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The Certified Coders’ Ambiguous Job Description

Posted by Donna Kober on Tue, Sep 22, 2015

CoderCertified coders’ job descriptions have once again been redefined due to CMS, OIG, their respective audits, and many other factors over time. We are now the gatekeeper of diagnoses, document translators, and finally coders.  I am not sure how we managed to obtain all this power, and I am not even sure we should have it!  Coders are trained to review documentation and abstract the correct diagnoses and procedures…code what the clinician documents.

Our new job descriptions now have us determining if sections of the chart have been copied and pasted from the previous visits (whatever happened to coding each DOS/encounter as a distinct document?), translating what the clinician documented (is the condition really a history or does the clinician mean the member has a history of….), and finally, we get to decide which codes are going to be submitted by determining if the diagnoses are “supported” by the documentation (what does “supported” really mean?).

The most frustrating aspect of this transformation is that no two coders are on the same page!  Heck, no two national organizations are on the same page!!  Wait, no two governmental organizations are on the same page!!!

There will always be “gray” areas in medical coding, but some of those “gray” areas could become black and white if representatives from the coding community had an opportunity to sit down with the governmental agencies monitoring health care coding (CMS and OIG) and have an open dialogue. Discussions around the use of “history of” and of chronic conditions documented in the PMH as well as standardization of coding rules for both outpatient and inpatient coding (Coding Clinics are customarily based on the inpatient setting and the majority of coding work is in the outpatient settings) would be a good place to start.  

In my next blog entry, I will discuss best practices to address the challenges with these inherent ambiguities and to align coders and their work products in a meaningful and beneficial way.

Tags: medical record abstraction, CMS, ICD-10, healthcare coders, audit, Coding, PMH, encounter, OIG

Ways to Improve your HEDIS® 2016 Scores Now

Posted by Michael Curran on Mon, Aug 31, 2015

medical_billingWith HEDIS® 2015 well behind us, now is the time to start planning for HEDIS® 2016. While the active medical record collection period is short, HEDIS® is a year-round activity and there are many opportunities to make next year results even better. It boils down to data gaps and identifying where those gaps exist. With that in mind, you can identify interventions for your health plans, providers, and members. Taking action to close these gaps can drastically improve your HEDIS® and STAR Ratings for the following year.  


A few specific ways to improve HEDIS® 2016 scores:

  • Assess and analyze what is driving gaps and close them: Such as out of network visits, providers not cooperating, and/or EMR integration not being utilized.
  • Ratchet up provider engagement: Targeted reports that give providers up-to-date patient information can assist them in their outreach efforts to encourage members to receive timely care.
  • Supplemental Data: Seek out other supplemental data sources that can help improve rates such as state registries for immunizations, health assessment data, and prior year hybrid exclusions (colorectal screening, breast cancer screening, etc.).
  • Look for opportunities to reduce provider abrasion: Consider ways to help providers anticipate and schedule HEDIS® requests and explore technologies that reduce office disruption such as remotely accessing EMRs.
  • Revaluate member engagement strategies: Consumers are demonstrating a willingness to adopt new care delivery models that are more convenient and lower cost. Payers need to experiment with technology enabled outreach programs that accommodate member’s increasingly mobile lifestyle.

The healthcare system is inherently challenging to navigate. By exercising strategies that encourage members to manage their health and facilitate greater provider collaboration, you lay the foundation for improving HEDIS® scores for 2016 and beyond.


Tags: STAR ratings, CMS 5 Star Rating, HEDIS audit, provider data, provider relations, HEDIS, NCQA HEDIS, provider abrasion, gap closure, EMR, HEDIS 2015, gaps, supplemental data, provider engagement, HEDIS 2016

Leverage Risk Adjustment Charts for Medicare HEDIS® Gains in the Off–Season

Posted by Michael Curran on Thu, Aug 13, 2015


Just because the HEDIS® reporting season has ended, doesn’t mean that there is not still valuable chart review to be done. Those charts that hold value for HEDIS® scores and Stars rating could be coming into your organization right now.

Risk Adjustment chart collection occurs virtually year-round and there is a very good chance that your plan is acquiring charts right now for that purpose. Although there are clearly limits to how you can use partial year chart data for HEDIS® reporting, mining these charts in the HEDIS® off-season can yield potential outreach opportunities and possible valid exclusions for low denominator, administrative-only HEDIS® measures.

HDVI’s STARs Improvement initiatives help plans leverage existing chart information from risk activities as well as gather additional charts as needed to impact several hybrid and administrative measures, including:

  • Controlling High Blood Pressure
  • Comprehensive Diabetes Care – BP
  • Comprehensive Diabetes Care - Eye Exam
  • Osteoporosis Management in Women who had a Fracture (OMW)
  • Drug Therapy for Rheumatoid Arthritis (ART)

Although you cannot use the blood pressure values found in the chart to satisfy the actual reporting for HEDIS® 2016, review of these charts can help identify non-compliance mid-year and potentially focus outreach. In the cases of measures like OMW and ART, these generally have low denominators and fairly wide exclusion criteria. Locating only a few valid exclusions, that your auditor approves, can help a plan move the needle on these administrative-only measures.

