NCMGMA Advocacy Days are June 6-7 in Raleigh


Meet with North Carolina Legislators
Make a Difference in Healthcare in our State

June 6-7, 2018
Holiday Inn Raleigh Downtown
North Carolina State Capitol

This year, join us June 6th and 7th in Raleigh as we host our 10th annual Advocacy Days which we promise to be packed full of information you do not want to miss! There is no shortage of issues at hand in North Carolina and NOW is the time to make our voices heard!

Schedule of Events

Wednesday, June 6, 2018
1:00 pm – 5:00 pm — Legislative Updates and Presentations at the Holiday Inn
6:00 pm – 9:00 pm — Dinner Sponsored by Medical Mutual

Thursday, June 7, 2018
9:00 am – 12:00 pm — Legislative Visits and General Assembly Meetings

General Information

Register and join fellow NCMGMA members in Raleigh on Wednesday, June 6th for a half-day of education sessions and a dinner program sponsored by Medical Mutual. Stay on Thursday, June 7th and meet with our legislators, along with other North Carolina administrators. For members of NCMGMA, the cost is $55 per person. For non-members, the cost is $75 per person. Registration cost covers education and dinner. After May 21st, the cost of registrations increases by $10.

Hotel Accommodations
Reserve your room now at the Holiday Inn Raleigh Downtown. Limited standard rooms available at the discounted rate of $109/night for single/double occupancy plus tax. To reserve your hotel room, please call the hotel directly at 919-832-0501. Reservations will be accepted until rooms are sold out or until Monday, May 21st. Self-parking is available for $7.00.

If you have any questions about the NCMGMA Advocacy Days, please contact the NCMGMA offices at 800-753-MGMA (6462) or by email at

MLN Connects: Thursday, February 15, 2018

MLN Connects is the official news source of the Medicare Learning Network (MLN). Here is the latest news, posted February 15, 2018. Click on the header links for detailed information about each bullet item.

News & Announcements

  • MIPS Reporting Deadlines Fast Approaching: 10 Things to Do and Know
  • Quality Payment Program: Performance Scores for 2017 Claims Data
  • Diabetic Self-Management Training Accreditation Program: New Webpage and Helpdesk
  • Measures of Hospital Harm: Comment by February 16
  • EHR Incentive Program: Accepting Proposals for New Measures by June 29
  • New Option for Submission of Medicare Cost Reports

Provider Compliance

  • Home Health Care: Proper Certification Required — Reminder

Claims, Pricers & Codes

  • January 2018 OPPS Pricer File

Upcoming Events

  • Improving Accessibility of Provider Settings Webinar — February 21
  • ESRD QIP: Final Rule for CY 2018 Call — February 22
  • 2018 QCDR Measures Workgroup Webinar — February 27
  • Serving Adults with Disabilities on the Autism Spectrum Webinar — February 28
  • MIPS Quality Data Submission Webinar — February 28
  • Palliative and Hospice Care for Adults with Disabilities Webinar — March 7
  • Low Volume Appeals Settlement Option Update Call — March 13
  • Open Payments: The Program and Your Role Call — March 14
  • MIPS Attestation for Advancing Care Information and Improvement Activities Webinar — March 14

Medicare Learning Network Publications & Multimedia

  • Medicare Enrollment Resources Educational Tool — Revised
  • PECOS FAQs Booklet — Revised
  • PECOS for DMEPOS Suppliers Booklet — Revised
  • Safeguard Your Identity and Privacy Using PECOS Booklet —Revised
  • PECOS for Provider and Supplier Organizations Booklet — Revised
  • PECOS Technical Assistance Contact Information Fact Sheet — Revised
  • Health Professional Shortage Area Physician Bonus Program Fact Sheet — Revised
  • Medicare Secondary Payer Booklet – Reminder
    Beneficiaries in Custody under a Penal Authority Fact Sheet — Reminder

NCMGMA-NCMSF February 20th Webinar: NC HealthConnex

NCMGMA-NCMS Webinar Series

NC HealthConnex:  A Statewide Approach
to the Health Information Exchange

February 20, 2018 | 12:00 PM – 1:00 PM


The North Carolina Medical Society Foundation, in cooperation with the North Carolina Medical Group Management Association, invites you to learn about the connection process for NC HealthConnex, and how it operates to improve health care quality, enhance patient safety, improve health outcomes, and reduce overall health care costs by making health information available securely, and on demand. Find out where each participant is in the connection process, the connection deadline, and how to access patient data from a provider within a shared treatment relationship. Full participants of NC HealthConnex have value-added features such as gaining connectivity to public health registries, direct secure messaging, and future analytic reporting, which will enhance health care conversations between providers as they move to value-based care.

