MRA Overview
Yasmin
McLaughlin,CPC
SER Manager
1
For internal use only
Confidential

2
What is MRA?
• The Medicare Risk Adjustment payment system uses clinical coding information (HCCs) to calculate risk premiums for
Medicare Advantage plans enrollees
• MRA activity is the key process to ensure accurate payment from CMS for Humana Medicare Advantage enrollees based on the CMS-HCC payment model
• The primary focus of the MRA department is to obtain accurate healthcare information from providers in order to maintain accurate payment levels through chart reviews and provider education
Confidential

3
Humana’s MRA Team
Confidential

4
Market Team’s work with Providers
• Review Medical Records
• Provide feedback to providers regarding documentation.
• Coding Seminars are conducted to help practices in their coding efforts.
Confidential

5
Providers must be engaged in MRA
Goal = Properly Reflect the Member’s Health Status
• Fully Assess All Chronic Conditions
…every six months
• Thoroughly Document in the Chart ALL conditions evaluated each visit
• Code to the Highest Level of Specificity (fully utilize the ICD-9
Diagnosis Coding System)
Confidential

6
6
Confidential

7
“Code all documented conditions which coexist at the time of the visit that require or affect patient care or treatment”
Confidential

8
Best Practices for Excellent Documentation
 Chronic Conditions (CHF, COPD, DM)
 Active Status conditions (amputations, colostomy)
 Pertinent past conditions (Old MI)
 All conditions that require medication
 Conditions that affect the patient’s day to day life.
Confidential

9
Best Practices for Excellent Documentation
(when applicable)
 “Major Depression”, not “depression”
 “Chronic bronchitis”, not “bronchitis”
 “Atrial Fibrillation”, not “cardiac dysrhythmia”
 “Malnutrition”, not “loss of weight”
 “History of MI”, not “CAD”
Confidential

10
Documentation
• Be complete and legible—it has to be readable to someone else.
• Include patient name, DOB and date of service on every page.
• Note chief complaint (CC), reason for visit, assessment, and plan of care.
• Specify basis for ordering ancillary/diagnostic services
• Indicate appropriate health risk factors.
• Indicate past and present diagnoses if still of any medical significance.
• Show patient’s progress or lack of progress.
• Substantiate service rendered.
• Sign the progress note with full name and credentials.
• Problem list should be up-to-date and include onset AND end dates.
Confidential

11
Documentation Tips
• Always document the status of each diagnosis using specific and descriptive words to document the problem.
• Use the word history to mean that the condition no longer exists, not the medical history of the patient includes these conditions.
• All medications listed should have the reason they are taking it listed also.
• Always use an approved abbreviations list!
Confidential

12
“Why is thorough and specific documentation so important?”
Confidential

13
Risk Adjustment
 Wrap Up
 Questions
Confidential