November 28, 2017

MACRA, MIPS, and APMs: Why is CDI an Essential Ingredient to the Alphabet Soup?

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Quality of clinical documentation and ICD-10 diagnosis code accuracy and specificity are essential under MACRA.

My presentation at the 2017 American Health Information Management (AHIMA) convention stressed the need for understanding a basic overview of the Medicare Access and CHIP Reauthorization Act (MACRA) and its performance categories.

These performance categories and quality measures are important for us to understand so we can assist providers. In 2017, the quality category represents a large percentage of the overall score for providers, and in looking at the quality measures, coding and documentation are vital if a provider hopes to score well.

To move forward in 2018, it is necessary to put to rest some of the myths about MACRA and bring the facts and benefits to the forefront. We are hearing a lot of rumors amid the current changes and uncertainties, and although we don’t have all the answers, approaching MACRA with a focus on care quality and making patients healthier is important. MACRA, MIPS (the Merit-Based Incentive Payment System), and APMs (Advanced Payment Models) all focus on quality care for patients, cost reduction, and improved communication among caregivers, and these are objectives we can all get behind.

Health information management (HIM) professionals should continue to focus on quality of clinical documentation and ICD-10 diagnosis code accuracy and specificity. Measuring our performance under ICD-10-CM will provide important key metrics that we can focus on to improve performance under MACRA. If you have not already begun to measure unspecified code usage, Hierarchical Condition Category (HCC) risk adjustment, and diagnosis coding depth, you should begin now. My AHIMA session fully explained why these key metrics are so important.

Data accuracy is going to be a challenge as we move forward with the growth of the ICD-10 coding system. The big question is this: is your clinical documentation specificity growing at the same rate as ICD-10? A good example are the new ICD-10-CM myocardial infarction and heart failure codes, which feature much greater specificity. Coders are glad to see them, but wonder if we will have the documentation to use them.

The quality measures under MACRA are very specific, and clinical documentation will need to match or exceed that level of specificity for physicians to be successful in participating. Understanding that there are penalties under MACRA, we must also understand that this payment system presents opportunity for higher reimbursement to physicians with exceptional performance. Exceptional performance can only be achieved with accurate clinical documentation, data gathering, and reporting.

Many of the fears regarding MACRA exist because of its complexity. I often use the analogy that asks, “how do you eat an elephant?” One bite at a time, of course. Learn the intricacies of this payment system in small doses by reading about it, attending educational sessions, and most importantly, discussion with your peers. There is probably already someone in your organization who can assist you in learning and preparing for 2018. I started by reading everything I could get my hands on, and it has paid off.

MACRA is one of the initiatives that is moving clinical documentation improvement (CDI) to the outpatient arena. Sometimes, in that setting, coders are called upon to wear multiple hats, including being the first line of defense for CDI. But the entire team, including scheduling, nursing, and others, can relieve some of the burden for providers when they can identify gaps and needs for more specific documentation before it reaches the coding stage. Focusing on frequently treated diagnoses and chronic illnesses will be a valuable effort under value-based payment.

I get a lot of questions about HCCs, including: “well, if we are coding it right, won’t it be right under MACRA?” While that is partially true, we cannot assume that all coders understand the nuances of HCC coding or the compliance issues. Coders must understand certain important questions. Where does risk-adjusted data come from? What are the risk-adjusted guidelines and regulations? How do diagnoses meet the reporting criteria under HCCs? We must first educate and then audit. Some physicians have focused on CPT® accuracy and specificity; after all, CPT is how we get paid. The growth of risk adjustment models will require a change in thinking as ICD-10 diagnosis codes will drive risk-adjusted scores and payments.

Upcoding and downcoding under risk adjustment have significant consequences, so we must code accurately. HCCs are very different in that the diagnoses and codes that drive DRG assignment are not the same that drive risk adjustment scores. Chronic illnesses are more important and must be documented well. There are also status codes, which are sometimes seen as unimportant in the inpatient arena, but will drive risk-adjusted scores in HCC coding. It is a whole new ballgame, so to speak, which requires coders to think differently. Most coders will adjust to it quickly given the right education, feedback, and auditing.

It is important to emphasize the value of having staff along the continuum of care with a full understanding of MACRA. For example, is nursing fully involved in all CDI outpatient programs? They can sometimes be a forgotten asset, but they spend a lot of the time with patients and are the perfect staff to gather data for reporting quality in the performance categories. Some examples include depression screening, tobacco use, screening and others.

Collaboration between nursing and coding is the perfect combination for outpatient CDI.
Laura Legg, RHIT, CCS, CDIP

Linda Pottinger is the director of payer initiatives with the Innovative Practice Services team of McKesson Specialty Health, providing operational and educational support to practices as they prepare for value-based and quality payment programs.


Linda has more than 35 years of experience in the healthcare industry, both in financial and operational positions, including CFO at two Chicago area hospitals. She has also worked in and provided operational support to physician practices, including Rheumatology and Oncology specialties.

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