Note: Providers, who receive state funds (Medicaid, Health Choice, State Health Plan, etc.) for the provision of health care services, must connect and submit clinical and demographic data by certain dates in 2018 and 2019 in order to continue to receive payment for services provided.


Alice Miller
Business and Outreach Specialist
North Carolina Health Information Exchange Authority (NC HIEA)
Alice Miller works closely with providers across the state to educate and assist them in the onboarding process to the state designated health information exchange, NC HealthConnex. She joined the NC HIEA in 2016 having a commitment to public service and the citizens of North Carolina by expanding the interoperability within the health care setting. She is currently pursuing her Master’s degree in Clinical Informatics from Duke University.


This webinar is complimentary but space is limited so make sure to register early! After you register, you will receive an emailed confirmation with webinar and phone-in instructions.

Continuing education credit may be granted through your professional organization (MGMA, PAHCOM, AHIMA, etc.). Please self-submit for these organizations.


For questions or more information please contact the NC Medical Society offices at

NCHIE Deadlines and Updates

As we approach the first mandated deadline of June 1, 2018, NCMGMA leadership has been working directly with NCHIE and they have sent some information we thought would be helpful for our members. Please check out our Resources page of the NCMGMA website, which includes the HIE Toolkit.

If you have questions, please reach out to NCHIE directly, at or via phone at 919.754.6912. You can also visit their website for other updates and general information at

MLN Connects: Thursday, February 1, 2018

MLN Connects is the official news source of the Medicare Learning Network (MLN). Here is the latest news, posted February 1, 2018. Click on the header links for detailed information about each bullet item.

News & Announcements

  • Medicare Diabetes Prevention Program: Supplier Enrollment Open
  • Targeted Probe and Educate: New Resources
  • MIPS Clinicians: 2017 Extreme and Uncontrollable Circumstances Policy
  • Quality Payment Program: Patient-facing Encounters Resources
  • Eligible Hospitals and CAHs: Get Help with Attestation on QNet
  • Find Medicare FFS Payment Regulations
  • February is American Heart Month

Provider Compliance

  • Cochlear Devices Replaced Without Cost: Bill Correctly — Reminder

Upcoming Events

  • eCQM Reporting for Hospital IQR-EHR Incentive Program Webinar — February 6
  • Low Volume Appeals Settlement Option Call — February 13

Medicare Learning Network Publications & Multimedia

  • Next Generation Accountable Care Organization – Implementation MLN Matters® Article — Revised
  • DMEPOS Quality Standards Educational Tool — Revised
  • Home Oxygen Therapy Booklet — Revised
  • Looking for Educational Materials?

MLN Connects: Thursday, January 18, 2018

MLN Connects is the official news source of the Medicare Learning Network (MLN).  Below is the latest news from Thursday, January 18th:

News & Announcements

  • 2018 Value Modifier Results and Payment Adjustment Factor
  • Final DMEPOS Quality Standards for Therapeutic Shoe Inserts
  • Glaucoma Awareness Month: Make a Resolution for Healthy Vision

Provider Compliance

  • CMS Provider Minute Video: CT Scans – Reminder

Upcoming Events

  • New Medicare Card Project Special Open Door Forum – January 23
  • ESRD QIP: Final Rule for CY 2018 Call – January 23
  • MIPS Annual Call for Measures and Activities Webinar – February 5
  • Comparative Billing Report on Opioid Prescribers Webinar – February 21

Medicare Learning Network Publications & Multimedia

  • QRUR Video Presentation – New
  • Low Volume Appeals Settlement Call: Audio Recording and Transcript – New
  • Avoiding Medicare Fraud & Abuse: A Roadmap for Physicians Web-based Training – Revised
  • How to Use the Medicare Coverage Database Booklet – Revised
  • Behavioral Health Integration Services Fact Sheet – Revised

Value-Based Coding in a Changing Environment


With ICD-10-CM comes a new dawn in physician documentation and a much more transparent clinical footprint.  Government payers, insurers, hospitals, health systems, medical groups and others will use ICD-10’s granular data to determine accurate, fair physician compensation and reimbursement.

