Research and develop a WBS (work breakdown structure) based on the topic below. Include references.

Topic: The initiative focused on improving enterprise coding and documentation to address Gaps in documenting Hierarchical Condition Categories (HCC)s to improve the Risk Adjustment Factor (RAF), as well as to improve the quality metrics

Background:

An internal audit was performed on our office's documentation and coding practices to improve value-based health with increased Risk Adjustment Factor (RAF) and quality metrics. The best way to improve quality metrics and the RAF is to upgrade the documentation to report HCCs. Hierarchical Condition Categories (HCC)s is a risk adjustment model that calculates the expected medical costs for Medicare Advantage patients who are disabled and may have chronic conditions. HCC coding helps Medicare better understand the type of care these patients need and determine reimbursement for the following year. (Formativ Health, 2018) The Risk Adjustment Factor (RAF) is based on the patient's demographics, including age, gender, if the patient lives in an SNF or community, and if the patient is enrolled in Medicare, Medicaid, or a dual plan. They are combined with the reported diagnoses based on ICD-10 and HCC codes. For the practice to report HCCs successfully, the documentation needs to back up the coding of each HCC-approved diagnosis that the patient is experiencing. (Formativ Health, 2018) This objective was accomplished with high success almost entirely due to upgrades to the enterprise's coding and documentation. To boost the RAF and the quality metrics, the initiative aims to improve the coding of HCCs and their documentation.

Scope:

• Accurate reporting of health conditions that impact risk adjustment
  • Validation of medical record eligibility
  • Assignment of appropriate ICD-10-CM codes
  • Submission of ICD-10-CM codes to CMS reporting
• Predict the healthcare spending for a specific patient population (patients over 65)
• Predict the estimated future healthcare costs for individual patients (long-term conditions such as diabetes, chronic obstructive pulmonary disease (COPD), and congestive heart failure (CHF)
• Risk adjustment training address the following topics:
  • Overview of the HCC/risk adjustment factor (RAF) methodology
  • Review of criteria to identify reportable conditions (TAMPER)
  • Education of the ICD-10-CM Official Guidelines for Coding and Reporting with a focus on risk adjustment coding and where correct coding is most impactful in the applicable HCC model
  • Education for the appropriate interpretation and use of AHA Coding Clinic advice
  • Familiarity with clinical indicators (e.g., testing, treatment, medications) for chronic conditions to recognize the current nature and/or presentation of the condition
  • Review of audit requirements to ensure understanding of the monitoring processes employed by CMS for validation of code abstractions to limit coding errors

Project Milestones:

Start: 10/24/2022

End: 12/16/2022

Invoice Date: 11/14/2022