Humana's Your Practice

Accurate Documentation and Coding Benefits Your Patients

The Medicare beneficiaries you treat are probably not aware of Medicare risk adjustment (MRA). But when physicians follow the documentation and coding regulations set forth under this model, patients benefit. Complete documentation and accurate coding can help your Medicare patients receive better service from their health plans, better care from their providers and better health outcomes for themselves.

The Centers for Medicare & Medicaid Services (CMS) Hierarchical Condition Category (HCC) risk adjustment model encourages plans and providers to compete strictly on the basis of quality and efficiency, not risk selection. The HCC model is based on ICD-9 coding and CMS guidelines. By taking each enrollee’s health status into account, the model pays the appropriate amount to provide necessary health services.

This not only protects the financial position of health plans and providers — it also helps facilitate access to health care for people with serious illnesses, such as cancer, diabetes or cardiovascular disease. Detailed risk adjustment data provide a complete picture of members’ health status. This allows health plans to offer better coordination of care, which can benefit seriously ill members.

At Humana, increased data accuracy through thorough documentation and coding helps identify individuals who may benefit from disease management and other medical support programs. More accurate health status information can be used to ensure that individuals are receiving the right level of care within the Humana network. It can also help to identify Humana programs and partnerships that would be beneficial.

Even patients without chronic health concerns benefit when their providers submit detailed data to health plans. Health plans with the most accurate risk adjustment data are able to:

Offer richer, more robust benefits
Provide more coverage and services
Offer improved cost sharing
Build more comprehensive provider networks, allowing for more member choice

When health plans are able to offer more comprehensive benefits at improved costs, membership grows. With more members, health plans can continue to improve service and coverage, feeding the continuous improvement cycle.

Medicare risk adjustment data also are being used to help identify best practices and alternative treatment options. For these decisions, which may affect coverage and reimbursement decisions in the future, it is critical to provide the most comprehensive data possible.

Ultimately, CMS makes funding and other program decisions based upon the accuracy of the information that Medicare Advantage (MA) organizations supply. Careful documentation and coding in accordance with the CMS-HCC model helps to improve the quality of that information, and therefore influences decisions that impact the coverage your Medicare patients receive.

Humana needs your help in improving the accuracy and completeness of Medicare risk adjustment data. Physicians with additional questions about Medicare risk adjustment can contact the Humana MRA department at 1-866-836-6658 or mra@humana.com.

H. pylori Testing Improves
Peptic Ulcer Disease Outcomes

In the United States, as many as one in 10 people suffer from peptic ulcers at some time in their lives, according to the National Institutes of Health¹. Some ulcers are caused by conditions, such as the use of nonsteroidal anti-inflammatory drugs (NSAIDs), but many are caused by a bacterium, Helicobacter pylori.

The good news about ulcerative diseases caused by H. pylori: Several tests can identify it, and affected members can be treated, eliminating the cause of peptic ulcer disease (PUD).

What is H. pylori's impact?
H. pylori is a bacterium that:

Causes more than 90 percent of duodenal ulcers and up to 80 percent of gastric ulcers.
Accounts for 90 percent of PUD.
Infects two-thirds of the world’s population. In the United States, H. pylori is most common among older adults, African Americans, Hispanics and lower socioeconomic groups ².
Increases the likelihood of developing gastric cancers and mucosal-associated lymphoid type lymphoma.
In 1998, the Centers for Disease Control and Prevention (CDC) estimated that PUD accounts for $6 billion in annual health care costs, $3 billion in hospitalization costs, $2 billion in physician office visits and $1 billion in decreased productivity and lost work days. ³

Testing and treatment
Prior to the discovery of H. pylori as the cause of PUD and other gastric problems, people suffering from ulcers were given an array of treatments to treat the ulcer symptoms without treating the source of the infection. Fortunately, today, the infection can be treated and eliminated. First, however, the correct source of gastrointestinal problems must be identified.

Three tests for H. pylori are available: serum, breath and stool. The serum H. pylori test does not reveal active disease because it tests for the antibody, not antigen; thus, 50 percent of patients with positive serology do not have active disease.

H. pylori antigen is optimally identified by a breath or stool test.

The breath test requires the patient to be off certain medications for two weeks prior to the test, requires multiple samples and cannot be performed in children. The H. pylori breath test is 95 percent sensitive and 89 percent specific.
The stool test, which does not require the patient to be off of medications, is 96 percent sensitive and 95 percent specific, and can be performed in children.

Therefore, the H. pylori stool antigen test is the most sensitive, specific and cost-effective H. pylori test available.

When H. pylori is identified, it can be treated with a regimen of 10 to 14 days of appropriate antibiotic drugs. For patients with ulcers, treatment sometimes involves acid suppression by an H2 blocker or proton pump inhibitor. The combined treatment can help relieve ulcer-related symptoms, heal gastric mucosal inflammation and may enhance the antibiotics’ efficacy. The FDA has approved eight H. pylori treatment regimens, listed at the CDC’s Web site at http://www.cdc.gov/ulcer/keytocure.htm.