Diagnoses with the highest risk adjustment impact

Laurie.a.Engeldinger@healthpartners.com

Our team has been doing an increased amount of risk adjustment work including in-depth mortality reviews on the key CMS diagnoses.  We have reviewed and understand that certain diagnoses IE: severe protein- calorie malnutrition, and iron deficiency anemia are important. Is there a way to develop a list of the risk adjusted diagnoses that make the highest impact that we may not be catching with SOI and ROM etc...??  Is there anything in our CDIS software that might help us with this?

Thank you!

lprescott1

Great question Laurie, there are a number of different risk adjustment methodologies, all of which mirror each other in what diagnoses will assist in capturing the patient's true risk. I would guess for your mortality reviews you are likely using an APR grouper. This logic was developed and is proprietary to 3M, and they hold their logic very close to home. A diagnosis may influence SOI/ROM with one patient due to other existing co-morbidities and the same diagnosis may not impact the next patient to the same degree. Because the algorithm is not consistent, it is difficult to predict the diagnoses as they are patient specific. That said as you continue to perform these reviews, many are able to "think" like the grouper and predict the impact of specific diagnoses. 

We teach in our Risk Adjustment Bootcamp the CMS-HCC methodology related to risk adjustment and stress that although there are a number of methodologies used for a number of different reasons, specific diagnoses seem to used in the majority of these methodologies. You may wish to review the listing of HCC (Hierarchical Condition Categories) diagnoses which can be found at CMS.gov. 

nloshaw@mhc.net

Risk adjustment and HCCs are a target for outpatient CDI right now, however, what if a facility does not use capitated payments?  This is where I am having a dilemma.  Our physician practices are paid based on a "cost based encounter rate" for RHC, therefore risk adjustment would not pertain to us from what I am told.  Do you have any insight on what organizations are doing as far as outpatient measures if they do not fall within capitation payment methods?
Thanks.

19152671

I have a table for FY2017 codes available on the CDIMD website.   It correlates HCCs with MS-DRGs.  Go to the CDIMD Resource Page website and look in the lower left hand corner.  Dr. James Kennedy
https://www.cdimd.com/resources   Its free.

lprescott1

nloshaw@myomh.org- Even if your providers are being paid based on "cost based encounters" , i would think they are subject to quality measures and the concept of risk adjustment will assist in a number of outcome measures related to quality. Is that what you are asking?