U.S. patent application number 13/167976 was filed with the patent office on 2012-12-27 for hierarchical condition categories program.
Invention is credited to DEBRA THESMAN.
Application Number | 20120329015 13/167976 |
Document ID | / |
Family ID | 47362176 |
Filed Date | 2012-12-27 |
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United States Patent
Application |
20120329015 |
Kind Code |
A1 |
THESMAN; DEBRA |
December 27, 2012 |
HIERARCHICAL CONDITION CATEGORIES PROGRAM
Abstract
Systems and methods of recording patient's medical documents and
training programs for improving medical document recordation. The
system includes a computer readable medium capable of storing
medical data obtained from patients, including disease codes, a
computer with software capable of evaluating the data stored on the
computer readable medium for completeness, and a notification
system capable of presenting to the user of the system a warning if
any of the data is found to be incomplete or incorrect. The
training includes evaluating the healthcare provider's current
medical documentation process, training the healthcare provider in
methods of recording medical documents, providing a system for
recording medical documents, and training the healthcare provider
in use of the system.
Inventors: |
THESMAN; DEBRA; (Garden
City, NY) |
Family ID: |
47362176 |
Appl. No.: |
13/167976 |
Filed: |
June 24, 2011 |
Current U.S.
Class: |
434/219 ;
707/812; 707/E17.005 |
Current CPC
Class: |
G09B 19/00 20130101;
G06Q 10/101 20130101; G16H 10/60 20180101; G16H 15/00 20180101 |
Class at
Publication: |
434/219 ;
707/812; 707/E17.005 |
International
Class: |
G09B 19/00 20060101
G09B019/00; G06F 17/30 20060101 G06F017/30 |
Claims
1. A method of recording a patient's medical documents comprising:
a. obtaining medical data from the patient, wherein the data
comprises disease codes; b. storing such data obtained in step (a)
in electronic medical records embodied on a computer readable
medium; c. evaluating said data stored in step (b) via a computer
capable of interpreting said electronic medical records to ensure
that the data entry is complete; and d. presenting a notification
if any of the data evaluated in step (c) is found to be incomplete
or incorrect.
2. The method of claim 1, wherein the disease codes are ICD-9
codes.
3. The method of claim 1, wherein the evaluation in step (c)
comprises evaluating whether for each disease code there is
recorded a corresponding diagnosis of the disease, status of the
disease, and plan of action for the disease.
4. The method of claim 1, wherein the evaluation in step (c)
comprises evaluating the obtained disease code to determine whether
an improper code has been entered.
5. The method of claim 4, wherein the obtained disease code is
evaluated to determine whether a more specific code should be
used.
6. The method of claim 4, wherein the evaluation of the obtained
disease code is determining whether a current disease has been
improperly coded as a history of the disease.
7. The method of claim 1, wherein the evaluation in step (c)
comprises evaluating whether there are likely disease codes that
have not been obtained in step (a).
8. The method of claim 7, wherein if a diabetes code is obtained in
step (a), a notification in step (d) is presented to the user that
complications of diabetes should be properly coded.
9. The method of claim 1, wherein the data obtained in step (a)
further comprises medication prescriptions of the patient.
10. The method of claim 9, wherein the evaluation of step (c)
determines whether there is a linking disease code for each
medication prescription.
11. The method of claim 1 further comprising presenting a
notification to the user of the system to review the medical
records for commonly unreported or miscoded diseases within a
population of patients.
12. The method of claim 11, wherein the commonly unreported or
miscoded diseases are selected from the group consisting of chronic
kidney disease, neuropathy, peripheral vascular disease, and
malnutrition.
13. A method of training healthcare providers to properly record
medical documents, said method comprising the steps: a. evaluating
the healthcare provider's current medical documentation process; b.
training the healthcare provider in methods of recording medical
documents; c. providing a system for recording medical documents,
wherein the system comprises: i. a computer readable medium capable
of storing medical data obtained from patients, wherein the data
comprises disease codes; ii. a computer with software capable of
evaluating the data stored on the computer readable medium for
completeness; and iii. a notification system capable of presenting
to the user of the system a warning if any of the data is found to
be incomplete or incorrect; and d. training the healthcare provider
in use of said system.