Diagnosis Coding is Vital to Fair Provider Compensation.   Medical groups are signing payer contracts that adjust payment for a contract year based on quality measures, outcomes, utilization and the acuity of care for a patient population. The payor measures acuity of care by reviewing the patient’s age, gender and medical conditions. Where does the payor get the list of medical conditions? Diagnosis codes on claims!  Medicare Advantage Plans base incentive payment on Risk Adjustment Factor (RAF) Scores.

Diagnosis Coding is Vital to Fair Funding to Insurance Plans. The purpose of a Risk Adjustment model is to predict the future health care costs for enrollees in Medicare Advantage plans. CMS is then able to provide capitation payments to these plans. Additional funding to the plans in the form of Capitation payments help the health plans to enroll not only healthier individuals but those with chronic conditions or who are more seriously ill.

HHS Payment Goals are to help drive the health care system towards greater value-based purchasing. Rather than continuing to reward volume regardless of quality of care delivered CMS is focused in improving outcomes and reducing cost. Alternative payment models include Accountable Care Organizations (ACOs), bundled payments, and advanced primary care medical homes. Specifically, they want to:

  • move 50% of Medicare payments into alternative payment models by the end of 2018.
  • move 90% of Medicare payments to a model tied to quality or value by 2018.

Under MACRA (Medicare Access and Chip Reauthorization Act) there is a merge of previously introduced payment incentive programs, including: 

  • Merit-Based Incentive Program (MIPS)
  • Physician Quality Reporting System (PQRS)
  • Value-Based Payment Modifier (VBM)

Clinical Practice Improvement Programs have included Meaningful use of certified EHR technology and Alternative Payment Models (APMs). From 2019-2024, some providers will receive a lump-sum payment for Increased transparency of physician-focused payment models. Starting in 2026, CMS will offer some providers higher annual payments.  APM Criteria includes coordinating care; improving quality, reducing costs.

Hierarchical Condition Category Model (HCC) affects Medicare Advantage Plans (aka Medicare Part C) which have been paid under an HCC model since 2004. HCC is a risk adjustment model which identifies patients with serious acute or chronic illnesses and assigns a risk factor score to the beneficiary based on the patient’s demographics and medical history.  The government contracts with for-profit insurers to manage health care for these patients, and pays insurers a yearly fee for each member they enroll. The higher the risk score, the higher the annual fee.

Hierarchical Condition Category Model (HCC) Calculations

Each patient is assigned a Risk Adjustment Factor (RAF) score. RAF scores are based on:

  • Patient’s age and sex
  • Medicaid or disability status
  • Total of all chronic conditions and disease interactions

RAF scores identify the patient’s health status. Lower RAF scores indicate a healthier patient and higher RAF scores indicate a sicker patient.  The Average FFS patient has a score of 1.00.

How does HCC Affect Payment? RAF scores are additive. All qualifying diagnoses are included in the RAF score. Risk factors are added to achieve total RAF scores for each patient. RAF scores are predictive, and ICD-10 codes reported this year determine payments for next year.  Remember, the payment for the RAF score is from CMS to the Medicare Advantage Plan. Then Plan distributes the incentive bonus to all providers participating in the care of the patient.  This payment is in addition to the contractual fee-for-service payments and is paid annually.

It is important to remember that the health status is re-determined each year, therefore codes must be submitted every year to be counted.  Past data is not carried forward, and the RAF for each patient is reset every year.  Also, payment is made per HCC category (not per diagnosis code). A patient with 4 ICD-10 codes from category E11 for Type II Diabetes Mellitus with complications will only receive credit once for complicated Diabetes Mellitus (HCC 18), and not 4 times that value in the RAF score.

How to Achieve Accurate RAF Payment

The Annual Health Assessment is very important. Consider implementing a program to have a staff member call all Medicare Advantage members to schedule their Annual Wellness Visit and be sure the Risk Assessment, required screenings, and status of all chronic conditions is addressed and documented to qualify as a “reportable” diagnosis.  The claim should include accurate and specific diagnosis coding.

