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AI muHCC Risk Adjustment Coding
AI muHCC yenjodzi yekugadzirisa coding inotarisa marekodhi ekurapa ezvinyorwa zvisingaperi zvinoratidzira kune Hierarchical Condition Categories, iyo CMS inoshandisa kuverenga njodzi zvibodzwa uye kubhadhara kune Medicare Advantage vakanyoresa.
Pa peji ino4 min verenga
Pfupiso
Imwe neimwe inotsigirwa kuongororwa inogona kushandura iyo chirongwa chinobhadharwa, saka chokwadi chakakosha mumativi ese. Kushaya mamiriro chaiwo kunoreva kubhadhara mari shoma. Kuwedzera kuongororwa iyo rekodhi haitsigire inogadzira kubhadhara kwakawandisa, mhosva yekuongorora uye zvinogona kuitika zveFalse Claims Act kufumurwa.
Kudzika Kwakadzika
Iyo CMS-HCC modhi inofanotaura imwe neimwe Medicare Advantage yakanyoreswa mutengo unotarisirwa kubva kuhuwandu hwevanhu uye kubva kuongororo macode akaiswa muHierarchical Condition Categories. Mhedzisiro ndeye njodzi yekugadzirisa chinhu (RAF) inoyera kubhadhara kune chirongwa. Hierarchies inoreva kuti kana mamiriro ane hukama ekuomarara kwakasiyana akaiswa macode, chikamu chakaomarara chete mumhuri iyoyo ndicho chakakosha. Diagnostics reset gore rega rega rekarenda, saka chirwere chisingaperi chinofanira kunyorwa zvakare gore rega rega. Inofanirawo kuuya kubva mukutarisana nekutarisana nemhando inogamuchirwa yevapi. Diagnostic radiology mishumo, semuenzaniso, haikodzeri. CMS yakapinda mumuenzaniso wakadzokororwa, unozivikanwa seV28, pamusoro pe2024 kuburikidza ne2026. Yakagadzirisa zvakare zvikamu uye yakabvisa makodhi akawanda ekuongorora kubva mukubhadhara, izvo zvakashandura izvo zvakawanikwa zvakakosha. Zvishandiso zveAI zvinoverenga zvinyorwa zvekiriniki, tsvaga kutaurwa nezvemamiriro, tarisa kuti chimwe nechimwe chiripo, chakarambwa kana kuti nhoroondo, zvimepe kune ICD-10-CM macode uyezve kuHCCs, uye batanidza kuwana kwega kwega kune magwaro anotsigira. MaCoders anoongorora mazano. Ongororo iyoyo yakakosha nekuti yakajairika AI kukanganisa kubata kutaurwa sechirwere. Rondedzero yematambudziko, mazita emishonga, nhoroondo yemhuri uye mitsara yakaita se "nhoroondo ye" hairatidze kuti chirwere chakaongororwa kana kurapwa pakushanya. Audit ngozi ndeyechokwadi. CMS inoitisa Risk Adjustment Data Validation (RADV) kuongororwa, uye mutemo we 2023 wakabvumira extrapolating kuongororwa kwekutsvaga mukati mechibvumirano chinotanga negore rekubhadhara 2018. Mishumo yeOIG yakabvunza kuongororwa kunongotaurwa chete kuburikidza nekuongorora kwechati kana kuongororwa kwehutano hwemumba. Dhipatimendi reJustice rakaunza nyaya dzeNhema dzeChirevo cheMutemo dzichiti zvirongwa zvakashandisa ongororo yechati chete kuwedzera makodhi, pasina kudzima vasina kutsigirwa. Kugara kusinganzwisisike ndeyekuti MEAT (Monitor, Ongorora, Ongorora kana Kero, Bata) mutemo weCMS. Iko gungano reindasitiri rekuongorora. Chinodiwa chaicho magwaro anotsigira kodhi pasi peICD-10-CM nhungamiro.
Strategic Impact
Mamiriro ezvinhu nemitemo
Mamiriro eindasitiri anosarudza kana mazano eAI achirarama nekusangana neicho chaicho.
Kudzora kwemhando yepamusoro
Zvisungo zveDomain zvinopesvedzera mwero wezvikanganiso zvinogamuchirika uye mamodheru etarisiro.
Vaka sarudzo
Kuendesa kwakabudirira kunonanisa kugona kwehunyanzvi nekumberi kwekufambiswa kwebasa.
Ramangwana reAI muHCC Risk Adjustment Coding
Dzvinyiriro pakugadzirisa njodzi iri kusimuka kubva kwakati wandei: shanduko yeV28, yakawedzera maodhisheni eRADV nekuwedzera, uye kuenderera mberi kwemubatanidzwa. Zvishandiso zvinotengeswa chete pamusoro pekuti vangani macode matsva avanowana iri mutoro uri kukura. Zvishandiso zvinosanganisa kutsvaga mamiriro akarasika nekudzima macode asina kutsigirwa, uye anochengeta humbowo nzira, inokodzera uko vanodzora vanoita sevari kunanga. Kushandisa AI tisati tashanya, kukurudzira varapi kuti vaongorore mamiriro ekushanya pane kuvhima makodhi mushure, inzira inodzivirirwa. Kuchinja kwakananga kweramangwana kumhando yekubhadhara kunofanirwa kutorwa kubva kukuzivisa kweCMS, kwete kubva mukufungidzira.