14. The method of claim 13, wherein the training provided in step
(b) comprises instructing the healthcare provider to ensure the
medical documents are sufficiently detailed and coded to achieve
the correct RAF score.
15. A system for recording medical documents comprising: a. a
computer readable medium capable of storing medical data obtained
from patients, wherein the data comprises disease codes; b. a
computer with software capable of evaluating the data stored on the
computer readable medium for completeness; and c. a notification
system capable of presenting to the user of the system a warning if
any of the data is found to be incomplete or incorrect.
16. The system of claim 15, wherein the notification system
presents a warning if a disease code does not have a corresponding
recorded diagnosis of disease, status of disease, and plan of
action for the disease.
17. The system of claim 15, wherein the notification system
presents a warning if an improper disease code has been
entered.
18. The system of claim 15, wherein the notification system
presents a warning if there are likely disease codes that have not
been recorded.
19. The system of claim 15, wherein the notification system
presents a warning if a medical prescription is recorded without a
linking disease code for the medication.
Description
CROSS-REFERENCE TO RELATED APPLICATIONS
[0001] Not Applicable
STATEMENT RE: FEDERALLY SPONSORED RESEARCH/DEVELOPMENT
[0002] Not Applicable
BACKGROUND
[0003] The present invention is directed toward improved systems
and methods for collecting and reporting Hierarchical Condition
Categories (HCC). More particularly, the present invention
comprises training programs and software systems useful by health
plans and medical practitioners to more accurately code and report
HCC to comply with the Centers for Medicare and Medicaid Services
(CMS) documentation and reporting requirements.
[0004] Essential to high quality and cost-effective healthcare is
the proper diagnosis of a patient's condition. From a proper
diagnosis, the appropriate medical attention utilized to treat the
underlying condition, whether it be the performance of a medical
procedure, laboratory tests, and/or prescription of medication, can
be determined. To that end, and as is well-known in the art,
standard diagnoses codes are extensively utilized pursuant to
conventional disease classification techniques that provide a
quick, well-understood method to document medical care administered
to a patient. Exemplary of, and perhaps most widely utilized of
such formats, is the International Classification of Diseases 9th
Edition (ICD-9) three digit codes. Likewise, with respect to the
medical treatment that has been rendered, such procedures are
typically referenced according to Current Procedural Terminology
(CPT). Also frequently referenced in connection with the delivery
of healthcare are drug codes (e.g., National Drug Code, or NDC),
other service codes (e.g., Healthcare Common Procedure Coding
System, or HCPCS), among others.
[0005] The Balanced Budget Act of 1997 (BBA) mandated a change in
Medicare's payment methodology intended to pay health plans, and
subsequently medical providers, based on a patient's health status
through a process called Risk Adjustment Factor (RAF). Prior to the
implementation of risk adjustment, reimbursement was based solely
on demographic factors, such as, age, sex, Medicaid status, county
of residence, etc.
[0006] In 2004, the Centers for Medicare and Medicaid Services
(CMS) implemented a new model, the Hierarchical Condition
Categories (HCC), as an additive model to adjust Medicare
capitation payments to private healthcare plans for their
expenditure risk of enrollees based on serious or chronic
conditions. In theory, the CMS-HCC model pays more accurately for
predicted health expenditures, based on health status and some
demographic factors. In short, treat the patient appropriately and
get reimbursed for doing so.
[0007] The collection and reporting of HCCs provides important
benefits to patients and improves reimbursement. When health plans
and/or practitioners have their own programs for documenting,
auditing, and reporting HCCs, there is an opportunity to identify
those at-risk enrollees/patients who, because of their disease
markers, would benefit from increased frequency of visits and
intensity of services, enrollment in complex care management,
chronic care programs, and/or transitional care programs when
appropriate - all designed to ensure the best possible clinical
outcome for patients and cost savings for health plans and
practitioners. Examples of such other programs are described in
U.S. Pat. Nos. 7,657,442 and 7,464,041 and U.S. patent application
Ser. Nos. 11/352,028 and 12/834,767, the entire teachings of which
are collectively incorporated by reference herein.
