Conditions That Risk-Adjust for Inpatients Not Always the Same for Outpatients

Last week Tracy Boldt contacted me to ask a question about outpatient clinical documentation integrity (CDI), and we are lucky to have her on the Talk-Ten-Tuesdays broadcast today, detailing Essentia Health’s successful outpatient CDI program. She also mentioned that she had been awaiting the third installment of my three-part series on outpatient CDI. I was embarrassed to discover that it had never been published, so we posted it last week.

How serendipitous, because we also had Dr. Adele Towers on last Tuesday to discuss risk adjustment. I shamelessly piggybacked on the topic and added my two cents.

You are all old pros at risk adjustment – complications and comorbidities (CCs) and major CCs (MCCs) risk-adjust the DRG, and they predict increased resource utilization, so they increase the relative weight and corresponding reimbursement.

Hierarchical condition categories (HCCs) prospectively risk-adjust capitation. My son Scott, who placed fourth in the 2008 Scripps National Spelling Bee and went on to write the definitive guide on how to be successful in it, would tell you that “capitation” comes from “caput,” which means “head.” It is the money allotted per insurance-covered patient. If the body and head are healthy, less money is expected to be expended over the following year to cover medical costs, whereas if the head and/or body are in poor health, more money will likely be utilized. This is one of the reasons a universal mandate is so crucial to being able to provide healthcare to all – the premiums from the pool of healthy insured offset the higher costs of the sicker individuals. But let’s not go there today.

The conditions that risk-adjust for inpatients are not always the same, or of the same impact, as the ones that risk-adjust for outpatients. Inpatient, acute, or acute-on-chronic, conditions demand higher-intensity workup and therapy than chronic conditions. For outpatients, acute conditions are often less relevant because they may not predict future costs, whereas chronic conditions do.

Let’s take pneumonia. Almost all pneumonias are MCCs. If a patient has pneumonia, this may be included in the risk adjustment for the next year. But when the patient visits the office for follow-up, if he or she no longer has active pneumonia, it would not be a valid condition for the outpatient visit. I suspect that the provider would use Z09, Encounter for follow-up examination after completed treatment for conditions other than malignant neoplasm, and Z87.01, Personal history of pneumonia. If we didn’t capture the code during the inpatient stay, we wouldn’t get the risk adjustment in the outpatient arena. Fortunately, all principal and secondary inpatient diagnoses are fodder for HCC risk-adjustment collection.

What we call complex pneumonias among inpatients are divided between HCC 114, Aspiration and specified bacterial pneumonias, which has a risk adjustment factor (RAF) of 0.599 and HCC 115, and Pneumococcal pneumonia, empyema and lung abscess, with a RAF of 0.221. Be aware, there is a hierarchy in play here. A patient only gets risk adjustment for HCC 114 or 115, even if he or she was treated for two different pneumonias in the same calendar year. Of note, although J18.1, Lobar pneumonia, unspecified organism, can be found in HCC 115, J18.9, Pneumonia, unspecified organism, is not included in any HCC.

However, look at chronic bronchitis, which serves as neither a CC nor MCC among inpatients. Even lowly unspecified chronic bronchitis is grouped in HCC 111, COPD, with a RAF of 0.328. This exceeds the RAF of HCC 115. Having this chronic condition predicts consumption of resources on an ongoing basis, so it risk-adjusts accordingly.

The bottom line for providers is this: you must produce excellent documentation with special attention to maximum specificity and precise linkage. Risk adjustment is not always intuitive or predictable, and providers should not be expected to investigate the HCC status of every condition for every patient.

I know I sound like a broken record, but “make the patient look as sick in the medical record (inpatient or outpatient), and let the risk adjustment factors, quality metrics, and reimbursement fall where they may.”