) after opting out of traditional Medicare fee-for-service coverage. If an enrollee new to an MA organization enrolls in January of a calendar year, then CMS will use up to 12-months of prior fee-for-service data within the data collection period (both Part A and Part B) to obtain diagnostic data. Where data for a person have been submitted via RAPS, those data are also used in calculating the risk score for a person. 18

19 Components of MRA Model The risk score used in calculating payments under the CMS-HCC model includes demographics as part of the risk model as well as different disease groups or HCCs. The model allows for the recognition of coexisting diseases when calculating payment by recognizing multiple chronic conditions listed for the beneficiary. Interactions (i.e., combinations) are used to account for expected costs that are higher because, for example, multiple coexisting diseases cause additional complications. Hierarchies are imposed to provide payments only for the most severe manifestation of a certain disease. Components of MRA Model: Demographic Factors The risk score uses five demographic factors in calculating the risk score under the CMS-HCC model: Age and Sex: Based upon the enrollee s age and sex, risk adjusted demographic factors are assigned for the calculation of the enrollee s risk factor. Under the CMS-HCC model, CMS bases payments for the entire payment year upon the age an enrollee attains as of February 1st of each year with one exception, when an enrollee ages in to Medicare. (i.e., Beneficiaries are treated as age 65 for risk adjustment purposes when they attained 65 years of age in the payment year and the reason for entitlement is age.) Disabled Status: The disabled factors for enrollees under 65 years old are labeled as disabled and those over 65 years old are labeled as aged. Under the CMS-HCC model, additional payments are made for Medicaid eligible disabled individuals. Components of MRA Model: Demographic Factors Original Reason for Medicare Entitlement (OREC): The factors labeled originally disabled apply to enrollees that are 65 years old or over who were originally entitled for Medicare due to disability. Under the CMS-HCC model, additional payments are made for OREC individuals with Medicaid based on age and sex. Medicaid Status: The Medicaid factor applies to enrollees who are entitled to Medicaid under Title XIX of the Social Security Act. A Medicaid factor is applied based on the aged, disabled, or originally disabled status of the Medicaid enrollee. 19

20 Components of MRA Model 3466 out of ICD-9 codes and 9329 out of ICD-10 codes (Community Model) ICD-9 ICD-10 Total # of MRA Codes HCC (Part C) Only RxHCC (Part D) Only Both C&D Components of MRA Model: The 25 HCC Main Categories (Disease Groups) 1. Infection 2. Neoplasm 3. Diabetes 4. Metabolic 5. Liver 6. Gastrointestinal 7. Musculoskeletal 8. Blood 9. Substance Abuse 10. Psychiatric 11. Spinal 12. Neurological 13. Arrest 14. Heart 15. Cerebrovascular Disease 16. Vascular 17. Lung 18. Eye 19. Kidney 20. Skin 21. Injury 22. Complications 23. Transplant 24. Openings 25. Amputation Components of MRA Model: The 25 HCC Main Categories (Disease Groups) Healthy No Cat 1. Infection 2. Neoplasm 3. Diabetes 4. Metabolic 5. Liver 6. Gastrointestinal 7. Musculoskeletal 8. Blood 9. Substance Abuse 10. Psychiatric 11. Spinal 12. Neurological 13. Arrest 14. Heart 15. Cerebrovascular Disease 16. Vascular 17. Lung 18. Eye 19. Kidney 20. Skin 21. Injury 22. Complications 23. Transplant 24. Openings 25. Amputation DM uses Insulin Cat 3 COPD uses O2 Cat 17 A Fib on Coumadin Cat 14 20