[0008] Accordingly, there is a need in the art for a program
designed to train and support health plans and practitioners the
art and skill of correctly coding and reporting HCC to comply with
CMS-HCC documentation and reporting requirements.
BRIEF SUMMARY
[0009] One aspect of the present invention is directed toward
methods of recording a patient's medical documents. The methods
include obtaining medical data from the patient, storing the data
in electronic medical records embodied on a computer readable
medium, evaluating the data via a computer capable of interpreting
said electronic medical records to ensure that the data entry is
complete, and presenting a notification to a user if any of the
data is found to be incomplete or incorrect. The medical data
obtained from the patient may include any of various relevant data,
such as demographic information, medications taken, and symptoms
suffered, but particularly includes disease codes. For example, the
disease codes may be ICD-9 codes.
[0010] The data evaluation may take numerous forms, for example,
whether for each disease code there is recorded a corresponding
diagnosis of the disease, status of the disease, and plan of action
for the disease and/or whether an improper code has been entered
for each disease. More particularly, the obtained disease code may
be evaluated to determine whether a more specific code should be
used in its place. For example, whether a current disease has been
improperly coded as a history of the disease. Another possible
evaluation is whether there are likely disease codes that the
patient may be suffering from that were not recorded. One example
of this is when the patient is suffering from diabetes. A majority
of patients suffering from diabetes have complications due to the
diabetes. A notification may be provided to the user that
complications of diabetes should be properly coded.
[0011] The medical data obtained may further include medication
prescriptions of the patient and evaluating whether there is a
linking disease code for each medication prescription.
Additionally, a notification may be presented to the user of the
system to review the medical records for commonly unreported
diagnosed diseases within a set population of patients. Examples of
commonly unreported diagnosed diseases include chronic kidney
disease, neuropathy, peripheral vascular disease, and
malnutrition.
[0012] Another aspect of the present invention is directed toward
methods of training healthcare providers to properly record medical
documents. This training includes evaluating the healthcare
provider's current medical documentation process, training the
healthcare provider in methods of recording medical documents,
providing a system for recording medical documents, and training
the healthcare provider in use of the system. The system includes a
computer readable medium capable of storing medical data obtained
from patients, including disease codes, a computer with software
capable of evaluating the data stored on the computer readable
medium for completeness, and a notification system capable of
presenting to the user of the system a warning if any of the data
is found to be incomplete or incorrect.
[0013] In particular, the training provided may include instructing
the healthcare provider to ensure the medical documents are
sufficiently detailed and coded to achieve the correct RAF score
for each patient.
[0014] Yet another aspect of the present invention contemplates a
system for recording medical documents. The system includes a
computer readable medium capable of storing medical data obtained
from patients, including disease codes, a computer with software
capable of evaluating the data stored on the computer readable
medium for completeness, and a notification system capable of
presenting to the user of the system a warning if any of the data
is found to be incomplete or incorrect.
[0015] For example, the notification system may present a warning
if a disease code does not have a corresponding recorded diagnosis
of disease, status of disease, and plan of action for the disease,
if an improper disease code has been entered, if there are likely
disease codes that have not been recorded and/or if a medical
prescription is recorded without a linking disease code for the
medication.
BRIEF DESCRIPTION OF THE DRAWINGS
[0016] These and other features and advantages of the various
embodiments disclosed herein will be better understood with respect
to the following description and drawings, in which like numbers
refer to like parts throughout, and in which:
[0017] FIG. 1 is a flowchart depicting the steps for practicing the
present invention as it relates to training healthcare providers in
improved medical document recordation practices.
DETAILED DESCRIPTION
[0018] The detailed description set forth below is intended as a
description of the presently preferred embodiment of the invention,
and is not intended to represent the only form in which the present
invention may be constructed or utilized. The description sets
forth the functions and sequences of steps for constructing and
operating the invention. It is to be understood, however, that the
same or equivalent functions and sequences may be accomplished by
different embodiments and that they are also intended to be
encompassed within the scope of the invention.
