Chad needs your help: How your organization can capture metabolic syndrome

By Rose Bernards

“Chad” is a fictional person and moniker for cholesterol, hypertension and diabetes.

Chad is 74 years old, a retired engineer, happily married. But his health tells a different story. He has a BMI of 34, wears corrective lenses and is being monitored for retinopathy. He also has high cholesterol, high blood pressure, and is taking medications for those and his diabetes.

You probably know a Chad. He could be your dad, your grandpa, or a fun uncle. There are more than 37 million seniors with metabolic syndrome today, a cluster of conditions that includes cholesterol, hypertension, and pre-diabetes.

Capturing all these associated conditions are critical for Medicare Advantage and its multiple program models:

• CMS-HCC/Part C Risk Adjustment Model
• RX-HCC/Part D Pharmacy Model
• Star Ratings (HEDIS®, CAHPS, HOS)

Even though CMS recently constrained the coefficient values across diabetes HCCs in the V28 CMS-HCC model, your OP CDI and coding teams need to capture it at the appropriate diagnostic specificity as well as other conditions that comprise metabolic syndrome due to critical downstream impacts including appropriate value-based care funding needed to treat the constellation of conditions we call metabolic syndrome.

The documentation and coding associated with medical face-to-face provider visits impact not only the Part C model, but also are foundation to conditions and medications in the Part D model.

A typical example is a patient with type 2 diabetes on metformin. The documented condition is not only part of the Part C or CMS-HCC model, but the condition and medication also are linked to payments under the Part D or Rx-HCC model. And that is just one example. Diabetes also plays a significant role in Stars. High cholesterol, hypertension and other associated co-morbidities also have linkages to risk adjustment and Stars programs.

In short, we need all pieces of the puzzle assembled. The slide below offers some suggestions for how your organization can do just that.

I recommend you listen to the 30-minute webinar I presented this week on metabolic syndrome. And if you need help with chart auditing, risk adjustment, or CDI/coding support for this or other conditions, contact us at consulting@norwood.com.

Screenshot