By Sarah Katz, National VP, Payor Partnerships
Medicare Advantage (MA), Managed Medicaid and Commercial Exchange plan leaders are well versed in the importance of accurate documentation through various government risk adjustment models (e.g., CMS’s Hierarchical Condition Category (HCC) model for MA). Accurately coding a population ensures members receive timely, appropriate care and the plan receives payment commensurate with the population’s acuity.
Although plans have been successful with risk adjustment for the general population, our conversations with industry leaders reveal a significant performance opportunity for members with chronic kidney disease (CKD) and end-stage kidney disease (ESKD). The average member with kidney disease has five to 11 comorbidities and faces a disproportionate number of socioeconomic barriers to care, limiting regular, timely engagement with their provider. As a result, members with CKD and ESKD have numerous un- or under-diagnosed conditions and plan reimbursement is inadequate, particularly when these conditions are eventually treated at a more acute stage.
Providers face numerous challenges in accurately documenting members with CKD & ESKD
Beyond sheer population complexity, there are numerous factors specific to CKD and ESKD that present challenges to accurate coding.
For CKD, many PCPs do not conduct testing in a timely manner when symptoms indicating kidney disease are present. This is due to PCPs often having to manage much more obvious and apparent chronic illnesses like diabetes, heart failure, and hypertension. For those who do conduct appropriate testing, many don’t take the time to accurately stage CKD — particularly given the recent introduction of codes for CKD 3a and 3b — and submit a CKD unspecified code, which has an equivalent risk adjustment factor for CKD 1/2.
This effect is compounded by physicians under-coding conditions typically found with CKD, such as coding for “type 2 diabetes unspecified” instead of diabetes with complications of neuropathy. There is a similar trend at play for members with ESKD, with nephrologists frequently not documenting complexities such as vascular access complications or under-coding common co-morbidities (e.g., documenting essential instead of malignant hypertension).
Payors no longer able to close documentation gaps through RAPS submissions
Shortcomings in provider documentation are now even more pressing, with CMS completing its shift to exclusively using encounter data for risk adjustment in 2022. As a result, plans are no longer able to make risk adjustment processing system (RAPS) submissions, which relied on retrospective chart reviews to document conditions not coded for by providers.
We anticipate this will have an especially substantial impact on reimbursement for the CKD population. A 2021 CMS analysis revealed that only 27% of MA members with a positive lab value for CKD also had a CKD diagnosis code. Looking specifically at the CKD 3 population — when diagnosis should be more prevalent — only 49% of members with lab values indicating CKD 3 had a diagnosis code.
Without a comprehensive strategy to support providers in accurate documentation for kidney disease, payors face a significant reimbursement shortfall. Strive analysis suggests that a focused solution can increase premium revenue by up to 20% and more adequately cover the costs of this population.
Three essential capabilities for accurate documentation of members with CKD & ESKD
As a first step in implementing a CKD and ESKD documentation strategy, payors should assess their options for developing — and deploying to their provider network — three core capabilities:
Building trust through more frequent and longer visits is a key feature of the high-touch care model that supports documentation accuracy. Although analytics and clinical assessments are essential, they can miss emerging issues. Making space for members to share their observations and for providers to conduct holistic assessment ensures the full scope of clinical issues is captured and addressed. Similarly, increasing the frequency of visits allows for changes in health status to be addressed in a timely manner, a pressing concern with CKD.
The multidisciplinary nature of the high-touch care model also supports documentation accuracy by creating opportunities for holistic assessments from different vantage points. For example, a 1:1 with a social worker might reveal the member is suffering from insomnia due to a challenging living situation. The social worker can work with the member to find alternative housing and share this information with the nurse practitioner, so the condition can be accurately documented in the next visit.
Learn about Strive’s comprehensive approach to risk adjustment
By empowering your provider network with the right analytics, workflows and care model, payors can be confident their members with CKD and ESKD are receiving comprehensive, timely care and that the population is accurately documented. Strive Health has developed these capabilities as part of our value-based kidney care model and is seeing positive early results from our work with MA and CKCC (Medicare FFS risk) populations. To learn more about our approach and how we can deliver rapid results for your organization, please connect with us here.
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