[0019] Referring now to FIG. 1, there is schematically illustrated
the various steps by which a method of the present invention
operates to train healthcare providers in improved medical document
recordation practices. In particular, there is a first step 100 of
evaluating the healthcare provider's current medical document
recordation processes. For example, a team consisting of
physicians, nurses, and financial auditors may conduct a two day
on-site evaluation of the client's current HCC activities to
determine data extraction and reporting methodology and validates
the client's current RAF score.
[0020] A written report may be given to the client outlining the
team's findings and recommendations that include staffing
requirements, system requirements, and/or a program training and
implementation work plan.
[0021] The second step 200 includes a comprehensive educational
training program. For example, the training program may be offered
as a ten day class with overhead presentations, case studies, and
reference material, with topics including risk adjustment
methodology, documentation training, Hierarchical Condition Coding
(including commonly unreported or miscoded conditions), and
training on systems for recording medical documents. The training
section 200 may include a ninety day post-implementation followup
with client's staff to evaluate program progress and/or an at least
annual update to keep client apprised of changes in the CMS-HCC
model.
[0022] The third step 300 is providing to the healthcare provider a
system for recording medical documents, wherein the system includes
at least a computer readable medium capable of storing medical data
obtained from patients, wherein the data comprises disease codes; a
computer with software capable of evaluating the data stored on the
computer readable medium for completeness; and a notification
system capable of presenting to the user of the system a warning if
any of the data is found to be incomplete or incorrect. Examples of
data to be recorded and warnings that may be presented by the
system are discussed in greater detail below.
Risk Adjustment Methodology and Documentation Training
[0023] In order for the diagnostic classification system of the
present invention to function properly the following principles may
be used: 1) diagnostic categories should be clinically meaningful;
2) diagnostic categories should predict medical expenditures; 3)
diagnostic categories that will affect payments should have
adequate sample sizes to permit accurate and stable estimates of
expenditures; 4) in creating an individual's clinical profile,
hierarchies should be used to characterize the person's illness
level with each disease process; 5) the diagnosis classification
should encourage specific coding; 6) the diagnostic classification
should not reward coding proliferation; 7) providers should not be
penalized for recording additional diagnoses; 8) the classification
system should be internally consistent; 9) the diagnostic
classification should assign all ICD-9 codes; and 10) discretionary
diagnostic categories should be excluded from payment models.
[0024] The Risk Adjustment Factor (RAF) is calculated by adding
together a demographic factor (based upon, for example, the age and
sex of the patient) and the total of a Hierarchical Condition
Category (HCC) risk adjusted diagnosis. There are seventy disease
categories, with over 3,100 diagnoses, available to apply toward
the HCC risk adjusted diagnosis. A particular numerical "risk
factor" is assigned to each category. Since the HCC is an additive
model, the risk factor from all diagnoses are combined to reach the
total RAF. Furthermore, the HCC is a predictive model, i.e., it is
utilized to determine a future year payment based on coding this
year's date of service. In summary, a higher RAF is obtained by
sicker patients, thereby resulting in higher payments; whereas
healthier patients will have a lower RAF, resulting in lower
payments.
[0025] In particular, payments are determined through diagnosis
coding after providing face to face patient evaluation at least
once a year. As such, appropriate chart documentation and diagnosis
reporting is required for accurate reimbursement. This documented
information is submitted from the healthcare provider to the
patient's health plan (HP), which in turn submits the data to the
Centers for Medicare and Medicaid Services (CMS). CMS then takes
the provided data and scrubs it for duplication and accuracy. The
scrubbed data is then used by CMS to determine the revenue to
provide to the HP. The HP then reimburses the health care provider
based upon their contract. As such, it can readily be seen that
proper diagnosis coding drives the RAF scorers, which in turn
drives the reimbursement. Without proper documentation, the full
reimbursement will not be retained.
[0026] It is important to note that with proper coding, patient
care remains the priority. Once appropriate care is delivered to
the patient, how to properly code for that care becomes important.
However, care is not altered to meet coding strategies; rather, the
reverse is the case, i.e., proper care drives proper coding. CPT
codes reflect the level of care provided, but ICD-9 codes reflect
the disease state addressed. Disease states submitted for a
specific visit must be addressed and documented for that visit. The
most missed diagnoses in senior patients are chronic kidney
disease, peripheral vascular disease, peripheral neuropathy, and
major depression. In order to properly document a patient visit,
the chart must contain the patient's name (on each page, if the
notes span multiple pages), the patient's date of birth or some
other unique identifier, the date of service, and a handwritten or
electronic signature of the caregiver, including credentials.