Tags: quality improvement, STAR ratings, HEDIS quality improvement, CMS 5 Star Rating, chart review, medical records, HEDIS measures, STAR rating, Medicare Advantage, HEDIS, off season

HHS Skips RADV in 2015 – Should Exchange Plans Take the Year Off?

Posted by Bryan Lee on Thu, Aug 06, 2015

HHS_LogoWith CMS’ recent announcement of the delayed implementation of HHS Risk Adjustment Data Validation (HRADV), a number of colleagues involved in risk adjustment for commercial exchange plans have been wondering if they should still be conducting mock RADV audits; or do something else; or do nothing for now.   While I have never been an advocate for conducting ‘MOCK’ RADV audits in a manner that exposes a health plan to greater financial risk, I do strongly encourage everyone I talk with to conduct periodic RADV Preparedness ‘Fire Drills’ and Targeted Audits. Those plans that just got a reprieve from the HHS RADV are no exception.

So why should one bother conducting an internal audit of the accuracy and completeness of their Risk Adjustment data, when the regulators won’t be looking over their shoulder until 2018?  To be ready when it counts.  Clean up your data so that when the ‘one and only trial audit’ in 2016 occurs against your 2015 data, your plan doesn’t find itself trying to catchup with the competition.  With only 20-30% of a commercially risk adjusted population having an HCC relevant diagnosis, just one missed code could mean the difference between a plan receiving a payment, or having to pay a competitor.

What are some of the things plans should be doing now? If you haven’t already engaged an IVA firm, hire one. Not necessarily to duplicate the exact IVA (for a number of reasons), but a targeted audit.  The second thing I encourage is putting together a work team charged with conducting targeted audits of their data to get a better understanding of where the holes are in both process and data. Fix them. And audit again. It is worth the effort and not just for peace of mind, but financially as well. 2016 is just around the corner.

Tags: CMS, risk adjustment, health exchange, HIX, RADV, commercial plans, HCC, IVA, Mock RADV, HHS, HRADV

Carnegie, Bridges, and Our Antiquated MRR Processes

Posted by Michael Klotz on Thu, Jul 30, 2015

I recently watched a documentary series called ‘The Men Who Built America’ on Netflix. One of these men, Andrew Carnegie, is usually known as a Pittsburgh steel magnate, one of the richest people in history, and his philanthropic legacy including Carnegie Hall. Less well known, perhaps, is the fact that he started out in the railroad business.

So what does any of this, you may ask, have to do with how we perform Medical Records Reviews today? Bear with me…

After learning the ins and outs of the railroad business for a number of years, Carnegie started his first company which built railroad bridges like the Eads Bridge over the Mississippi which was completed in 1874. That bridge, with its massive span, could only be realized through innovation, specifically the use of steel. Daring and new at the time, the use of steel soon changed transportation and construction forever.


While these bridges are beautiful and amazing feats of engineering, the usefulness and benefits ultimately drove their realization. Innovation by itself never stands the test of time. Among other things, these bridges made travel and transportation much more seamless. No more loading and unloading, use of ferry boats, long waits, unpredictable schedules, etc.

Looking at how our industry performs Medical Records Reviews, especially the retrieval steps, I couldn’t help but think of what transportation must have been like before those bridges. Multiple vendors involved (even if it doesn’t appear that way on the surface), the tasks and steps are disjointed, disconnected or both, ability to keep track of status and issues is manual and delayed, and handoffs to coding teams are often clunky and painful.

I’d like to suggest that our industry can now widely embrace the innovation enabled and realized through software to run MRR projects in a seamless and integrated fashion. The technology for the end-to-end workflow exists, is proven, our industry is aching for it, and the plans using it are seeing the obvious and a number of additional benefits. So it’s about time we use software to build these bridges supporting a seamless process to get our MRR trains running fast, reliable, and inexpensively while making the experience a much better one for all involved.


Tags: SaaS, medical record review, MRRV, MRCS Platform, software platform, medical records retrieval, MRR, medical record analysis, workflow, Coding, vendor

4 Key Obstacles to Operationalizing Concurrent Risk Adjustment Reviews

Posted by Bryan Lee on Tue, Jul 21, 2015

If you are reading this, chances are you agree with my previous blog’s premise that performing concurrent risk adjustment activities are increasingly important. Or perhaps you had already arrived at that conclusion previously.

