#545 - HCC Coding and Value-Based Care, UPF Clothing, Being Intentional
Take 3 – Practical Practice Pointers©
From AAFP Family Practice Management
1) HCC Coding and Succeeding in Value-Based Care
The Centers for Medicare and Medicaid Services (CMS) has as its strategic plan to have “all Medicare…and the vast majority of Medicaid beneficiaries…in a care relationship with accountability for quality and total cost of care by 2030.” Most of the care delivery models that CMS has been experimenting with for Medicare (like Next Generation Accountable Care Organization (NG-ACO), Medicare Shared Savings Program (MSSP), etc.) to prepare the health care system for this transition are models of capitated funding where the financial resources available to deliver care over a year are allocated per patient. Because patients with more chronic disease require more healthcare resources, in a fair system, the capitated payments should be adjusted based on the overall risk of healthcare spending for a patient.
Enter Hierarchical Condition Category (HCC) coding, also called Risk-Adjustment Factor (RAF) coding. For CMS to allocate an appropriately risk-adjusted amount of funding to care for a patient, they must have some idea of how much care that patient will need based on their medical problems. The way we let CMS know about our patients’ medical problems is by submitting diagnosis codes on healthcare claims. The financial reckoning happens at the end of each year, and the system resets (or “forgets”) each year, requiring that each of the applicable diagnosis codes be entered at least once per year. HCC codes are a specific list of ICD-10 codes that have been deemed by CMS to predict significant healthcare cost, so, if a patient has one of these diagnoses, it is important to use this specific HCC code on a claim each year.
Our success in value-based care, then, depends on a shift in thinking from precisely describing the work we do (the basis for the detailed Evaluation and Management-based coding under which we have lived for years) to precisely describing our patients’ active diagnoses every year. Most healthcare organizations that do well in value-based care have set up a system to ensure that our patients’ diagnoses are appropriately coded each year:
- A reminder system to submit an HCC code in the current year that has been coded in a previous year. (called “reconfirmation” coding)
- A system to look for diagnoses that are appropriate for a patient, but haven’t yet been coded (e.g., an obesity code for a patient with an elevated body mass index, called “suspected condition” coding)
- For both reconfirmation and suspect coding, the system should help clinicians code to the highest specificity to accurately describe the patient’s condition and maximize reimbursement for their care. (e.g., avoiding “unspecified” codes and symptom codes where a more specific code is possible).
- An emphasis on yearly health maintenance visits (especially the Medicare Annual Wellness visit), where there is an opportunity to code any active conditions that have not yet been documented that year.
- A way to ensure proper documentation to support a code on a claim. We cannot simply list diagnoses, we must document an effort to monitor, evaluate, assess and/or treat (“MEAT”) the coded condition. For conditions we treat in primary care, this is usually straightforward, but for conditions that are treated by specialists, engaging the patient in a brief discussion about progress, symptoms and plans for returning to the specialist and documenting these items is usually sufficient.
- Working in partnership with coding compliance staff to ensure that we are accurately coding and documenting.
John’s Comments:
Family Medicine organizations have long advocated for a way to “get off the RVU treadmill” – a system that is engineered to reward procedures and frequent visits over thoughtful primary care. In a sense, we have gotten what was requested, but change in a massive bureaucratic system that affects our financial well-being is always going to be difficult. Simply put, rather than worrying about the number of review-of-systems and physical exam bullet points we document to meet an E&M code, we must begin to shift our focus to diagnoses and documentation of our assessment and plan thinking. It is incumbent upon healthcare organizations to recognize the difficulty of this transition for clinicians and create systems that minimize the burden of change.
References:
Question/Reminder From a Colleague
2) The Effectiveness of UPF Clothing for Sun Protection
Question: “Thanks for your annual Take 3 sunscreen review last week. What about SPF clothing? Is it effective and worth the cost?”
Answer: There is actually no such thing as SPF clothing. Clothing/fabrics are tested using a UPF (Ultraviolet Protection Factor) rating system. The UPF rating indicates how much UV radiation (UV-R) will pass through the fabric – the higher the rating the greater the protection. A UPF 25 means 1/25 (4%) of UV-R will pass. UPF 50 means 1/50 (2%) will be able to penetrate the fabrics. The highest UPF protective level is 50+, which means less than 2% of the UV-R may be penetrating the clothes. There is no “official” UPF higher than 50+.
Currently, manufacturers follow voluntary testing guidelines and use private labs to determine a fabric’s UPF rating. The most common standard used in the US to “rate” UPF clothing is ASTM (formerly the American Society for Testing and Materials). Some manufacturers also use the AS/NZS (Australia/New Zealand Standard). They are similar in terms of the measurement process used. In general, advanced textiles and fabrics score better for UPF ratings. Polyester & Nylon are best for UV reflection. Wool and silk are moderately effective. Cotton, rayon, flax and hemp are the least effective.