Furthermore, validated HCC coding requires three documented points:
1) The diagnosis or assessment; 2) the status or condition (e.g.,
stable, condition worsening, medication adjusted, tests ordered,
documentation reviewed, condition improving, etc.); and 3) a plan
of action. Under the official ICD-9 coding guidelines, a diagnosis
can only be coded when it is explicitly spelled out in the medical
record. Accordingly, all documentation used for coding must be
specific, and the mere fact that a patient has a condition is not
sufficient on its own. Additionally, under ICD-9 guidelines, a
diagnosis cannot be coded unless it is stated in the current visit
documentation. All conditions that coexist at the time of the visit
should be coded if they require or affect patient care, treatment,
or management and are addressed in the medical record for the
specified visit.
[0027] As discussed above, merely listing diagnoses is not
sufficient documentation, as a diagnosis, status, and plan of
action must all be documented for proper coding. Furthermore,
merely listing medications does not meet documentation requirements
to indicate that an evaluation for that condition was done. Also,
superbills, encounter forms, and referrals are not acceptable forms
of documentation as they are not considered a part of the medical
record. Therefore, when a diagnostic report is provided it must be
interpreted by the medical practitioner and documented for proper
coding purposes. Additionally, a diagnosis must be presented
unconditionally, without using terms such as "ruled out",
"probable", "consistent with" and the like.
[0028] In an attempt to verify that diagnoses are being properly
documented, CMS annually audits medical records. These audits are
called Risk Adjustment Data Validation (RADV). Health plans,
hospitals, medical groups, and physician offices are required to
comply with CMS requests for medical records, and unsubstantiated
diagnoses may result in recoupment of payments. In particular, the
documentation substantiating that the patient was evaluated,
monitored, or treated for the condition is a requirement for
receiving reimbursement and must include all three of a diagnosis,
status, and plan of action.
[0029] It is important to note that causal relationships of
diseases need to be explicitly stated in the record, they cannot be
inferred. Accordingly, linkage can be established in the chart with
terms such as the specific disease being "due to", "associated
with", "secondary to" or the like should be used to establish a
cause and effect relationship. Terms such as "with", "probable",
"more than likely" and the like do not sufficiently support
linkage. For example, merely charting Type II Diabetes and Chronic
Kidney Disease results in a significantly lower HCC RAF weight than
would a proper charting of Type II Diabetes with Renal
Manifestations and Chronic Kidney Disease due to Diabetes. Coding
in the latter manner leaves no room for error in interpretation as
to the disease states.
[0030] Another key aspect of proper charting is the correct
documentation of a patient's "history of" a disease. The "history
of" a disease should only be charted when the patient has been
cured and is no longer being actively treated for the disease. A
"history of" indicates that the medical condition no longer exists
and the patient is not receiving any treatment, but there is the
potential for recurrence and therefore requires continued
monitoring. A "history of" a disease should not be used to describe
a current acute or chronic condition even if it is controlled on
medication. As long as the condition exists, despite totally
successful and stable status, the condition must be coded as an
active condition.
[0031] On an at least annual basis, a patient's chronic and active
conditions should be documented so as to not overlook certain
conditions. For example, chronic heart failure (CHF), chronic
obstructive pulmonary disease (COPD), diabetes mellitus (DM),
chronic kidney disease (CKD), neuropathy, and peripheral vascular
disease (PVD) are chronic conditions that should be charted and are
commonly unreported diagnoses. Furthermore, the patient's
medication list should be reviewed to ensure there is a diagnosis
associated with each medication. While patient care remains the
priority at all times, without proper documentation in the medical
record reimbursement will not occur. Following are certain examples
of chronic conditions and proper methods of charting.
