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Association for Rural & Community Health Professional Coding (Arch Pro Coding)

Reporting Quality in Rural Health: A Focus on Clinical Documentation

EDUCATION :: CERTIFICATION :: AUDIT SUPPORT

Hosted by:

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Instructor – Gary Lucas

Vice President of Education Association for Rural & Community Health Professional Coding, 2014-current

Booz Allen Hamilton, Associate, 2009-2014 Discover Compliance Resources, Inc., President 2004-current

Medical Management Institute, Director of Professional Development, 1994-2004

Phone: 404-937-6633, option #4Email: Gary@ArchProCoding.comWeb: http://www.RuralHealthCoding.com

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Reporting Quality in Rural Health: A Focus on Clinical Documentation

• This is a high-level basic explanation of how to report accurate quality metrics dealing with HEDIS, HCC, QIP, Risk Adjustment, and Shared Savings.

• After a brief overview the attendees will dive into relevant sections of ICD-10–CM to review instructional notes associated with key diagnosis in order to accurately report the true complexity of care for their patients.

• More ongoing education and training will certainly be needed!

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© 2018 American Medical Association. All rights reserved.

Arch Pro Coding & Gary Lucas also wish to express thanks to Shekinah

Bishop, ACO Practice Specialist, of Imperium Health for some great

content and perspective contained in this presentation!

Also - selected slides in this presentation are copyrighted by the American

Medical Association and have the AMA logo at the bottom of the slides:

“Risk Adjustment Documentation & Coding”

by Sheri Poe Bernard, CCS-P, CDEO, CPC, CRC

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Who is this class designed for?

Clinicians and others licensed and operating under

their state’s scope of care.

How would you score your provider education plan?

KEY: Clinical Documentation

Those who manage clinical and revenue staff and make

policy, hiring, and IT decisions.

How do we merge clinical and financial goals?

KEY: Professional Coding

Those who use clinical documentation to compliantly code, bill, and report services on behalf of a RHC.

Nurses play a new key role!

KEY: Accurate Coding & Billing and communication with providers.

Develop a shared foundation of knowledge and get results!

Clinical Providers Management Coders/Billers/Quality Staff

Are payers “changing” how you treat your patient?

Source: http://www.sbh4all.org/current_initiatives/nqi/

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What is Risk Adjustment Factor Coding

• CMS uses a prospective risk adjustment methodology to annually predict individual healthcare expenditures

for Medicare beneficiaries (using diagnoses from the previous year)

• Risk adjustment methodology is applied to each Medicare beneficiary

• CMS categorizes ICD-10-CM diagnoses by the costs associated with key chronic or some acute conditions

• These condition categories are then placed into hierarchies, reflecting severity and cost (known as HCC)

• An HCC risk score is a measure of the predicted or expected cost that will be incurred by the beneficiary during

the calendar year

• Hierarchies allow for stratifications of the most serious conditions when less serious conditions exist

© 2018 American Medical Association. All rights reserved.

Two-Pronged Goal of Diagnosis-Based Risk Adjustment

• Ensure conditions are diagnosed, documented, coded, and regularly

monitored.

• Accurately track the care requirements of patients so that future demands

on resources can be predicted.

Note: Previously, “risky” patients with pre-existing conditions would not be

able to find insurers willing to cover them or face unaffordable premiums and

deductibles. The Affordable Care Act aimed to make insurance available to

more Americans.

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© 2018 American Medical Association. All rights reserved.

What Does This Mean For Physicians and Coders?

• Records must be:

o Specific

o Accurate

o Clinically valid

o Unambiguous

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• Coding must be:

o According to guidelines

o Accurate

o To highest specificity

o Complete

© 2018 American Medical Association. All rights reserved.

Medicare Advantage: Unintended Consequences

• Poor outpatient diagnostic coding due to few ICD-10-CM audits in past

o Upcoding of conditions (eg, coding from past medical history)

o Downcoding of conditions (eg, failing to code documented causal links)

o Underdocumenting conditions that led to nonspecific codes being reported

o Not coding all diagnoses because comorbidities were not the reason for the encounter

• MAOs are held accountable for codes submitted by physicians within their plans, but don’t control documentation or coding

o MAOs are offering clinical documentation improvement initiatives for diagnoses

o MAOs are hiring auditors to review chart documentation

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We focus on PEOPLE working

TOGETHER to get

REAL RESULTS

Clinical Providers

Management

Coders/Billers

Revenue

Opportunities

EHR/IT Impacts

Policies & Compliance

Patient Impacts

Workflow Dependencies

Self-Study, Exercises, or Certification

Exam

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Impact of Clinical

Documentation

Clinical

Documentation

Encounter note is created

Coding

Provider Gets

“Credit”

Billing

Quality

Reporting

Shared Savings?

13 Sample: Medicare Claims Processing Manual, Chapter 9 , Section 70

Please review the entire Table of

Contents!

14 Sample: Medicare Benefit Policy Manual, Chapter 13 , Section 40.4

Did you see the updates

for 2019?

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Which payers does “quality” apply to in an RHC?https://www.cms.gov/medicare/health-

plans/medicareadvtgspecratestats/downloads/advance2019part1.pdf

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CMS-1450 Form

• Instructions on completing the CMS-1450 form (also known as the “UB-04”) can be found here: https://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/Downloads/R1104CP.pdf

• This form is used for most “__________” Medicare services, especially those provided in a RHC/FQHC including office visits, procedures, preventive medicine, etc.

• Need to include Type of Bill and Revenue Codes not needed on the CMS1500 form.

• No requirement to “link” diagnosis codes

covered

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CMS-1500 Form

• Instructions on completing the CMS-1500 form can be found here: https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads/clm104c26.pdf

• This form is used for reporting ____________ and “some” Medicare covered services such as hospital visits and the technical portion of some diagnostic tests.

• Diagnosis codes must be “linked” to services/procedures in box 24e.

non-RHC/FQHC

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Our Shared Path

* CC/HPI/ROS/Assessment

* Sick vs. “well” visits

* ICD-10-CM documentation

* Perform any procedures?

* Do “quality” rules affect the clinical approach?

* “Encounter forms” use

* Link diagnosis codes?

* EHR “wizards”

* HCPCS-II “look-alikes”

* Accurate ICD-10-CM & E/M coding is crucial!

* AIR vs PPS vs FFS?

* Who can “change” codes?

* Global package differences & modifiers

* Patient $$, track denials/audits

* Historical vs Hybrid Data & “Closing Gaps”

* Shared Savings via Risk Adjustment/HCCs

* CDI & ICD-10-CM education is key

* Active CMO and management buy-in

How well do your Clinical Providers, Managers, Coder/Billers work together?

Patient Encounter Provider Selects Code(s) Coder/Biller Formats Bill Cost/Quality Reporting

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Measuring “quality” in an RHC is complicated and evolving

• How much does this transition change the focus on completely and accurately documenting your care in your medical record?

• Which staff should participate in the additional coding/reporting responsibilities necessary for quality reporting?

• Is it necessary for us to adjust how we train our clinical providers and coders/billers?

• Have you experienced any push-back from your providers over the additional coding responsibilities they have been given over the last few years?

• We obviously want to continue to make our patients the primary focus of our work day, but are there any new reforms that are taking your time away from YOUR primary focus?

© 2018 American Medical Association. All rights reserved.

Medicare Advantage: Unintended Consequences

• Poor outpatient diagnostic coding due to few ICD-10-CM audits in past

o Upcoding of conditions (eg, coding from past medical history)

o Downcoding of conditions (eg, failing to code documented causal links)

o Underdocumenting conditions that led to nonspecific codes being reported

o Not coding all diagnoses because comorbidities were not the reason for the encounter

• MAOs are held accountable for codes submitted by physicians within their plans, but don’t control documentation or coding

o MAOs are offering clinical documentation improvement initiatives for diagnoses

o MAOs are hiring auditors to review chart documentation

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© 2018 American Medical Association. All rights reserved.21

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Hot Topics: Training for Quality Reporting?

• What needs to be a focus when dealing with these issues?

• HEDIS- Should have a clinical background, be a ____________, understand _________________and have direct access to CMO who may “adjust” the clinical approach based on the patient’s insurance requirements.

• HCC- Heavy ____________________ and in-depth knowledge of their “Official Guidelines for Coding and Reporting”.

• Find out which categories your managed care companies are focusing on for that year – usually 5-8 areas like diabetes, pain management, heart disease, etc.

• Risk Adjustment and “Shared Savings” - Work with your managed care plans and ACOs to “close gaps” typically by ensuring that you are painting a complete clinical picture of your patients on an annual basis, especially during your IPPE/AWV encounters.

EHR “super-user”

CPT/HCPCS-II, ICD-10-CM

ICD-10-CM implications

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Basic Definition –Healthcare Effectiveness Data & Information Set (HEDIS) • As of 2018 there were just under a hundred “Performance measures” that

are updated annually and are created and maintained by the National Committee for Quality Assurance (NCQA).

• These made up by a combination of CPT/HCPCS-II, nor ICD-10-CM codes and must be submitted on a periodic basis depending on the insurers desired timeframe as per your participation agreement.

• Typically measured via a percentage of “eligible” patients who may receive key medical services compared to how many actually received it via administrative or hybrid methods which includes claims data and audits.

• Used by Medicare/Medicaid Advantage programs to determine performance of “recommended or required” services are focused on “closing gaps”

• Broken into 5 areas that go FAR BEYOND coding: Effectiveness of Care, Access/Availability of Care, Experience of Care, Utilization and Relative Resource Use, Health Plan Descriptive Information

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HCC Overview

• Should be considered as the primary method to capture the Risk Adjustment needs of primarily Medicare/Medicaid managed care plans via ICD-10-CM codes using ___________data and ____________ that may include onsite or virtual audits by payers.

• Hierarchal Conditions Categories (HCC) for 2019 ties together around ______ ICD-10-CM codes into around ____ different categories.

• These HCCs are assigned a value that when combined with all diagnoseshelps a carrier assign a ______________ to each individual patient being evaluated by the plan.

• These scores are updated annually and requires everyone associated with the clinical documentation and coding processes to learn, understand, and apply the ICD-10-CM’s “Official Guidelines for Coding & Reporting” to help (typically) Medicaid Managed Care organizations __________.

historical claims “hybrid” methods

9500 83

“risk score”

“close gaps”

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Matching ICD-10-CM codes to HCCs risk scores

Source:https://www11.empireblue.com/provider/noapplication/f2/s2/t4/pw_g312847.pdf?refer=ehpprovider

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2019 CMS Hierarchical Condition Categories (HCC)HCC HCC Description Weight*

1 HIV/AIDS 0.344

2 Septicemia, Sepsis, SIRS/Shock 0.428

6 Opportunistic Infections 0.446

8 Metastatic Cancer and Acute Leukemia 2.654

9 Lung and Other Severe Cancers 1.027

10 Lymphoma and Other Cancers 0.675

11 Colorectal, Bladder, and Other Cancers 0.309

12 Breast, Prostate, and Other Cancers and Tumors 0.153

17 Diabetes with Acute Complications 0.307

18 Diabetes with Chronic Complications 0.307

19 Diabetes without Complication 0.106

21 Protein-Calorie Malnutrition 0.554

22 Morbid Obesity 0.262

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Other Significant Endocrine and Metabolic

Disorders 0.212

27 End-Stage Liver Disease 0.913

28 Cirrhosis of Liver 0.381

29 Chronic Hepatitis 0.153

33 Intestinal Obstruction/Perforation 0.243

34 Chronic Pancreatitis 0.308

35 Inflammatory Bowel Disease 0.315

39 Bone/Joint/Muscle Infections/Necrosis 0.431

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Rheumatoid Arthritis and Inflammatory

Connective Tissue Disease 0.426

46 Severe Hematological Disorders 1.394

47 Disorders of Immunity 0.683

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Coagulation Defects and Other Specified

Hematological Disorders 0.214

54 Substance Use with Psychotic Complications 0.368

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Substance Use Disorder, Moderate/Severe, or

Substance Use with Complications 0.368

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Subtance Use Disorder, Mild, Except Alcohol and

Cannabis 0.368

HCC HCC Description Weight*

57 Schizophrenia 0.606

58 Reactive and Unspecified Psychosis 0.546

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Major Depressive, Bipolar, and Paranoid

Disorders 0.353

60 Personality Disorders 0.353

70 Quadriplegia 1.338

71 Paraplegia 1.121

72 Spinal Cord Disorders/Injuries 0.519

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Amyotrophic Lateral Sclerosis and Other Motor

Neuron Disease 1.026

74 Cerebral Palsy 0.354

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Myasthenia Gravis/Myoneural Disorders and

Guillain-Barre Syndrome/ Inflammatory and Toxic

Neuropathy 0.491

76 Muscular Dystrophy 0.533

77 Multiple Sclerosis 0.441

78 Parkinson’s and Huntington’s Diseases 0.686

79 Seizure Disorders and Convulsions 0.277

80 Coma, Brain Compression/Anoxic Damage 0.575

82 Respirator Dependence/Tracheostomy Status 1.051

83 Respiratory Arrest 0.404

84 Cardio-Respiratory Failure and Shock 0.314

85 Congestive Heart Failure 0.310

86 Acute Myocardial Infarction 0.220

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Unstable Angina and Other Acute Ischemic Heart

Disease 0.219

88 Angina Pectoris 0.143

96 Specified Heart Arrhythmias 0.271

99 Cerebral Hemorrhage 0.276

100 Ischemic or Unspecified Stroke 0.276

103 Hemiplegia/Hemiparesis 0.498

104 Monoplegia, Other Paralytic Syndromes 0.368

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Atherosclerosis of the Extremities with Ulceration

or Gangrene 1.537

HCC HCC Description Weight*

107 Vascular Disease with Complications 0.401

108 Vascular Disease 0.305

110 Cystic Fibrosis 0.509

111 Chronic Obstructive Pulmonary Disease 0.335

112

Fibrosis of Lung and Other Chronic Lung

Disorders 0.216

114 Aspiration and Specified Bacterial Pneumonias 0.612

115

Pneumococcal Pneumonia, Empyema, Lung

Abscess 0.164

122

Proliferative Diabetic Retinopathy and Vitreous

Hemorrhage 0.232

124 Exudative Macular Degeneration 0.522

134 Dialysis Status 0.474

135 Acute Renal Failure 0.474

136 Chronic Kidney Disease, Stage 5 0.284

137 Chronic Kidney Disease, Severe (Stage 4) 0.284

138 Chronic Kidney Disease, Moderate (Stage 3) 0.068

157

Pressure Ulcer of Skin with Necrosis Through to

Muscle, Tendon, or Bone 2.112

158

Pressure Ulcer of Skin with Full Thickness Skin

Loss 1.153

161 Chronic Ulcer of Skin, Except Pressure 0.551

162 Severe Skin Burn or Condition 0.262

166 Severe Head Injury 0.575

167 Major Head Injury 0.143

169 Vertebral Fractures without Spinal Cord Injury 0.508

170 Hip Fracture/Dislocation 0.406

173 Traumatic Amputations and Complications 0.249

176

Complications of Specified Implanted Device or

Graft 0.609

186 Major Organ Transplant or Replacement Status 0.855

188 Artificial Openings for Feeding or Elimination 0.581

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Amputation Status, Lower Limb/Amputation

Complications 0.567

*Weight based on Community-Based Aged/ Non-Dual Risk Factor | Factor may be slightly different for other beneficiaries

https://www.cms.gov/Medicare/Health-Plans/MedicareAdvtgSpecRateStats/Downloads/Announcement2019.pdf

Different

categories address

different body

systems or

condition related

issues

27https://www.cms.gov/Medicare/Health-Plans/MedicareAdvtgSpecRateStats/Downloads/Announcement2019.pdf

HCC If the Disease Group is Listed in this column…

…Then these conditions will not

contribute to HCC Score

8 Metastatic Cancer and Acute Leukemia 9, 10, 11, 12

9 Lung and Other Severe Cancers 10, 11, 12

10 Lymphoma and Other Cancers 11, 12

11 Colorectal, Bladder, and Other Cancers 12

17 Diabetes with Acute Complications 18, 19

18 Diabetes with Chronic Complications 19

27 End-Stage Liver Disease 28, 29, 80

28 Cirrhosis of Liver 29

46 Severe Hematological Disorders 48

54 Substance Use with Psychotic Complications 55, 56

55 Substance Use Disorder, Moderate/Severe, or Substance Use with Complications 56

57 Schizophrenia 58, 59, 60

58 Reactive and Unspecified Psychosis 59, 60

59 Major Depressive, Bipolar, and Paranoid Disorders 60

70 Quadriplegia 71, 72, 103, 104, 169

71 Paraplegia 72, 104, 169

72 Spinal Cord Disorders/Injuries 169

82 Respirator Dependence/Tracheostomy Status 83, 84

83 Respiratory Arrest 84

86 Acute Myocardial Infarction 87, 88

87 Unstable Angina and Other Acute Ischemic Heart Disease 88

99 Intracranial Hemorrhage 100

103 Hemiplegia/Hemiparesis 104

106 Atherosclerosis of the Extremities with Ulceration or Gangrene 107, 108, 161, 189

107 Vascular Disease with Complications 108

110 Cystic Fibrosis 111, 112

111 Chronic Obstructive Pulmonary Disease 112

114 Aspiration and Specified Bacterial Pneumonias 115

134 Dialysis Status 135, 136, 137, 138

135 Acute Renal Failure 136, 137, 138

136 Chronic Kidney Disease, Stage 5 137, 138

137 Chronic Kidney Disease, Severe (Stage 4) 138

157 Pressure Ulcer of Skin with Necrosis Through to Muscle, Tendon, or Bone 158, 161

158 Pressure Ulcer of Skin with Full Thickness Skin 161

166 Severe Head Injury 80, 167

Accurate and thorough coding should always be

the highest priority

• The HCC model ranks

diagnoses into categories

that represent conditions

with similar cost patterns

• Some conditions will

“trump” or override other

conditions

2019 HCC Hierarchy

When a condition is reported with a higher HCC value…

Any reported condition within the same disease hierarchy with a lower value will be dropped

HCC Code Description Weight Retained Code

HCC 8

Metastatic Cancer and Acute

Leukemia 2.654

Metastatic Cancer and Acute

Leukemia

HCC 9

Lung and Other Severe

Cancers 1.027 Lung and Other Severe Cancers

HCC 10

Lymphoma and Other

Cancers 0.675 Lymphoma and Other Cancers

HCC 11

Colorectal, Bladder, and

Other Cancers 0.309

Colorectal, Bladder, and Other

Cancers

HCC 12

Breast, Prostate, and Other

Cancers and Tumors 0.153

Breast, Prostate, and Other Cancers

and Tumors

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Source: https://www.medicare.gov/manage-your-health/coordinating-your-care/accountable-care-organizations.html

Medicare offers several ACO programs, including:

• Medicare Shared Savings Program (cms.gov) -For fee-for-service beneficiaries

• ACO Investment Model - For Medicare Shared Savings Program ACOs to test pre-paid savings in rural and underserved areas

• Advance Payment ACO Model - For certain eligible providers already in or interested in the Medicare Shared Savings Program

• Comprehensive ESRD Care Initiative - For beneficiaries receiving dialysis services

• Next Generation ACO Model - For ACOs experienced in managing care for populations of patients

• Pioneer ACO Model - Health care organizations and providers already experienced in coordinating care for patients across care settings

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Source: https://www.medicare.gov/manage-your-health/coordinating-your-care/accountable-care-organizations.html

Accountable Care Organizations (ACO) and “Shared Savings”

1. The benchmark is a dollar amount set by CMS. They look at the currently attributed beneficiaries and develop an expectation (or benchmark) of how much they expect the total cost of care will be.

2. Obviously, if risk scores are higher, then CMS would expect the cost of care will be higher. Shared savings are experienced when actual expenditures are lower than that expectation or benchmark.

3. So the higher the benchmark, the more room there is underneath it to achieve shared savings.

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Commonly Missed Codes

• Amputation Status (Z89)

• Artificial Openings (Z93)

• Depression vs. Major Depressive Disorder (F32)

• DM vs. DM w/ Comorbidities (E11)

• HTN vs HTN w/ Renal or HTN w/ or w/o HF

(I12-I13)

• Transplant Status (Z94)

• Morbid Obesity (E66.0)

• BMI > 40 or

• BMI > 35 w/ documented co-

morbidities

• Protein Calorie Malnutrition (E44.)

• Can utilize Nestle Mini-Nutritional

Assessment (MNA)

Impact of Terminology on Risk Adjustment

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Common terms or phrases that are notinterchangeable

Lesion Wound UlcerIf Ulcer: Indicate Type (Pressure/Non-pressure, location, laterality, stage, severity, underlying conditions)

Elevated Blood Pressure Hypertension (Essential)

Diastolic Dysfunction Diastolic Heart Failure

Weakness Hemiparesis (except when sequela of a CVA)

Renal Insufficiency Syndrome Chronic Kidney DiseaseIf CKD, identify Stage I-V or ESRD

Failure to Thrive (common use) MalnutritionIf Malnutrition: Identify Type (If protein-calorie malnutrition provide supportive evidence, labs % weight loss, BMI <18.5)

Mass Neoplasm

Language is Important: Causal Relationship

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• Some conditions are the result of or manifestation of another condition

• Coders cannot interpret causal relationships between conditions if the “causal language” is not documented

• Causal or “linking” language establishes the connection between the condition and a resulting manifestation or late effect.

Examples:

Hypertensive Heart Disease: where the Heart Disease is a manifestation of hypertension. Heart Disease secondary to HTN is acceptable.

Right hemiplegia caused by stroke: where the hemiplegia is a late effect of a stroke

Language is Important: History vs. Active

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“History of” terminology is different for clinicians and coders:ICD-9 & 10 Coding Guidelines

History of means: Condition has resolved and is now historicalProviders

History of means: it happened, maybe it’s in the past, or it may be ongoing

Phrases that can be used to reflect a current condition:In the HPI state:

Patient is here for management of……Patient is here for follow-up of…..

Assessment/Plan section:“Compensated CHF” vs “Hx of CHF”“Leukemia in remission” vs “Hx of leukemia”

History vs Active Conditions

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Medical Note States: Coder and CMS Interpretation:

H/O CHF CHF has resolved

CHF Compensated CHF active and stable

History of Angina Angina has resolved

Stable Angina Nitrostat® PRN Angina is stable on active treatment

H/O Afib Afib has resolved

Afib controlled on digoxin Afib is stable on active treatment

Prostate Cancer s/p Chemotherapy Prostate cancer is eradicatedDocumentation does not indicate when patient completed chemotherapy

Prostate Cancer Lupron® Injections Q3mo Prostate cancer is active with active treatment

If your patient has an active condition documentation must reflect the correct story.“History of” language should not be used.

Non-Specific Documentation

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Diagnoses that often default to “Unspecified” due to the use of non-specific language

Example Document specificity such as

Arrhythmia TYPE: SSS, Tachy-brady syndrome, Afib, A-Flutter, Tachycardia, Bradycardia

CKD STAGE: Stage I-V, ESRD

Heart Failure TYPE: Systolic, Diastolic, CombinedSEVERITY: Acute, Chronic, Acute on Chronic

Depression TYPE: Situational, Major Depression, Manic, Seasonal, Severe

Major Depression EPISODE: Single, RecurrentSEVERITY: Mild, Moderate, Severe, In Remission, Unspecified

Arthritis TYPE: Rheumatoid, Degenerative, Inflammatory, Psoriatic

Atherosclerosis LOCATION: Coronary Artery, Extremities, Graft, Aorta

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Clinical Documentation Pitfalls

• “Missing” documentation

• Lack of “medical necessity”

• Not knowing when “time” impacts coding

• Lacking “key component” documentation

• Lacking (or untimely) signatures

• Billing under the wrong provider on team visits

• Not separating preventive service documentation from problem-oriented visits – it depends on the EHR!

• Unaware of CPT Guidelines

• “One-coding” and “block billing”

• Ever look at your provider’s billing ‘patterns’?

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The Medical Record

• According to CMS, §482.24(c)(1) All patient medical record entries must be _________________________________ (x5) in written or electronic form by the person responsible for providing or evaluating the service provided.

• CMS states “providers should submit adequate documentation to ensure that claims are supported as billed” and that each note must “_______” to support services claimed.

• When “Incident-To” billing is employed, know the rules (ex. established patients with established problems and compare scope of services).

• The medical record is the proof you may need to support payment and prevent claims of fraud/abuse.

• The medical record also serves as a legal document beyond billing to include _______________ scenarios.

legible, complete, dated, timed, and authenticated

stand alone

malpractice/liability

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Section 2: Impact of Insurance on Documentation

Does documentation change based on insurance type?

• Role of the CPT in “coding”

• We use the codes for “billing” purposes that can differ by payer!

CPT does not “imply any • (Hint: Read the 2nd paragraph of the CPT’s Introduction)

The AMA does not pay healthcare claims.

Payment rules come from various payers in their _____________.

• Medicare sets the trends in the industry so we will use CMS as our foundation here…but realize that commercial insurance variations exist, and payment/billing differences are normal and legal.

__________________________________

participation agreements

“…health insurance coverage or reimbursement policy”

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Section 2: Documentation Basics

• What must be documented by provider (e.g., CC, HPI, ROS, PFSH)?

• Ancillary staff documentation is OK? Role of “scribes”?

• Familiar with CMS signature requirements? Commercials have policies and track? Do you have an internal policy that is enforced?

• Focus on the need to manage who can enter in the reasons for the patient’s visits into the EHR:

• Does cc: get pulled in from your scheduling system?

• Who has access to those EHR fields?

• Does your system combine the CC and HPI?

• Who performs HPI/ROS/PFSH

• What about previously documented history?

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Why we must learn to love the ICD-10-CM• Focus on the “Official Guidelines for Coding & Reporting” for the most

educational benefits

• “Shared Savings”, Risk Adjustment via HCC, HEDIS

• Mild vs. Moderate vs. Persistent Asthma in manual or not?

• Use of unspecified codes?

• Definition of “and” is provided here – believe it or not!

• Where in the documentation can you pull diagnoses? (ex. HPI vs. ROS vs. Assessments)

• How many diagnoses must/can go on each claim? When to link diagnoses?

• Role of the Nurse Auditor in quality capture and reporting?

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• Code reason for visit first

• Code to the highest level of known specificity

• Don’t code “probable, suspected, questionable or rule out”

• Code chronic diseases as often and as long as the patient receives treatment for them

• Code coexisting conditions affecting patient care at the time of the visit

What Did Not Change With ICD-10-CM

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• You know how to navigate the physical ICD-10-CM manuals – specifically knowing the differences between Volume 1 (Tabular List) & Volume 2 (Alphabetic Index) and each section’s content.

• Ever look through the “Official Guidelines for Coding & Reporting”?

• Table of Drugs/Chemicals – know what each column means, please.

• You have performed hands-on testing on how to use your IT tools such as your EHR’s code look-up features, software encoders, and other IT short cuts, etc. and fully understand their limitations.

• Your providers know how to locate vital documentation notes located at each ICD-10-CM “Base Code” rather than just doing a basic index look-up.

Assumptions and Prerequisites on ICD-10-CM

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• Section I: A. Conventions of ICD-10• Conventions of ICD-10-CM

• Alphabetic Indexing and Tabular Listings

• Format and Structure

• Use of Codes for Reporting Purposes

• Placeholder Character

• 7th Digit Characters

• Abbreviations (Index and Tabular)

• Punctuation

• Use of “And”, “With”, “See Also”, “Code Also”

• “Unspecified” Codes, “Includes” and “Excludes”

• Etiology/Manifestation Conventions (e.g., “code first”, “use additional code”, “in diseases classified elsewhere”

• Default codes and Syndromes

Official ICD-10-CM Guidelines Review

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• Section I: B. General Coding Guidelines

• Locating ICD-10 codes, levels of detail in coding

• Codes A00.0-T88.9, Z00-Z99.8

• Signs and Symptoms

• Conditions that are integral part of disease process

• Conditions that are not integral part of disease process

• Multiple coding for a single condition

• Acute and Chronic conditions

• Combination codes

• Late effects (sequela)

• Impending or threatened conditions

• Reporting same diagnostic code more than once

• Laterality

• Documentation for BMI and Pressure Ulcer stages

Official ICD-10-CM Guidelines Review

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• Chapter 1: Infectious and Parasitic Disease (A00-B99)

• Chapter 2: Neoplasms (C00-D49)

• Chapter 3: Diseases of Blood and Blood Forming Organs (D50-D89)

• Chapter 4: Endocrine, Nutritional and Metabolic Diseases (E00-E89)

• Diabetes is located in this Section (E08-E13)

• Chapter 5: Mental and Behavioral Disorders (F01-F99)

• Chapter 6: Diseases of the Nervous System and Sense Organs (G00-G99)

• Chapter 7: Diseases of the Eye and Adnexa (H00-H59)

• Chapter 8: Diseases of the Ear and Mastoid Process (H60-H95)

• Chapter 9: Disease of the Circulatory System (I00-I99)

• Hypertension is located in this Section (I10-I15), R03.0 for elevated BP (ICD-9 code 796.2)

• Chapter 10: Diseases of the Respiratory System (J00-J99)

• Chapter 11: Diseases of the Digestive System (K00-K94)

• Chapter 12: Diseases of Skin and Subcutaneous Tissue (L00-L99)

• Chapter 13: Diseases of the Musculoskeletal System and Connective Tissue (M00-M99)

Section I: C. Chapter Specific Coding Guidelines

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• Chapter 14: Diseases of the Genitourinary System (N00-N99)

• Chapter 15: Pregnancy, Childbirth, Pueperium (O00-O9A)

• OB, Delivery and Postpartum Services

• Chapter 16: Newborn (Perinatal) Guidelines (P00-P96)

• Newborn services and reporting stillborns

• Chapter 17: Congenital Malformations, Deformations, and Chromosomal Abnormalities (Q00-Q99)

➢Chapter 18: Symptoms, Signs, and Abnormal Clinical and Laboratory Findings, Not Elsewhere Classified (R00-R99)

• Codes that describe symptoms and signs are acceptable for reporting purposes when a related definitive diagnosis has not been established (confirmed) by the provider.

• Chapter 19: Injury, Poisoning and Certain Other Consequences of External Causes (S00-T88)

• Chapter 20: External Causes of Morbidity (V01-Y99)

• Chapter 21: Factors Influencing Health Status and Contact With Health Services (Z00-Z99)

Section I: C. Chapter Specific Coding Guidelines

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Such notes are likely not visible to providers who only use an electronic index to simply search keywords or primarily use favorites lists!!!

Can your providers see their “Base Code” notes?

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ICD-10-CM –7th Character Extensions

.

Initial = Providing active treatment.

Subsequent = During period of healing and recovery.

Sequela = a “late effect” of a previous injury, poisoning, or trauma.

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Action Items & How to Get Results

Action Items• Review the full E/M

documentation guidelines from AMA and CMS.

• Update the encounter form a minimum of twice a year.

• Have providers review key areas of the ICD-10-CM Official Guidelines for Coding & Reporting.

• Identify codes that have both CPT and HCPCS-II options

Get Results

• Make your electric superbill a fully functional and usable document rather than a list of favorite codes.

• Establish a process for providers to report codes not on the superbill.

• Report diagnoses in order of importance and link diagnoses for all patients.

• Focus on chief complaints and “stand-alone” documentation.

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CPT® Category II Codes – revenue or quality?

• CPT Category II codes are “a set of supplemental tracking codes that can be used for performance measurement”

• “These codes are intended to facilitate data collection about the quality of care rendered by coding certain services and test results that support nationally established performance measures and that have an evidence base as contributing to quality patient care.”

• “The use of these codes is optional. The codes are not required for correct coding and may not be used as a substitute for Category I codes.”

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When do we need to use CPT - Category II codes?

• It will be highly variable by facility and is primarily based on your participation agreements with Medicare Advantage, Medicaid Managed Care, and commercial plans who may “require” or “encourage” this type of reporting.

• In a perfect world, your EHR vendor can design modules that “auto-magically” pull such key data from your completed medical encounter such as BMI being calculated or tobacco-use assessment performed. Good luck! ☺

• What they are really trying to determine is a ratio of how many eligible people got “X” of who is considered “eligible.”

• 0% through 100% with a targeted amount or minimum threshold to be reached that will impact future payment rates or incentive monies.

• This can be done at an individual provider level, for an entire facility, or for an entire network or facility type (e.g., FQHCs in a county/state).

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CPT Category II code highlights

• Patient History 1000F = Tobacco use assessed (CAD, CAP, COPD, PV) (DM)

• Patient History 1031F = Smoking status and exposure to 2nd

hand smoke in the home assessed (asthma) – see also 1032F-1039F

• Patient History 1125F and 1126F = Pain severity assessed (present vs. not present)

• Physical Examination 2000F = Blood pressure measured (CKD and DM)

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CPT Category II Diagnostic/Screening Processes or Results

• BMI 3008F - Body Mass Index (BMI) documented (PV)

• Physical Examination 3044F-3046F = Documentation of most recent hemoglobin A1c levels, less than 7%, 7-9%, or greater than 9%

• For CAD & DM see 3048F-3050F – Most recent LDL-C less than, equal to, or greater than 100-129mg/dL.

• Diagnostic/Screening Processes or Results 3074F-3080F –Systolic pressure readings below 130, 130-139, over 140 mmHg

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Case Study/ Example 1A 78 year old male with Type II DM that is controlled with diet.

• He is being followed by a nephrologist for his kidney issues caused by DM and receives dialysis 3 days a week.

• Mr. Jones also has Hypertension with CHF which has been in control with continued use of his medication.

• In 2008 Mr. Jones had his prostate removed due to prostate cancer and successfully completed all of his prostate cancer treatment.

• Urinalysis performed today shows white cells, Mr. Jones is positive for a UTI.

Not Coded to the highest level of specificity in ICD-10 Coded to the highest level of specificity in ICD-10-CM:

N39.0 UTI N39.0 UTI

E11.9 Type II DM w/o complications (HCC 19) 0.106 E11.22 DM II with diabetic CKD (HCC 18) 0.307

N18.9 CKD Unspecified N18.6 End stage renal disease (HCC 136) 0.284

I10 Essential Primary HTN I13.2 Hypertensive Heart and CKD w/HF w/ Stage 5 CKF or ESRD

(HCC 85) (HCC 136) 0.284I50.9 CHF NOS (HCC 85) 0.31

I50.9 CHF NOS (HCC 85) 0.31

Z85.46 Personal History of Prostate Cancer Z85.46 Personal History of Prostate Cancer

Z99.2 Dialysis Status (HCC 134) 0.474 Z99.2 Dialysis Status (HCC 134) 0.474

Calculated HCC Score: 0.89 Calculated HCC Score: 1.375

Coding to include disease interaction increases HCC risk weight

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Case Study/ Example 2

A 68-year-old patient with type 2 diabetes with no complications, hypertension, and a

body mass index (BMI) of 37.2

Not Coded to the highest level of specificity in ICD-10 Coded to the highest level of specificity in ICD-10-CM:

E11.9 DM II with no complication 0.106 E11.42 DM II with diabetic polyneuropathy (HCC 18) 0.307

I10 Hypertension 0.31 I10 Hypertension

Z68.37 BMI of 37.2 0E66.01 & Z68.37 Morbid obesity with a BMI of 37.2

(HCC 22) 0.262

Z89.512 Status post-left BKA (HCC 189) 0.567

Calculated HCC Score: 0.416 Calculated HCC Score: 1.136

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Case Study/ Example 3

This 62-year-old male is being seen for mild non-proliferative diabetic retinopathy with

macular edema. He has type 2 DM and takes insulin on a daily basis. He also has

diabetic cataract in his right eye.

Not Coded to the highest level of specificity in ICD-10 Coded to the highest level of specificity in ICD-10-CM:

E11.9 Type II DM w/o complications (HCC 19) 0.106E11.321 DM II with mild non-proliferative retinopathy and

macular edema (HCC 18)

E11.36 DM II with cataract (HCC 18) 0.307

Z79.4 Long term use of insulin (HCC 19)

Calculated HCC Score: 0.106 Calculated HCC Score: 0.307

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Case Study/ Example 4

This 72-year-old female is being seen for a diabetic checkup. She has type 2 DM with

mononeuropathy and takes insulin on a daily basis. She also has Crohn’s disease and

rheumatoid arthritis.

Not Coded to the highest level of specificity in ICD-10 Coded to the highest level of specificity in ICD-10-CM:

E11.9 Type II DM w/o complications (HCC 19) 0.106 E11.41 DM II w/ diabetic mononeuropathy (HCC 18) 0.307

K50.0 Crohn’s disease of small intestine w/o complications (HCC

35) 0.315

M05.6 Rheumatoid arthritis of unspecified site with involvement of

other organs and systems (HCC 40) 0.426

Calculated HCC Score: 0.106 Calculated HCC Score: 1.048

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Summary of Action Items &How to Get Results

Section 5:

© 2018 American Medical Association. All rights reserved.

Tips for Risk-Adjustment Coders

• Verify the patient by checking the name and DOB against the file’s

demographics.

• Go to the inpatient discharge summary and review the chart for a proper

signature, then skim the entire file for additional diagnoses.

• For outpatient charts, start with the assessment/plan and then start again

at the beginning.

• Look for diagnoses in the physical examination and the history of present

illness, not just in the assessment/plan.

• Always code to the highest level of specificity and follow coding rules.

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Section 5 Overview: Actions & Results

Determine how coding & revenue impact your clinical care

Know the documentation guidelines!

Recognize coders/billers as high-level pros

Update policies and workflows

Integrate documentation, coding, and revenue needs

Invest in annual education for all job roles

Get certified and achieve a career growth plan

Use caution if being asked coding vs. billing questions

Validate codes before billing and query through mgt.

Print/bookmark/download key materials

Know variations in payer $ rules, focus on CMS

Find revenue opportunities from non-Medicare payers

Focus on team-based training & communication

Be prepared for changes to rules!

Audit>Educate>Repeat

Learn More to Earn More!

GET RESULTS: Learn together, work together, grow together

Clinical Providers Management Coders/Billers Areas for Research GET RESULTS

© 2018 American Medical Association. All rights reserved.

The AMA has created some very nice laminated training materials for

those with their manual

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Source: “Risk Adjustment Documentation & Coding”by Sheri Poe Bernard, CCS-P, CDEO, CPC, CRC

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The End?