The Federal Trade Commission monitors UPF advertising claims. If a manufacturer adds a tag with a UPF 15-50+ rating to any product, it must adhere to the testing standards outlined above. No clothing item with an Ultraviolet Protection of less than 15 can be labeled “sun-protective”.
Interestingly, Consumer Reports did a study in 2015 comparing the UPF of three white shirts, only one of which had a UPF claim. The UPF 50+ rated rash guard, which was a blend of 84 percent polyester and 16 percent spandex embedded with titanium dioxide, delivered a UPF of 174. A cotton long-sleeve T-shirt which was thicker than a regular T-shirt had a UPF of 115 and a non-rated long-sleeve compression crew made of the same polyester/spandex blend as the UPF 50+ rash guard had a UPF of 392. When wet, the 50+ UPF shirt’s UPF actually increased to 211, the blend decreased to 304, and the cotton T-shirt decreased to a UPF of 39.
Mark’s Comments:
Clothing can offer excellent sun protection without having a UPF label. For example, it is estimated that jeans have a UPF of approximately 1700! However, a normal-thickness white t-shirt has a UPF of 5. Note there is great price variation of UPF products, but one can be purchased for under $20. My favorite long sleeve shirt for paddle-boarding cost me $19. Even at a higher price, a sun-shirt that will last years (and that you don’t have to worry about “reapplying” 2 hours after swimming or after sweating like sunscreen) begins to look like a good bargain indeed.
There is a distinction between a shirt made of UPF material and a “rash guard” UPF shirt. Rash guards are made to fit snugly (think 2nd skin) and can be used during swimming. Both are effective, though with rash guards, stretch points (like shoulders) can decrease UPF effectiveness. Note as well that the most popular “sun hat,” the baseball cap, protects the head and forehead well, but not much else. That’s why I’m a big fan of the broad-brimmed sunhat, even if I get some good-natured teasing about it. Sure beats MOH’s surgery!
Reference:
From PeerRxMed ( www.PeerRxMed.org )
3) Practicing the Art of Intentional Living
“Intentional living is the art of making our own choices before others’ choices make us.” Richie Norton, author and podcaster
Consider for a moment how you started this day. Literally, what are the first things you thought and did? If you are like many, your day started with some type of alarm going off, and then your thoughts immediately started planning for the day while you reached to check your mobile device.
What might it look like if you started your day more intentionally, from a place I call “by design”? This is something I started doing a few years ago and it has completely changed my life for the better. Even before my feet hit the floor each morning, I pause and ask myself, “Who and how will I show up this day?” In other words, what will be the “experience of myself” for my family, friends, colleagues, patients, care team, neighbors, and strangers throughout the many opportunities, challenges, frustrations, and “surprises” that await. In doing this, I am recognizing there are many “Marks” who have the potential to appear and there is a window of opportunity before the sun rises to consciously “choose” before some of the more assertive “selves” or the busyness of the day try to take charge.
The Sanskrit name for this approach to “whole life” intention-setting is sankalpa. A sankalpa is an intention formed by the heart and mind – it is a is a vow and commitment made to support one’s highest truth and best self, and is something lived into in the present, not some time off in the future. Doing so is what makes it more powerful than a goal. Think of it as “a promise to your Soul.”
As my day progresses, I keep some words in my “toolbox” that serve as a reminder of my intention. These include “remember” “choose,” “pause” and “A-Game” that I repeat silently to myself when thoughts or circumstances are causing me to potentially “veer” from my stated desire as to how I want to be in that moment. For you, this reminder could be a word, phrase, symbol, or even picture. Not surprisingly, research has found that such regular intention setting can actually “rewire” our brain, alter our psyche, and even change our physiology.
How about you? What “Soul promise” are you embracing each day to help provide focus as you connect with others? If you’re not doing so by intention, you’re doing so by default, and likely, as the quote above indicates, the “world” is making many of “your” choices for you. Why not consider starting each morning for the next 7 days by consciously answering the question “Who and how will I show up this day?” and notice what happens. Better yet, why not agree with your PeerRx buddy to both do it, and then provide encouragement and support as you share the experience. Either way, a better version of you will likely guide your way to a much better day. You can thank me later …
______________
Mark and John
Carilion Clinic Department of Family and Community Medicine
Feel free to forward Take 3 to your colleagues. Glad to add them to the distribution list.
Email: mhgreenawald@carilionclinic.org