21 Components of MRA Model: The 79 HCCs Disease Group Disease Groups Description Community Disease Group Disease Groups Description Community RAF RAF HCC1 HIV/AIDS 0.47 HCC23 Other Significant Endocrine and Metabolic Disorders Septicemia, Sepsis, Systemic Inflammatory HCC HCC27 End-Stage Liver Disease Response Syndrome/Shock HCC6 Opportunistic Infections 0.44 HCC28 Cirrhosis of Liver HCC8 Metastatic Cancer and Acute Leukemia HCC29 Chronic Hepatitis HCC9 Lung and Other Severe Cancers HCC33 Intestinal Obstruction/Perforation 0.31 HCC10 Lymphoma and Other Cancers HCC34 Chronic Pancreatitis HCC11 Colorectal, Bladder, and Other Cancers HCC35 Inflammatory Bowel Disease Breast, Prostate, and Other Cancers and HCC HCC39 Bone/Joint/Muscle Infections/Necrosis Tumors HCC17 Diabetes with Acute Complications Rheumatoid Arthritis and Inflammatory Connective HCC Tissue Disease HCC18 Diabetes with Chronic Complications HCC46 Severe Hematological Disorders HCC19 Diabetes without Complication HCC47 Disorders of Immunity HCC21 Protein-Calorie Malnutrition Coagulation Defects and Other Specified HCC Hematological Disorders HCC22 Morbid Obesity HCC54 Drug/Alcohol Psychosis 0.42 Components of MRA Model: The 79 HCCs Disease Group Disease Groups Description Community Disease Group Disease Groups Description Community RAF RAF HCC55 Drug/Alcohol Dependence 0.42 HCC80 Coma, Brain Compression/Anoxic Damage 0.57 HCC57 Schizophrenia 0.49 HCC82 Respirator Dependence/Tracheostomy Status 1.52 Major Depressive, Bipolar, and Paranoid HCC HCC83 Respiratory Arrest Disorders HCC70 Quadriplegia HCC84 Cardio-Respiratory Failure and Shock HCC71 Paraplegia HCC85 Congestive Heart Failure HCC72 Spinal Cord Disorders/Injuries HCC86 Acute Myocardial Infarction Amyotrophic Lateral Sclerosis and Other Unstable Angina and Other Acute Ischemic Heart HCC HCC Motor Neuron Disease Disease HCC74 Cerebral Palsy HCC88 Angina Pectoris Myasthenia Gravis/Myoneural Disorders and HCC75 Guillain-Barre Syndrome/Inflammatory and HCC96 Specified Heart Arrhythmias Toxic Neuropathy HCC76 Muscular Dystrophy HCC99 Cerebral Hemorrhage HCC77 Multiple Sclerosis HCC100 Ischemic or Unspecified Stroke HCC78 Parkinson's and Huntington's Diseases HCC103 Hemiplegia/Hemiparesis HCC79 Seizure Disorders and Convulsions HCC104 Monoplegia, Other Paralytic Syndromes Components of MRA Model: The 79 HCCs Disease Group Disease Groups Description Community Disease Group Disease Groups Description Community RAF RAF Atherosclerosis of the Extremities with HCC HCC137 Chronic Kidney Disease, Severe (Stage 4) Ulceration or Gangrene HCC107 Vascular Disease with Complications 0.41 Pressure Ulcer of Skin with Necrosis Through to HCC Muscle, Tendon, or Bone HCC108 Vascular Disease HCC158 Pressure Ulcer of Skin with Full Thickness Skin Loss HCC110 Cystic Fibrosis HCC161 Chronic Ulcer of Skin, Except Pressure HCC111 Chronic Obstructive Pulmonary Disease HCC162 Severe Skin Burn or Condition Fibrosis of Lung and Other Chronic Lung HCC HCC166 Severe Head Injury 0.57 Disorders Aspiration and Specified Bacterial HCC HCC167 Major Head Injury Pneumonias Pneumococcal Pneumonia, Empyema, Lung HCC HCC169 Vertebral Fractures without Spinal Cord Injury Abscess Proliferative Diabetic Retinopathy and HCC HCC170 Hip Fracture/Dislocation Vitreous Hemorrhage HCC124 Exudative Macular Degeneration HCC173 Traumatic Amputations and Complications HCC134 Dialysis Status Complications of Specified Implanted Device or HCC176 Graft HCC135 Acute Renal Failure HCC186 Major Organ Transplant or Replacement Status HCC136 Chronic Kidney Disease (Stage 5) HCC188 Artificial Openings for Feeding or Elimination

22 Components of MRA Model: Disease Hierarchy Address multiple levels of severity for a disease Payment based on most severe manifestation of disease when less severe manifestations are also present If a patient has multiple medical conditions and some of those conditions map to the same category, only the most severe HCC (highest RAF) within the Disease Group is counted for Risk Adjustment If the multiple medical conditions mapped to different Disease Groups, the risk adjustment factors add up Components of MRA Model: Disease Hierarchy Payments are for only the most severe manifestation of a disease, within the same Disease Group Example: DM without complications (HCC19) progresses to DM with acute complications (HCC17). The costs of HCC19 are covered under HCC17, which is the more severe manifestation of the disease. In the above example only HCC17 will be included in payment calculation because both HCC19 and HCC17 are in the same category (Diabetes) Components of MRA Model: Disease Hierarchy Payments are for only the most severe manifestation of a disease, within the same Disease Group Example: DM without complications (HCC19) progresses to DM with acute complications (HCC17). The costs of HCC19 are covered under HCC17, which is the more severe manifestation of the disease. In the above example only HCC17 will be included in payment calculation because both HCC19 and HCC17 are in the same category (Diabetes) 22

23 Components of MRA Model: Disease Hierarchy When HCC 17 (DM with Acute Complication) is reported, HCC 18 (DM with Chronic Complication and HCC 19 (DM without Complication) will be dropped in payment calculation Components of MRA Model: Disease Hierarchy When HCC135 (Acute Renal Failure and HCC 136 (CKD V) are both reported in the calendar year, HCC136 will be dropped in payment calculation Components of MRA Model: Disease Hierarchy For example, patient is reported to have DM, CHF, and COPD. ICD-9 Code HCC Description Count or Drop? RAF Diabetes without Complication Count Congestive Heart Failure Count Chronic Obstructive Pulmonary Disease Count Total

24 Components of MRA Model: Disease Hierarchy For example, patient is reported to have Diabetic neuropathy, Diabetic hypoglycemia, PHTN, CHF, COPD and pulmonary fibrosis: ICD-9 Code HCC HCC Description Count or Drop? RAF Diabetes with Chronic Complications Count Diabetes with Chronic Complications Drop Diabetes with Chronic Complications Drop Congestive Heart Failure Count Congestive Heart Failure Drop Chronic Obstructive Pulmonary Disease Count Fibrosis of Lung and Other Chronic Lung Drop Disorders Total 7 ICD-9 codes 4 HCCs 3 RAFs QUESTIONS WE WILL SEE YOU ON DAY 2 APRIL 10, :00 PM EDT 11:00 AM CDT 10:00 AM MDT 9:00 AM PDT 24