Diabetes
[0032] More than sixty percent of seniors with diabetes have a
manifestation or complication of the diabetes. These complications
must be properly charted, but are the most frequently omitted
conditions in physician medical records. Good quality of care and
reimbursement rely on the details. For example, it needs to be
documented whether the patient suffers from Type I or Type II,
whether there are complications associated with the diabetes, which
systems are affected by the complications, and whether the blood
glucose levels are controlled or uncontrolled.
[0033] When complications are due to diabetes, the documentation
must make that connection explicitly. Additionally, every patient
with diabetes should be evaluated for the many manifestations,
complications, and co-morbidities of the disease, with progress
notes and tests to show the evaluation was done. Exemplary
possibilities are renal, ophthalmic, neurological, circulatory,
other specified, and unspecified manifestations. Diabetes with
manifestation codes have higher RAFs and, therefore, receive higher
reimbursements. Even though only the highest weighted diabetes code
will count toward the risk adjusted HCC model, all applicable
manifestations should be charted.
[0034] Diabetes with manifestations require at least two separate
codes; one for the diabetes with manifestation and one for the
supporting associated diagnosis. For example, a patient with
"diabetes with renal manifestation", aside from receiving a code
for the diabetes, would also require a second code for what the
manifestation is. Incomplete coding of the diabetes with renal
manifestation by itself does not fully describe the manifestation
or complication and would not receive the appropriate RAF.
Chronic Kidney Disease
[0035] Coding for CKD conforms to the stages of CKD, including
stages I-IV based on a patient's glomerular filtration rate (GFR)
(estimated from a urinalysis and/or serum creatinine levels) and/or
kidney damage. However, some patients with "normal" creatinine
levels have significant renal function impairment. As such, CKD-I
and CKD-II are commonly missed. For those at risk of renal disease,
creatinine clearance of GFR should be estimated at least twice per
year. Further, the cause of the CKD should be checked and coded for
a cause and effect linkage, for example, diabetes or hypertension.
Unspecified kidney issue terminology such as chronic renal disease,
chronic renal failure, and chronic renal insufficiency do not
affect the RAF and should be avoided in favor of more specific
diagnoses.
Cardiology
[0036] An important issue when documenting a significant cardiac
diagnosis is to be specific. For example, less specific terms, such
as, coronary artery disease or atherosclerotic heart disease,
should be avoided if the patient has more specific diagnoses, such
as, angina or history of myocardial infarction (MI). An acute MI is
considered to be present for the first eight weeks after
occurrence. If a patient is seen eight weeks after an acute MI and
has not continued anginal symptoms, the coding should be changed to
recent, old, or history of MI.
[0037] Cardiac angina is coded if currently being treated and may
be continue to be coded even if asymptomatic due to pharmacological
treatment. Other ongoing chronic cardiac conditions, such as,
atrial fibrillation or arrhythmias should be documented and coded
whether symptomatic or asymptomatic if continued pharmacological
treatment or interventional cardiology is present. Of note,
congestive heart failure is always a chronic condition after
diagnosis, and echocardiograms should be used to evaluate and
document diastolic heart failure.
Malnutrition
[0038] Malnutrition is often observed in senior patients due to
conditions that limit nutrient ingestion and absorption, such as,
cancer, pancreatitis, alcohol abuse, liver disease, obesity, CHF,
COPD, end stage renal disease (ESRD), celiac disease, cystic
fibrosis, depression, and dementia. However, malnutrition is often
underreported and merely reported as being "underweight", "failing
to thrive", or "loss of appetite" which do not affect the RAF. In
these situations, occurrences of malnutrition should be
identified.
Psychiatry
[0039] Episodic mood disorders are mental diseases that include
mood disturbances such as major depression. The characteristics of
these mood disturbances should be carefully documented and specific
mental disorder terminology should be used in the final diagnosis,
otherwise there will be no RAF adjustment. Furthermore, maladaptive
patterns of substance use, leading to clinical impairment or
distress should be coded as a dependence, rather than abuse.
Oncology
[0040] Malignancies are only coded until the patient has completed
definitive treatment, such as surgery, chemotherapy, and/or
radiation therapy aimed at eradicating the malignancy. Furthermore,
breast and prostate cancer patients on adjuvant therapy are coded
as having the active disease. However, once a patient has completed
therapy, he or she can only be coded with a "personal history of
cancer" diagnosis even if undergoing surveillance for reoccurrence
of the malignancy.