Real-World Implementation
Ongororo yakadzokororwa inowana mhando ye2 chirwere cheshuga neuropathy yakanyorwa mukiriniki chinyorwa, ine ongororo uye chirongwa, asi kuongororwa hakuna kumbosvika pakuda. Iyo coder inosimbisa zvinyorwa uye inotumira E11.40 yezuva iroro rebasa.
Iyo AI inomhanyisa ongororo yenzira mbiri mireza yekushanya kwehofisi ine kodhi yesitiroko yemurwere ane sitiroko yakaitika makore apfuura. Inokurudzira kubvisa iyo kodhi uye kuitsiva nekodhi yenhoroondo yesitiroko kana mhedzisiro yayo inogara, sezvakanyorwa.
Manotsi anotaura nezve dialysis katatu pasvondo, asi hapana mupi ane chinyorwa chekupedzisira-danho renal chirwere. Chishandiso hachina kodhi ESRD. Inotumira mubvunzo wezvinyorwa kuitira kuti murapi agadzirise pakushanya kunotevera.
Pamberi pekushanya kwegore negore kwehutano, sisitimu inonyora mamiriro akanyorwa gore rapfuura asi risati rasvika gore rino. Murapi anofanira kunyatsoongorora imwe neimwe panguva yekushanya. Cheki bhokisi rekusimbisa harina kukwana.
Njodzi & Guardrails
Regulatory zvinodiwa zvinogona kukanganisa zvimwe zvakasimba prototypes.
Nhoroondo yenhoroondo inogona kubatanidza kurerekera kunokuvadza nharaunda dzakati.
Nhaka masisitimu anogona kugadzira mabhodhoro ekubatanidza uye mitengo yakavanzika.
Implementation Roadmap
Batanidza domain nyanzvi kubva pakugadzirisa dambudziko kusvika pakuongorora.
Dhizaina nzira dzekuongorora uye zvinyorwa zvisati zvatanga.
Gadzirisa zvisungo zvekuteedzera uye kuchengetedza nekukurumidza.
Buritsa muzvikamu zvine kujeka kumira uye kudzoreredza maitiro.
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Mibvunzo inowanzo bvunzwa
Chii chinonzi AI muHCC Risk Adjustment Coding?
AI muHCC yenjodzi yekugadzirisa coding inotarisa marekodhi ekurapa ezvinyorwa zvisingaperi zvinoratidzira kune Hierarchical Condition Categories, iyo CMS inoshandisa kuverenga njodzi zvibodzwa uye kubhadhara kune Medicare Advantage vakanyoresa. Imwe neimwe inotsigirwa kuongororwa inogona kushandura iyo chirongwa chinobhadharwa, saka chokwadi chakakosha mumativi ese. Kushaya mamiriro chaiwo kunoreva kubhadhara mari shoma. Kuwedzera kuongororwa iyo rekodhi haitsigire inogadzira kubhadhara kwakawandisa, mhosva yekuongorora uye zvinogona kuitika zveFalse Claims Act kufumurwa.
Chii chinoitika pasi peCMS-HCC hierarchies kana mamiriro ane hukama ekuomarara kwakasiyana ese ari macoded?
Hierarchies inodzivirira kuverenga kaviri mukati memhuri yemamiriro. Chete chikamu chakanyanya kuomarara chinoverengera kune njodzi zvibodzwa.
Sei chirwere chisingaperi chichifanira kunyorwa zvakare gore rega rega rekarenda?
Njodzi dzengozi dzinovakwazve gore rega rega kubva mukusangana kwegore iroro, saka mamiriro ehupenyu hwese anofanira kutsigirwa zvakare gore rega rega.
Manotsi anotaura nezve dialysis, asi hapana mupi akanyora ESRD. Chii chinoita basa rechokwadi?
MaCoders haakwanise kugovera kuongororwa kwaasina kunyorwa nemupi. Nhanho chaiyo ndeyemubvunzo kuitira kuti murapi agadzirise mamiriro acho.
Chii chinoita ongororo yechati "nzira mbiri"?
Ongororo yenzira mbiri inogadzirisa zvikanganiso mumativi ese. Mhosva dzeFalse Claims Act dzakanangana nechati ongororo dzinonzi dzinongowedzera macode.
Ndechipi chirevo pamusoro peMEAT chakarurama maererano negwaro?
MEAT inzira inoshandiswa nevakawanda kuronga ongororo, asi chiyero chaicho cheCMS zvinyorwa zvinotsigira kuongororwa pasi peICD-10-CM nhungamiro.
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