ICD-10 and Risk Adjustment.pdf
Transcript of ICD-10 and Risk Adjustment.pdf
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Tonya Owens Coding Quality Educator
HCC coding, documentation and audit preparation
ICD-10 and Risk Adjustment
Confidential and proprietary – for internal use only Premera is an Independent Licensee of the Blue Cross Blue Shield Association
Meet the presenter
Tonya Owens is a Coding Quality Educator at Premera BlueCross. She received her CPC, CEMC, CPMA, and CRC certificates from the American Academy of Professional Coders, with over 10 years’ experience in the healthcare field coding and auditing multi-specialty professional services, outpatient surgeries, labs, and pro-fee.
Tonya enjoys assisting providers in identifying risks, opportunities, and clinical documentation improvement. Experiences also include an extensive knowledge in AR revenue cycle and HCC coding and risk adjustment auditing.
Confidential and proprietary – for internal use only Premera is an Independent Licensee of the Blue Cross Blue Shield Association
Webinar objectives
• By the end of the session, you will: Understand Risk Adjustment (RA) Know general RA guidelines Understand the significance of RA to you and your practice Know how to document thoroughly Be able to code completely and accurately using ICD-10-CM
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Risk adjustment and general guidelines
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Testing … 1, 2, 3 …
How familiar are you with
risk adjustment?
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Defining risk adjustment
Risk adjustment is a methodology of adjusting
estimated or perceived risks as they relate to diagnosis
codes of patients.
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Calculating risk scores
HCC HCC Label 11 Colorectal, Breast (Age < 50), Kidney, and Other
Cancers 12 Breast (Age 50+) and Prostate Cancer,
Benign/Uncertain Brain Tumors, and Other Cancers and Tumors
13 Thyroid Cancer, Melanoma, Neurofibromatosis, and Other Cancers and Tumors
18 Pancreas Transplant Status/Complications
19 Diabetes with Acute Complications
20 Diabetes with Chronic Complications 21
Diabetes without complications 23 Protein – Calorie Malnutrition
ICD10 ICD10 Label HCC E0821 Diabetes mellitus due to
underlying condition with diabetic nephropathy
20
E0822 Diabetes mellitus due to underlying condition with diabetic chronic kidney disease
20
E0829 Diabetes mellitus due to underlying condition with other diabetic kidney complication
20
E08311 Diabetes mellitus due to underlying condition with unspecified diabetic retinopathy with macular edema
20
E08319 Diabetes mellitus due to underlying condition with unspecified diabetic retinopathy without macular edema
20
E08321 Diabetes mellitus due to underlying condition with mild non-proliferative diabetic retinopathy with macular edema
20
Hierarchical Condition Category (HCC) classification system
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HCC hierarchy trump list Some HCCs hold more “value” than others…
If this HCC is found…
2015 Disease Group Label … Then drop these HCCs:
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
54 Drug/Alcohol Psychosis 55
57 Schizophrenia 58
70 Quadriplegia 71,72,103,104,169
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General risk adjustment (RA) guidelines
Face to Face visits • Collect and update
health status • Approved provider
type
Management • Clearly state
diagnoses • Sign/authenticate
record
Annual Review • Refreshed health
status • Report conditions
on claims
OUTCOMES: • Improved patient health • Better audit/ regulatory compliance • Enhanced reputation among patients and payers
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What does this mean for providers?
3 tie
r app
roac
h Identify new problems
early and avoid potential drug/disease interactions
Reinforce self-care and prevention strategies
Coordinate care collaboratively
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Diagnosis codes
Diagnosis with no
complication
DME, Rx, CPT, Labs,
etc.
Diagnosis with some
complication?
Using specific ICD diagnosis codes will help convey the true complexity of the conditions being addressed in each visit!
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Medical Records Review (MRR)
Retrospective:
• Medicare Risk Adjustment Data Validation Audits (RADV)
• Commercial Risk Adjustment – Initial Validation Audits (IVA)
• Medical Record Reviews (MRR) to validate that documentation matches codes reported on claims
Prospective:
• Receptive to feedback about the opportunities to improve coding and documentation
• Receive training (coders and/or clinicians) on requirements of complete coding and documentation
Does your documentation match what was sent on the claim?
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Documenting For Risk Adjustment
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Can’t use in Outpatient Records: May use in Outpatient Records:
Suggestive of/Symptoms of/Likely Early/Underlying
Consistent with/Compatible with Evidence of
Suspicious of/Pending Element of
Presumed/Sign(s) of/Suspect Significant
Cholesterol Thyroid Increased/elevated/decreased
Assessment: J44.9 – Stable, continue meds E11.9 – Stable, order labs return to office in 3 months
Assessment: 1. COPD (J44.9)– Stable, continue
current meds 2. Diabetes II (E11.9)– Stable, order
labs and return to office in 3 months
Improving documentation: Wording for diagnosis capture
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Documentation: chart notes, ICD-10, specificity
• Patient name, DOS, acceptable signature
• Verify medication list is updated
Complete Chart notes
• Show support for a condition – MEAT
• Coders can’t make assumptions – state conditions
Support for ICD Codes • Laterality, stage,
anatomical site • Is it acute, chronic,
a complication?
