Medicare Advantage Mastery: A Clinical Case Study

Thursday, April 28, 2016 | Larry Sobal

 

I didn’t start out writing last week’s blog, Medicare Advantage Ignorance Can Be Painful, intending to produce a Part 2; however, after receiving a large number of emails with many questions about how to optimize documentation and HCCs, I decided to write this follow-up. To illustrate the nuances of Medicare Advantage mastery, let’s start with a case study.

An 85-year old female patient presents to her physician for an annual physical. She has symptoms of a urinary tract infection (UTI). She feels tired, has less energy and a poor appetite. The patient had a myocardial infarction (MI), or heart attack, one year ago. She has mild malnutrition, frailty, and has lost 30 pounds in the past six months. A urinalysis was performed and shows white cells, leukocyte esterase, and microalbuminuria. Her serum creatinine is 1.4. She’s been complaining of urinary discomfort, weakness, and has had dry, itchy skin for the past six months. Her medical history includes stable diabetes mellitus (DM) with nephropathy, chronic kidney disease (CKD) exacerbated by diabetes, and stable below knee amputation (BKA). The patient also has a stable history of MI, UTI, and a serum creatinine of 1.3 six months ago. Lab findings revealed CKD—stage 3 (CKD3).

Medicare Advantage ignorance—or mastery—can have millions of dollars of implications to you or your organization

The treatment plan for this patient includes Glucophase, 500 milligrams b.i.d., for the DM; Cipro for the UTI; Ensure supplements for malnutrition; return to clinic (RTC) in three months; and referral to a nephrologist for CKD3.

What gets coded in the EHR? Probably diabetes mellitus and UTI. It’s pretty simple and what’s likely documented and coded by many physicians every day for a similar patient.

Here’s where Medicare Advantage mastery can make all the difference. As a Medicare Advantage patient, the administering health plan would likely get a monthly premium payment for this patient of around $500, give or take, using this formula: CMS approved base rate, X factors associated with HCCs, X factors associated with member demographics.

In this formula, the base rate and demographics are outside of a physician’s control. Therefore, it is critical that physicians and advanced practitioners be well-versed on appropriately assessing and documenting disease coefficients in order to fully influence the HCC. To do that, here are some important points to remember regarding HCCs.

• They are prospective in nature, meaning that a diagnosis from one year is used to establish the Medicare Advantage payment for the next year. Unfortunately, about 30%-40% of prior year disease coefficients for active patients are not documented the following year(s). The best example is that if a diabetic patient has an amputation, it must be documented each year, in order to count as an HCC.
• CMS will only consider diagnoses from inpatient and outpatient hospital and physician (or advanced practitioner) documentation.
• The provider should document and code to the highest-level of specificity. This means documenting and coding all diagnoses (not just primary diagnosis) that impact the patient’s evaluation, care and treatment.
• Documentation language is critical. For example, use of the phrase “history of” will often be interpreted as the patient no longer having the condition, and therefore, will not contribute to the HCC.
• Documentation must show that a condition was monitored, evaluated, assessed, or treated (MEAT) in order to count as an HCC.

Let’s revisit the patient example from above and see what an appropriate documentation might contain, given her pathophysiology: diabetes mellitus with renal manifestations; UTI; diabetic neuropathy; CKD-stage 3; mild degree of malnutrition; previous MI; and BKA status.

Assuming that all of these are being monitored, evaluated, assessed or treated (MEAT), the monthly Medicare Advantage payment would increase around five-fold, or to $2,500, give or take.

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Larry Sobal is Executive Vice President of Business Development at MedAxiom. He has a 35-year background as a senior executive in medical group leadership, hospital leadership and insurance. As part of his current role, Larry consults, writes and presents on topics relevant to transforming physician practices and health systems.

 

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