With the change in payment focusing on quality medicine instead of the old-fashioned fee for service, providers better be savvy with their coding or they will lose out on the money needed to run their practices. As individual and groups of physicians align with other groups to provide excellence in care while cutting costs, it is essential that the providers learn to code properly.
Our practice has joined with the local hospital to form an Integrated Delivery Network (IDN). As primary care providers, we will work with our community hospital and specialists to cut costs by decreasing the use of the emergency room and decreasing admissions to the hospital. We have also aligned with Tandigm Health, a physician-led group that uses experts in business, nursing and informatics to focus on ways to save money by decreasing hospital admissions, readmissions and ER visits.
One of the most important things to the success of these endeavors is accurate hierarchical condition category (HCC) coding. There is a major emphasis on coding properly in order to increase risk adjustment factor (RAF) scores and allow the above organizations to start with a bigger pot of money.
If more money comes into the entity to start, there will be more money, theoretically, to trickle down to the doctors in the trenches to support our work with our patients. This extra money that can be earned going forward with other ventures such as Medicare Shared Savings Program (MSSP) and Comprehensive Primary Care Plus (CPC+) will be reinvested in the practice to support better care of our patients, with post-discharge phone calls, post-hospitalization home visits and better overall support of our sickest patients.
These alliances will not be successful unless all of the providers code properly. If a physician does not code accurately, the risk score for the sickest patients may be too low, and the pool of money allotted to that patient’s care by the insurance company will be lower.
For instance, if the patient has coronary artery disease, and the provider picks coronary artery disease without angina pectoris, the RAF score is zero. If, however, the patient uses SL nitro prn for stable chest pain, the proper code would be coronary artery disease with stable angina pectoris, which increases the risk score from zero to 0.141. If the patient happens to have unstable angina, the risk increases to 0.258.
Another example that has significant variability in RAF scoring is diabetes mellitus. The risk increases if specific complications are present, and these complications should be coded, if present. The RAF score for diabetes II, uncomplicated is only .118. However, if the patient has chronic kidney disease stage 3 from diabetes, then the coding should be for diabetes with CKD -3 and the risk score goes up to 0.368. Diabetes II with neuropathy adds a similar risk with a score of 0.368.
Oncology codes also provide high risk scores, because the care of these patients is often quite costly. Providers should be as specific as possible when coding for cancer. If a breast cancer patient is still on tamoxifen, the proper code is breast cancer with a RAF score of 0.154. A personal history of breast cancer is the correct code if the cancer is no longer present and the patient is no longer receiving any active treatment, even if the patient is being monitored for recurrence. The risk score for this code is zero.
By no means, should providers up-code to increase risk. This is illegal and unethical. There was a physician recently who was apparently trying to bill with only HCC codes. This is not realistic nor is it principled. Only use the HCC codes if the patient has the diagnosis and you can support the code with lab work, diagnostic imaging or clinical evidence.
By focusing on more specific and accurate coding, the insurance company gets a truer look at how sick the patient really is. Then a larger amount of money can be dedicated to that patient’s care.
If the provider manages the patient better, and keeps him or her out of the hospital, some of the money not spent on that patient’s care should come back to the office through programs such as MSSP. This saved money can then be invested in the practice to enhance how it provides better quality care. This is a win-win situation. Both providers and patient