Document Specificity
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Documentation: unclear example 1
CC: “Annual comprehensive visit”
HPI: Patient is 38yr old female here for annual physical. She has a history of CHF, diabetes and neuropathy.
O: HT:5.6 WT:130 BMI: XX Physical exam shows no signs of distress…
Assessment: Annual exam, diabetes & neuropathy, CHF
Plan: Continue current medications; follow up in 3 months.
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Documentation: clear example
CC: “Annual comprehensive visit”
HPI: Patient is 38yr old female here for annual physical. She has CHF and Type II diabetes with neuropathy.
O: HT:5.6 WT:130 BMI: XX Physical exam shows no signs of distress…
Assessment: Annual exam, diabetic neuropathy, CHF Plan: Continue current medications; follow up in 3 months.
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Documentation: unclear example 2
Betty Borderline, a 36-year-old female, referred to psychiatrist by gynecologist for potential treatment of major depression. Reports difficulty sleeping and concentrating; she has been feeling sad for more than 2 years, often feels hopeless. The patient is on a trial of Prozac; recommend she begin seeing a psychologist as adjunctive therapy.
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Documentation: clear example 2 (part 1)
Betty Borderline - Medical history includes: • hyperlipidemia • allergic rhinitis • psoriasis • doesn’t smoke • occasional alcoholic drinks • no history of illicit drugs • family history is significant for type 2 diabetes mellitus and coronary
artery disease • currently on loratadine, fluticasone nasal spray for allergic rhinitis,
uses fluocinonide cream for psoriasis flare ups; atorvastatin for elevated cholesterol
Reports difficulty sleeping and concentrating; she has been feeling sad for more than 2 years, often feels hopeless. The patient is on a trial of Prozac; recommend she begin seeing a psychologist as adjunctive therapy.
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Documentation: clear example 2 (part 2)
Based on assessment and past medical history, diagnoses are: • Axis I: Major Depressive Disorder, recurrent, moderate • Axis II: None • Axis III: Hyperlipidemia, Allergic Rhinitis, Psoriasis • Axis: IV: None • Axis: V: 60 Treatment Plan/ Recommendations include: • Major Depressive Disorder: Cognitive Therapy and
Relaxation Techniques; Rx for Seroquel XR 150 mg PO QD; continue other medications as prescribed.
• Return 2 weeks or earlier if needed.
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Valid Provider Signatures
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What makes a signature valid?
Improper Authentication Proper Authentication Provider: Jane Doe, MD Status: Signed but not read
Provider: Jane Doe, MD Status: Auth (verified) Verified by: Jane Doe, MD on 5/5/2015 at 19:16
Electronically Signed by: John Smith
Electronically Signed by: John Smith, MD on 11/5/2015 at 9:05 am
Providers must always sign or authenticate their records
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Coding for Risk Adjustment
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Coding guidelines: ICD-10-CM
ICD-10-CM: Section IV. Diagnostic Coding & Reporting Guidelines for Outpatient Services G. ICD-10-CM code for the diagnosis, condition, problem, or other reason for encounter/visit List first the ICD-10-CM code for the diagnosis, condition, problem, or other reason for encounter/visit shown in the medical record to be chiefly responsible for the services provided. List additional codes that describe any coexisting conditions. In some cases the first-listed diagnosis may be a symptom when a diagnosis has not been established (confirmed) by the physician. (ICD- 10-CM, 2013 Draft) J. Code all documented conditions that coexist Code all documented conditions that coexist at the time of the encounter/ visit and require or affect patient care treatment or management. Do not code conditions that were previously treated and no longer exist. However, history codes (categories Z80-Z87) may be used as secondary codes if the historical condition or family history has an impact on current care or influences treatment. (ICD-10-CM, 2013 Draft)
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Coding guidelines: ICD-10-CM
ICD-10-CM: Section IV. Diagnostic Coding & Reporting Guidelines for Outpatient Services G. ICD-10-CM code for the diagnosis, condition, problem, or other reason for encounter/visit List first the ICD-10-CM code for the diagnosis, condition, problem, or other reason for encounter/visit shown in the medical record to be chiefly responsible for the services provided. List additional codes that describe any coexisting conditions. In some cases the first-listed diagnosis may be a symptom when a diagnosis has not been established (confirmed) by the physician. (ICD- 10-CM, 2013 Draft) J. Code all documented conditions that coexist Code all documented conditions that coexist at the time of the encounter/visit and require or affect patient care treatment or management. Do not code conditions that were previously treated and no longer exist. However, history codes (categories Z80-Z87) may be used as secondary codes if the historical condition or family history has an impact on current care or influences treatment. (ICD-10-CM, 2013 Draft)
List first the ICD-10-CM code for the diagnosis
Code all documented conditions that coexist at
the time of the encounter
List additional codes that describe any coexisting
conditions
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TAMPER or MEAT ?
