1 Confidential MRA Overview Yasmin McLaughlin,CPC SER Manager For internal use only

2 Confidential What is MRA? The Medicare Risk Adjustment payment system uses clinical coding information (HCCs) to calculate risk premiums for Medicare Advantage plans enrollees MRA activity is the key process to ensure accurate payment from CMS for Humana Medicare Advantage enrollees based on the CMS-HCC payment model The primary focus of the MRA department is to obtain accurate healthcare information from providers in order to maintain accurate payment levels through chart reviews and provider education

3 Confidential Humana’s MRA Team

4 Confidential Market Team’s work with Providers Review Medical Records Provide feedback to providers regarding documentation. Coding Seminars are conducted to help practices in their coding efforts.

5 Confidential Providers must be engaged in MRA Goal = Properly Reflect the Member’s Health Status Fully Assess All Chronic Conditions …every six months Thoroughly Document in the Chart ALL conditions evaluated each visit Code to the Highest Level of Specificity (fully utilize the ICD-9 Diagnosis Coding System)

6 Confidential 6 Ok, I understand the elements…

7 Confidential Medicare’s guidelines state: “Code all documented conditions which co- exist at the time of the visit that require or affect patient care or treatment” 7

8 Confidential Best Practices for Excellent Documentation Document at least once a year: Chronic Conditions (CHF, COPD, DM) Active Status conditions (amputations, colostomy) Pertinent past conditions (Old MI) All conditions that require medication Conditions that affect the patient’s day to day life. 8

9 Confidential Best Practices for Excellent Documentation BE SPECIFIC (when applicable) “Major Depression”, not “depression” “Chronic bronchitis”, not “bronchitis” “Atrial Fibrillation”, not “cardiac dysrhythmia” “Malnutrition”, not “loss of weight” “History of MI”, not “CAD” 9

10 Confidential Documentation Be complete and legible—it has to be readable to someone else. Include patient name, DOB and date of service on every page. Note chief complaint (CC), reason for visit, assessment, and plan of care. Specify basis for ordering ancillary/diagnostic services Indicate appropriate health risk factors. Indicate past and present diagnoses if still of any medical significance. Show patient’s progress or lack of progress. Substantiate service rendered. Sign the progress note with full name and credentials. Problem list should be up-to-date and include onset AND end dates. 10

11 Confidential Documentation Tips Always document the status of each diagnosis using specific and descriptive words to document the problem. Use the word history to mean that the condition no longer exists, not the medical history of the patient includes these conditions. All medications listed should have the reason they are taking it listed also. Always Always use an approved abbreviations list! 11

12 Confidential “Why is thorough and specific documentation so important?” If it isn’t documented, it hasn’t been done. 12

13 Confidential Medicare Risk Adjustment Wrap Up Questions