Revolutionize Your Revenue Cycle

Lori: Hi everyone and welcome to our AAPC Services podcast series. I'm Lori Cox, one of the regional directors here at AAPC Services and I'll be the host for today's podcast. I have here with me one of my good friends, Colleen Gianatasio. We are gonna talk a little bit today about risk adjustment. Hi Colleen.

Colleen: Hi Lori. How are you?

Lori: I'm good. How are you doing?

Colleen: Good, thanks.

Lori: So, tell us a little bit about yourself and what you're doing now.

Colleen: Sure. So, Lori, I've worked for the past 20 years on the payer side. I have experience in claims, customer service, and for the past 5 to 10 years, I've worked exclusively in ICD-10 and risk coding and quality metrics. And most recently, I've made a change from the payer side and joined Mount Sinai Health Partners as their director of Ambulatory CDQI.

Lori: Interesting. And let's not leave out that in 2022, you will be taking over the National Advisory Board. So you've got a lot on your plate.

Colleen: Thank you. But I'm looking forward to it.

Lori: Well, we have a few questions, so we'll just get started. Number one, what is the most important to you when we think about risk adjustment, like, what is the most important factor of that to you or to your company?

Colleen: Okay. So, it's important to first understand the basics of risk adjustment. So, I like to define it as risk adjustment is a form of predictive modeling that assesses the relative risk that a member is going to incur above or below an overall average over a defined period of time, right? That's a pretty dry definition, but it gives us an idea of why this model was created. It really does serve several purposes. First, it minimizes the incentive to select or reject enrollees based on their health status. Second, it encourages competition amongst health plans to create quality efficiency and premium stabilization so important in today's healthcare environment.

Lori: Yeah.

Colleen: And it assists with the financial forecasting of future medical need. All very important. With that being said, I think that we can all agree that risk adjustment is really important to the industry from a financial perspective. But your question is, what do I think is most important? And what I think is most important is that if this is done correctly and I truly believe this, it's a great way to identify those patients and those members who need our care the most. When we get accurate diagnosis coding correct, it lets us identify the most chronically ill patients and then to put the appropriate care management strategies into place. And that's really important, especially now that COVID-19 has really hit all of us at some point this year. We're relying on the data from risk adjustment more than ever to identify the patients who might not be able to come into the office. That's what's most important to me.

Lori: That's interesting. And that's some good points because I think sometimes when we start with risk adjustment and I don't do a lot of risk adjustment anymore, but we just focus on the know and we would get the codes in there, you know, that are documented and then we forget that this has a bigger picture here. This is affecting many different areas of healthcare. So, that was good. Second question, what are some of the pros and cons of retrospective versus prospective risk adjustment?

Colleen: Great question. Traditionally, most risk adjustment activity has been done on a retrospective basis. And really most risk adjustment is still done this way. Companies usually hire teams of coders and other risk adjustment professionals to review charts, but they're doing it on past medical encounters. And those coders and risk adjustment professionals are ensuring that the accurate severity of illness is captured. However, an exciting shift is happening right now, more and more organizations like my own are moving towards a prospective risk adjustment.

Lori: Really?

Colleen: So the pros of prospective is, first of all, it's going to focus more on provider engagement and education. And then rather than looking at encounters that have already occurred, prospective looks at upcoming encounters and it reviews it for opportunity before the patient encounter. And that's really... Yeah. That's so important because we have to always keep our providers in mind here, right? We're always thinking about, you know, member and customer service, but we really have to keep the primary care doctors in mind here. So, with prospective risk adjustment, the open opportunities are being presented to the provider at the point of care. This is going to allow the chronic conditions to be addressed appropriately while the patient is in the office.

Lori: That is interesting because so when I think of retrospective versus prospective, of course, I'm thinking about a claim being paid. So, I was thinking prospective meant before the claim was submitted but after the doctor's visit. And so, you're saying that they're looking at visits that are upcoming and so if I had an appointment with my OB doctor in the future, they could be looking at possible factors that could play into that appointment.

Colleen: Exactly. And you're not wrong, Lori, as far as retro versus prospective, because there is payment methodologies that are retrospective versus prospective. But this is more in relation to how the charts are reviewed.

Lori: Interesting.

Colleen: So, the prospective eliminates the need for retrospective chart review, and it also gives us time to present these opportunities when it's more relevant and timely to the provider. I think we can all agree, anybody who's been in risk adjustment, that it's really challenging to engage a provider on documentation and coding for a patient that she saw a year ago, right?

Lori: Absolutely.

Colleen: So, these changes to prospective risk adjustment are contributing to trends that we were seeing in outpatient CDI, which is clinical documentation improvement. Some people call it clinical documentation integrity. Another fascinating new branch of our field and I expect that to grow. Prospective risk adjustment in this prospective chart review can also be used to help with quality metrics that are becoming more and more important. So, it really is a win-win situation for all parties involved.

Lori: Well, that's really neat. I never even knew that that was coming about, so thank you for explaining that. It's interesting to see how that's going to be affected in the future as we move forward.

Colleen: Yeah. Definitely keep your eye on it.

Lori: Absolutely. So, how does your organization ensure that they're accurately reflecting the risk of their patients?

Colleen: Well, it's a big job, but we start with education. I think that's the core to any solid risk adjustment program. We start with both our internal CDI team and with our provider network. It's really important to stay on top of the many changes we're seeing in the industry right now. I don't think I've ever seen this many changes in one calendar year ever in my career.

Lori: Great.