[0041] It is extremely important to document when metastatic
disease is present, as it has a separate coding section and CMS-HCC
payment group. In this case, lack of specificity in the
documentation can lead directly to a lower payment rate. Often,
metastases are not clearly identified, thereby improperly leading
to the coding of multiple primary malignancy sites.
Podiatry
[0042] Commonly under-diagnosed HCC conditions may be uniquely
discovered by podiatrists, such as peripheral vascular disease,
peripheral neuropathy, and skin ulcers. Again, if these conditions
are due to a patient's diabetes, it is important to document by
using two separate codes: one for the diabetes with circulatory or
neurological manifestations and one for the supporting
manifestation code.
Software for Electronic Medical Records
[0043] As can be seen from the examples provided above, there are
numerous pitfalls that can be fallen into when documenting a
patient's medical record, resulting in improperly coded, and
under-reimbursed, diagnoses. Certain goals of the present invention
are to train caregivers to properly document medical diagnoses and
to provide a software platform for taking, storing, and aiding the
caregiver in properly coding the medical records of patients.
[0044] Aside from, and in addition to, the training provided to
caregivers in proper coding methodologies, as discussed in greater
detail above, the present invention envisions a software platform
(herein referred to as iCode) to improve compliance with CMS' s
correct coding initiative and HCC extraction and reporting. iCode
allows for the enhanced care of Medicare Advantage enrollees,
provides valuable information to the caregiver at the point of
care, reduces duplicate and costly services by providing a
comprehensive clinical history for each patient, and assists with
capturing qualifying CMS-HCC codes.
[0045] In particular, iCode is capable of importing data from a
caregiver's current medical records, billing files, health plan
claim files, and the like. iCode then auto-populates each field
from the data import to create new electronic medical records,
analyzes the data, and creates reports of the analyzed data.
Examples of such reports include, patient demographic information,
health plan eligibility history, outstanding tests/procedures
affecting performance per HEDIS measurements, summary of reported
chronic conditions, list of potential unreported HCCs per review
category, list of three year medical history by ICD-9 and CPT
classifications, last six months of pharmacy data, and notes and
comments. All captured data fields can be output as an iCode
report.
[0046] Of particular relevance, however, is the ability of iCode to
recommend potential missed coding opportunities based upon the
medical conditions that have been entered in relation to
historically incorrectly reported or underreported conditions. For
example, iCode may recommend to the caregiver that in order for
proper coding, a diagnosis of a disease, the status of the disease,
and a plan of action must all be recorded.
[0047] Similarly, iCode may recommend to the caregiver that certain
disease codes which do not affect the RAF have similar codes that
do affect the RAF and may have been overlooked. For example, if a
caregiver records a "history of" a disease, when in fact the
patient is still suffering from the disease state, or if the
records indicate less specific terminology for a disease state
which may be more accurately described with a condition that does
affect the RAF.
[0048] Another example of a suggestion iCode may make to the care
giver is whether related complications of a disease have been
improperly coded, or not coded at all. For example, patients
suffering from diabetes typically have other disease states that
are complications from the underlying diabetes. Unless these
conditions are coded as deriving from the underlying diabetes, the
RAF score is not properly assigned.
[0049] Additionally, iCode may recommend, upon annual reviews, that
each medication prescribed to the patient needs a corresponding
disease diagnosis coded, or recommend potential commonly miscoded
or unreported diseases, such as chronic kidney disease, peripheral
vascular disease, or malnutrition.
[0050] Along these lines, the recommendations provided by iCode are
just that, recommendations. It is noted that the iCode software
will never make changes or adjustments on its own to the entered
medical records, but rather acts as a warning system to the
caregiver for potentially overlooked diagnoses that should be coded
on further inspection by the caregiver.
[0051] Additional modifications and improvements of the present
invention may also be apparent to those of ordinary skill in the
art. Thus, the particular combinations of parts and steps described
and illustrated herein is intended to represent only certain
embodiments of the present invention, and is not intended to serve
as limitations of alternative devices and methods within the spirit
and scope of the invention.
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