Just wanting to do something is not enough, however. A concurrent review process is sufficiently different from a retrospective one to merit serious thought and planning. As we have been developing our platform and adapting our services, we have learned some valuable lessons. Here are some of the top obstacles and pitfalls to be considered when moving towards concurrent:

  1. Data Flow: Having the right data to start with is critical. Aside from good suspecting and provider data, plans should take a Verify-Delete-Add approach. This means good encounter data is needed and the MRR platform needs to be able to handle that data to be useful.
  2. Provider Abrasion: Providers are bombarded with increasing numbers of chart pull requests. Provider abrasion is ever increasing as all of your competitors get into or increase the scope of retrospective chart reviews, especially now that commercial exchange plans also risk adjust. With concurrent, the frequency of chart requests goes up. It is critical to have an approach that does not further tax the already thin patience of providers.
  3. Taking Action: Aside from getting a clear picture of revenue and other aspects derived from medical records, a key aspects of concurrent review is gap closure. Tight review cycles afford plans the time to perform meaningful campaigns to close identified gaps.  Make sure you have a plan and the tools to act on the information to close as many gaps as possible.
  4. Cost: It stands to reason that more chart review cycles will cost proportionately more money. Money that may not be in the budget. What can you do? Tackle the two main cost factors in the MRR process: Retrieval and Coding. A lot of it can be done with technology, to the point that the providers are actually less bothered than before. And a new approach to coding based on the encounter, not the chart. The numbers are surprisingly different.

Whether you are using our platform, another vendor’s or your own workflow, these issues will be constants and deserve all our attention as we expect to adopt concurrent reviews more and more.

Tags: SaaS, medical record review, risk adjustment, MRRV, provider data, provider relations, revenue optimization, MRR, revenue management, big data, provider abrasion, workflow, Coding, Concurrent, verify, verify-delete, retrospective chart review, gap closure, encounter, delete, retrospective, data flow

Why Concurrent Risk Adjustment Reviews Are Becoming an Imperative

Posted by Bryan Lee on Mon, Jul 13, 2015

Pretty much anyone within the Risk Adjustment world talk about similar topics of concern: the need to accurately capture and protect revenue, proactively assess and manage member health, contain cost, and improve quality. All while the regulatory landscape becomes more demanding and risk adjustment becomes more commonplace and varied. For example, submission of corrected claims are gaining greater scrutiny by regulators, as a means to identify fraudulent billing practices.

Historically, retrospective chart reviews were most commonly deployed for influencing risk scores and improving revenue. This look-back into a member’s medical record has often been 12 to 18 months beyond the encounter date. The delay in correcting the submission of data to a plan’s regulators contributes to a wide variability in risk scores and ultimately in reimbursement.

Regardless of which concern one focuses on, the need to submit COMPLETE and ACCURATE data in a TIMELY fashion is the recurring theme. Plans are compelled to remedy data (and document) lags. The sensible solution, then, is to continuously review medical records as medical encounter data becomes available.

This process essentially boils down to continual reviews focusing on recent encounters as driven by the encounter data (which is about as ‘concurrent’ as it gets). The triggering event for a concurrent RA review is driven by a claim submitted from a provider so abstraction of the medical record can be timely. In turn, this enables a host of follow-on activities, member outreach, provider education, and, more accurate and complete submissions to regulators through further integration with the plans EDPS processes.

So concurrent RA reviews enable a plan to better balance the information requirements of the regulators and to establish greater controls on revenue generating activities and the many related activities.

Implementing a concurrent review process can be tricky and costly. Read about some key considerations in our next blog.

Tags: quality improvement, quality measures, medical record review, risk adjustment, provider data, healthcare data, healthcare data analytics, revenue optimization, medical record analysis, revenue management, Concurrent, reimbursment, encounter, EDPS

HEDIS® Season - Why Being "On" in the Off-Season is So Critical

Posted by Michael Curran on Mon, Jun 29, 2015

             As another HEDIS season comes to an end, most of us are carrying reminders that no matter how you approach the business of chart retrieval and abstraction, it seems to remain hard work with numerous dependencies for most health plans.

             It’s typically at this time of year that I’m reminded of the guidance from W. Edwards Deming (one of the heads on my personal Mt. Rushmore of Quality Management) concerning supplier relationships. Deming’s philosophy of Total Quality Management and continuous improvement had been aggressively adopted by my then employer and having the good fortune of working at an organization with close ties to Harvard University, I had the privilege of attending a lecture given by Deming in 1990. Even at 90 years old he maintained an authoritative presence and spoke with a conviction and the passion of a recent convert.

            The key message I took away from that hour with Deming was how much quality depended on the quality of relationships both those internal to a company, embodied in his message of “driving out fear” within an organization, as well as outward facing, embodied in his message about the value of investing in long term relationships with suppliers or vendor partners, as I like to think of our organization. Vendor partners that understand the needs today, have a vision for the future, can execute and have the competence and passion to work with their plan partners year-round.