Colleen: Our internal CDI team needs to stay on top of the ICD-10 guidelines, the quarterly coding clinic updates, so that they know that they're applying the most current rules. Our providers, right, they're not coders, so they need to be given a basic understanding of risk adjustment. And then we have to provide ongoing training so that we build their knowledge. Really crucial in this foundational training is regular feedback so that they're aware of the areas that they're doing well in and areas where they have opportunity to improve. Because once you start these efforts, it's not enough just to say, "One and done, we've educated on risk adjustment." You need constant feedback so that we are addressing areas that might be coming up short because of EMR limitations or maybe a new provider is joining the practice. At our organization, we're ensuring that we're successful by making sure that providers are being presented with information about their patients as close to the point of care as possible like I talked about with our prospective risk. Another way we're ensuring success, and this is big, is making sure that our systems are updated. COVID-19 brought about massive changes...

Lori: Yes it did.

Colleen: for everybody, but for risk adjustment, one of the most significant is that telehealth services that have both audio and visual components are allowed for risk adjustment now. So, we made sure that our systems were updated to accurately capture these opportunities. And that was huge because now we've realized with patients not coming into the office, we can take advantage of that new leniency where telehealth is allowed. And we were able to update our systems and identify those encounters pretty quickly. But before we move on to the next question, I just wanna say again because there's been a lot of discussion regarding this, telehealth for risk adjustment needs both an audio and a video component. A telephone encounter alone is not sufficient, so I get a lot of questions on that. So if you're out there learning about risk adjustment, make sure that if you're using telehealth, that it does have the video and audio component.

Lori: Right. It's very important to document that not only for risk adjustment but for auditing purposes. I see so many encounters and it says this was a telehealth visit and I don't know if it was just telephone or if it was really, are they seeing the patient? So I'm digging through the documentation, looking for like an exam maybe, or something to say, "Hey, this is a video visit." But that was interesting to me when they did finally start allowing telehealth because really, they're still managing those patient's chronic conditions, even though it's audio-video, and they're not face-to-face with each other. So, I know a lot of people were concerned when that came up that they weren't going to allow it, and then thankfully, they changed that. So, hopefully, they will keep that going forward. It's going to be interesting to see how telehealth continues even, and I say after with air quotes around it, right, because we hope that this pandemic ends sooner or later. But it's interesting to see how they'll go on with telehealth afterwards and how that'll affect risk adjustment too.

Colleen: I agree. And I think you mentioned something really important there when you're looking through the documentation and you're struggling to find, was this telephone or was it, you know, telephone and video? Really important. So, take proactive steps now to make sure that's absolutely crystal clear because we don't know how long COVID is going to last, we don't know what changes are going to stay in place after COVID. But one thing we know for sure is audits will continue, right?

Lori: Yes they will.

Colleen: So, the easier we can make that for our own organization by easily being able to identify these telehealth encounters, I think that would be a great proactive step to take right now.

Lori: I agree. So, one of the hot topics that's always on social media is about coders and auditors, brand new, they're just certified or they're just learning. So what advice would you give to coders and auditors that are just kind of starting their career in risk adjustment?

Colleen: Thank you for that question. This is one of the areas that I'm so passionate about. I think we have a great organization that really is a great place to start a career. So, I have three pieces of advice for coders or auditors just starting their careers in risk adjustment. Number one, never stop learning. Getting your CRC, certified risk coding credential is just the first step. Don't be complacent, search out everything there is to learn. There's so much to learn, it's ever-changing, which brings me to piece of advice number two, make sure to stay on top of updates. Make sure that these updates that are coming are from reliable sources. So, check your ICD-10 guidelines, check your coding clinic, and your CMS updates. These are all reliable sources, they should be referenced very regularly. This year, I think beyond...I think it set a precedent. ICD-10 was updated before the normal October 1st updates because they introduced new codes for COVID. So, check your reliable sources, stay up to date. The changes are coming, they're coming fast.

And number three, explore your options. Risk adjustment offers so much growth opportunity. Job opportunities that are present not only in your traditional provider setting but on the payer side. There's also so many vendors that offer risk adjustment solutions, they're always looking for coders. If you're brand new to the field, consider getting your foot in the door by looking for non-coding opportunities. There's a need right now in risk adjustment for chart retrieval specialist, a great stepping stone for somebody who just wants to get your foot in the door.

Lori: Absolutely.

Colleen: Yeah. And so, risk adjustment, in my opinion, is a great area for coders, auditors, educators. It offers opportunity and is not only for our newbies which I'm really passionate about getting them started, but it also is a great way for more seasoned professionals who might be looking for a career change or something new.

Lori: I think that's what I like the most about our career field, is let's say I'm working in risk adjustment, and eventually, maybe I just feel like it's not where I need to be. You can branch out into so many different areas. You know, like I love surgery coding and auditing. That's kind of my forte, right? But I could do risk adjustment if I decide, "Hey, I want to step back from that." Because it can be a little stressful from time to time and go into risk adjustment, learn something new, and I mean, there's just so much we can do in our field.

Colleen: Absolutely. I've been doing this for years and I have never been bored. And I can tell you coming from the payer side and going to the provider side, it's a totally different perspective. It's a fresh new way of looking at things.

Lori: Right. And just like you said, it's always changing. There's never a static moment, I don't feel like, and especially this year with everything's always changing.

Colleen: Absolutely. It keeps us on our toes.

Lori: It does certainly. I think that's all the time we have for today. Thank you, Colleen, for joining me. I really appreciate it.

Colleen: Lori, it was great talking to you. Thanks for having me.

Lori: Excuse me. For all of our listeners, to replay this podcast or listen in on our other podcasts, please go to our website at www.aapc.com\business. Then click on the resources tab and you'll see a list of our podcasts as well as some whitepapers and eBriefs that we've put out there for you all free of charge. Thank you for listening, and we'll see you next time.