Example of How Diagnosis Codes Affect Payment

Table1A patient is seen in your office.  Patient is a 64-year-old disabled female.  She has Type II diabetes and Diabetic Chronic Kidney Disease. The patient also has congestive heart failure and Stage IV CKD (GFR 24 ml/min Filtration).  The patient is obese with a BMI of 56, is on insulin and is paraplegic.  (see table)

Common HCC Categories

Chronic Kidney Disease
Diabetes Mellitus
Peripheral Arterial Disease (PAD)
Major Depressive Disorders
Stroke and Late effects of prior Stroke
Chronic Conditions
History of Heart Attack
Renal Dialysis Status
Tracheostomy Status
Respirator Dependence
Lower Limb Amputee
Organ Transplant Status
Asymptomatic HIV Status
Protein Calorie Malnutrition
Alcohol Dependence & Drug Dependence

What supports coding for HCC?

Use Current ICD-10 Codes. Effective October 1, 2017 the Centers for Medicare & Medicaid Services (CMS) and the Centers for Disease Control and Prevention (CDC) added or updated approximately 620 diagnosis codes in the 2018 ICD-10-CM coding classification.

  • 360 new codes added
  • 226 code descriptions revised
  • 34 codes changed from valid to invalid
    • Validity changes are the result of new codes being added to the classification, changing a previously valid code to an invalid code, creating a new subcategory
    • Example: a valid 4-character code now requires 5 characters
  • There are also updates to the 2018 ICD-10-CM Official Guidelines for Coding and Reporting that impact medical record documentation, code selection and sequencing.

Adherence to the Guidelines when assigning ICD-10-CM diagnosis codes is required under HIPAA in all healthcare settings.

ICD-10-CM and Documentation – Use the MEAT Acronym.  A condition is reportable when the condition was Monitored, Evaluated, Assessed or Treated.  Do not report a diagnosis code that was not addressed during the encounter or documented in the note.  Our auditors have found errors when the main note does not mention a problem, but ancillary documentation such as medication lists and referrals contains orders for those conditions. The medication list may include Prednisone 5mb PO daily for asthma, but asthma is not mentioned in the history, exam or assessment portion of the note.  Referrals for consultations and tests can be found in the note (Ex: chest x-ray confirms pneumonia) without mentioning pneumonia in the assessment portion of the note.

Steps to take in your Practice: Identify HCC Categories that are clinically meaningful. What chronic diseases do your sickest patients have?  The HCC diagnosis categories are well defined. Meet with your clinicians and decide which specific diseases/conditions are common. The ICD-10 codes are grouped to each HCC category.  There are more than 9,000 ICD-10-CM codes map to 79 HCCs in the current risk adjustment model.  Diagnosis codes are excluded from mapping when they do not predict future cost or are vague or variable in diagnosis, coding or treatment. An example is symptom codes or osteoarthritis.

Risk Adjustment Data Validation (RADV) are a reality when participating in an incentive program.  CMS audits Medicare Advantage (MA) plans for accuracy of risk-adjustment payments and compares accuracy of coding to medical record. Medicare Advantage (MA) plans can be audited annually.  MA plans audit provider records to ensure compliance.  If you are selected, you will be required to submit medical records to substantiate coding. Audits may include the entire note to verify that it supports the level of service billed, medical necessity, and all codes reported.  Common errors from RADV audits show that electronic medical record was not authenticated, or medical record does not have legible signature or appropriate credentials

Parting Thoughts.  Does your practice have a compliance program? Make it stronger by Including risk adjustment audits to validate clinical documentation. Use audit results to provide education to all clinicians and coders, and continue to audit CPT coding documentation. Continue to monitor patient visits to ensure annual reporting.

About the Author: 

Nancy M Enos, FACMPE, CPC-I, CEMC is an independent consultant with the MGMA Health Care Consulting Group.   Nancy was a practice manager for 18 years before she joined LighthouseMD in 1995 as the Director of Physician Services and Compliance Officer.  In July 2008 Nancy established an independent consulting practice.

As an Approved PMCC Instructor by the American Academy of Professional Coders, Nancy provides coding certification courses and consultative services.  Nancy frequently speaks on coding, compliance and reimbursement issues.  Nancy is a Fellow of the American College of Medical Practice Executives. She is a Past President of MA/RI MGMA.  EMAIL: