What does it all mean?
Risk Adjustment
What is the mechanism by which government programs adjust the revenue to health plans based on the health status of their members?
Pt with:
Symptoms include:
Test results demonstrate:
Virtual physical exam findings include:
(Additional elements to include if appropriate)
What is "T" or "Treating"?
The section in the TOC protocol where the AI MEAT summary for HCCs are populated
What is the Condition Detail Summary?
Dx: I63.9 Cerebral Infarction
- admitted on 8/21, brought to ED with AMS, dizziness, unsteady gait
- Dx with bL CVAs affecting L parietal occipital temporal region
- CT head 8/24 w/stable findings
- taking ASA, atorvastatin, antihypertensives as prescribed
What is Cerebral infarction is not coded in outpatient setting?
- patient with CKD 4
- initial labs with Cr 2.5, K 5.5; admitted for IV fluid resuscitation, monitoring kidney function; Cr returned to baseline post rehydration
- treated with losartan, BP control
- encouraged f/up with nephrology
What is GFR?
The number of HCCs that TOC program is focused on capturing
What is twelve?
DX: E11.65 Type 2 DM w/hyperglycemia
- A1c 7.5%
- taking Jardiance, Ozempic, Tresiba as prescribed
- F/up with endocrinology as scheduled
- Contact COD with new/worsening symptoms
What is type 2 DM w/hyperglycemia inappropriate for A1c <9%?
Medical conditions that were determined to most predictably affect the health status and health care cost of an individual
What is a Hierarchical Condition Category (HCC)?
- patient with chronic respiratory failure with hypoxia
- remains on 2-3 L supplemental O2 per NC
- advised on importance of titration to goal SpO2>90%
- contact COD in not improving or with other questions
What is the etiology of respiratory failure?
The correct "drop down" selection if the AI generated MEAT criteria does not have enough information to code the HCC
What is "Insufficient Data, Unable to Assess"?
DX: I69.954 - Hemiplegia and hemiparesis following unspecified cerebrovascular disease affecting L non-dominant side
- initial presentation w/L sided weakness s/p fall and subdural hematoma
- resolved s/p surgical intervention, now back to baseline
- offered DME/HHC, declines
What is coding a condition that is in the past or resolved?
Monitoring, Evaluating, Assessing, and Treating
What is MEAT criteria?
- patient with DM2 w/other circulatory complications
- continue to monitor blood glucose and notify PCP or COD for BG <50 or >300
- Continue metformin as directed
- F/up with PCP as scheduled
What is the other circulatory complications?
The correct "drop down" selection when you plan to revisit an HCC during follow-up as you did not have time to address during today's visit.
What is "Not Addressed this Visit"?
DX: C61 Malignant neoplasm of prostate
- s/p radiation therapy, prostatectomy in 2024
- per discharge summary, hx of prostate CA
What is coding active cancer when it is actually history of?
Demographics + HCCs
What comprises the Risk Adjustment Factor (RAF)?
- Patient with morbid obesity
- BMI today of: 36.5
- Recommend increasing exercise regimen with Silver Sneakers and wellness benefits as tolerated.
- Discussed role of diet in weight maintenance.
What is co-morbid condition(s)?
The correct "drop down" selection when the patient's BMI has improved from 40 to 29 and is no longer Morbidly obese?
What is "Condition Resolved"?
DX: Non-pressure chronic ulcer of unspecified part of lower leg with unspecified severity
- Serial documentation of draining wound over the left knee, daily dressing changes, wound vac, and HH SN
- chronic infection/osteomyelitis positive for rare Klebsiella
- F/up with ID as scheduled
What is coding ulcer when actually referring to wound?