             I believe those two notions are exceedingly important in developing strategies to continuously improve the quality and completeness of hybrid reporting for HEDIS. A “one and done” approach to working with Medical Record Review or NCQA Certified HEDIS Software vendor partners will rarely address the issues related to reporting the most accurate HEDIS rates.

             As a standard practice at HDVI, we advocate for and build year-round relationships with our plan partners and recognize that HEDIS hybrid rates are improved more from the work done by the plan-vendor partner teams between June and January (often called the off-season) than what is done between January and June will go a long way toward improving rates across the board for hybrid measures while often saving a lot of stress, aggravation and even money.


Tags: quality improvement, NCQA, HEDIS hybrid, HEDIS, MRR, off season, vendor

PMH - To Code, or Not to Code?

Posted by Donna Kober on Mon, Jun 08, 2015

ICD_10_tri_colorI was writing an article for the AAPC Edge and I wanted to make sure I had my facts correct about the importance of the diagnoses in the PMH section of the documentation. So I called my sister in law who is an Emergency Room Trauma physician. I posed this question to her: Do doctors (providers) use medical history (PMH) diagnoses in their decision making when assessing a patient?

She responded that physicians review the PMH to form a foundation of the patient’s medical issues. Then after the examination they can use the PMH to assist with differential diagnoses or to assist in the determination of treatment for that specific encounter.

So, if the chronic and past conditions are used by physicians in the decision making process, wouldn’t that be considered as part of the evaluation of a patient therefore fulfilling the “E” in the MEAT validation concept? I know some coding experts say, “if it isn’t written, it wasn’t done.” At the same time, I can’t see any provider actually writing “I took into consideration the PMH diagnoses in my decision making”. Coding all chronic diagnoses from the PMH provides insurance companies and CMS with a holistic picture of the patient on that specific date of service.  

I am not saying coders should be coding all the diagnoses in the PMH as current diagnoses, if they are a “history of” they should be coded and categorized as such, but the chronic conditions that never go away will always have an impact on the decision making of providers, so why not code them?

Tags: CMS, ICD-10, healthcare coders, Coding, HCC, MEAT, PMH

It's Prime Time for the MRR Workflow Platform

Posted by Michael Klotz on Tue, May 26, 2015

When we set out to create a workflow platform for everything Medical Records Review a few years ago, we had a very good idea of what it should be and do, what its benefits would be and how it would address a number of pain points payers (and providers) have with the MRR process. A vision, if you will.

As another HEDIS season is coming to a close and we see, for example, how the preparation and response to the MRRV, the dreaded audit of the MRR portion of the annual quality review, has changed (among other things), I can’t help but be a little proud. Chaos, disorder and countless hours of pulling records together have been replaced with putting a checkbox next to a few member names and clicking a ‘Generate Audit Package’ button, in this case.

Certainly, the enterprise workflow platform we have created is not exactly what we had in mind at the time. We got a number of things right, we made mistakes (and fixed them), we heard from our customers what they really needed and addressed those needs and continue to do so. What we know with a good amount of certainty today what the key aspects of such a workflow platform are:

  1. Configurable and Flexible – we have realized how important it is to allow our customers to staff and run their projects the way they want to
  2. Comprehensive – the status quo was that health plans had to cobble together a number of people, vendors and technologies to get meaningful results. It felt more like herding cats than managing at times. We took the approach of creating a platform that addresses all MRR needs, from Risk Adjustment for all lines of business to HEDIS to one-off audits, the ability to get every medical record, with built-in functionality supporting everything from provider data verification to built-in RADV readiness
  3. Real-Time Visibility – as we look at real-time dashboards of every aspect of the MRR process, it’s hard to imagine how we ever managed without. The term ‘flying blind’ comes to mind when we think about how little timely information was available in the past.
  4. Provider-Friendly – to our surprise, a little feature called Secure Virtual Print, is a big hit. In retrospect, it’s not surprising since provider abrasion is one of the top concerns and Secure Virtual Print really helps on that front. A lot.
  5. Part of the Big Picture – as important as risk adjustment and HEDIS Hybrid projects are, they are part of a larger, usually member-centric, care cycle. To continuously add value we are making our platform a seamless part care management, provider education and gap closure processes. For example, a care manager can pull up the ‘Member Timeline’ dashboard, which visually shows all review periods where a medical record is available, with encounter dates and many additional data points and the ability to click through to the relevant pages on the record in a matter of seconds.
  6. Reliability, Scalability, Speed & Security – obvious ones, but without these, nothing else really matters

As we continue forward implementing some of those ideas we haven’t gotten to and the many we have come up with since, we will follow these guiding principles. They have served us and our customers well so far.

Tags: health plan providers, SaaS, chart review, medical record review, risk adjustment, MRRV, HEDIS, MRR, workflow, secure virtual print

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