Did the clinician “TAMPER” with the condition? • Treat, Assess, Medicate/Monitor, Plan,
Evaluate, Referral Is there enough “MEAT” to support this condition? • Monitor, Evaluate, Assess, Treat
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Coding from chief complaint: example 1
CC: Ms. Jones is a 70-year-old female who comes in today for her follow up of her diabetes and COPD. She has a history of DVT and peripheral vascular disease. She has had no issues or complaints since her last visit to the office.
What would you code?
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Coding from chief complaint: example 1
HPI: Ms. Jones is a 70-year old female who comes in today for her follow up of her diabetes and COPD. She has a history of DVT and peripheral vascular disease. She has had no issues or complaints since her last visit to the office.
C.) Diabetes, COPD, HX of DVT and PVD Primary Code: Diabetes: E11.9 Secondary code: COPD – J44.9
Territory Code: Personal HX of DVT Z86.718 Fourth Code: Personal HX of other diseases of the circulatory
system – Z86.79
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Coding from chief complaint: example 2
HPI: Mr. Smith is a 68-year-old male with a history of prostate cancer and rheumatoid arthritis. He is here today for a follow-up on his hormonal treatment of androgen deprivation therapy and to evaluate the effectiveness of his current dosage on Humira.
What would you code?
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Coding from chief complaint: example 2
HPI: Mr. Smith is a 68-year-old male with a history of prostate cancer and rheumatoid arthritis. He is here today for a follow-up on his hormonal treatment of androgen deprivation therapy and to evaluate the effectiveness of his current dosage on Humira
D.) Prostate cancer and RA Primary code: Prostate Cancer: C61
Secondary code: Rheumatoid Arthritis – M06.9
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Check-in: complete the codes
HISTORY OF PRESENT ILLNESS: • Stable CHF on current regimen • Diabetes type II with polyneuropathy • A1c improved with increased doses of NPH insulin • Nerve pain has improved on current medication • Chronic renal insufficiency is stable • Complaints: SOB and increased wheezing and coughing; no symptoms of CAD.
He had follow-up with Dr. X and she also thought he was doing quite well. PFSH: Quit smoking in 1998 MEDICATIONS: (Reviewed and reconciled with patient today 08/06/20xx) ASSESSMENTS: COPD Congestive heart failure Diabetes type II with polyneuropathy PLAN: Continue all current medications; follow-up in 3 months
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Check-in: how did you do?
J44.1 Coronary Obstructive Pulmonary Disease w/acute exacerbation
I50.9 Congestive heart failure, unspecified
E11.42 Type 2 diabetes mellitus with diabetic polyneuropathy
K21.9 Gastro-esophageal reflux disease without esophagitis
I12.9 Hypertensive chronic kidney disease with stage 1 through stage 4 chronic
kidney disease, or unspecified chronic kidney disease
N18.3 Chronic Kidney Disease, stage 3 (moderate)
I25.10 Atherosclerotic heart disease of native coronary artery w/out angina
pectoris
Z79.4 Long term (current) use of Insulin
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Check-in: a second Look
HISTORY OF PRESENT ILLNESS: • Stable CHF on current regimen • Diabetes type II with polyneuropathy • A1c improved with increased doses of NPH insulin • Nerve pain has improved on current medication • Chronic renal insufficiency is stable • Complaints: SOB and increased wheezing and coughing; no symptoms of CAD.
He had follow-up with Dr. X and she also thought he was doing quite well. PFSH: Quit smoking in 1998 MEDICATIONS: (Reviewed and reconciled with patient today 08/06/20xx) ASSESSMENTS: COPD Congestive heart failure Diabetes type II with polyneuropathy PLAN: Continue all current medications; follow-up in 3 months
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How does coding to the highest specificity impact RAF?
No Conditions Coded (Demographics only)
Some Coded Conditions (Claims Data Only)
All Conditions Coded (Chart reviewed by Certified
Coder)
76 year old female 0.468 76 year old female 0.468 76 year old female 0.468
DM Not Coded DM (no manifestations) 0.118 DM w/Vascular manifestation 0.368
Vascular Disease not coded
Vascular Disease w/out complications 0.299
Vascular disease w/complication 0.41
CHF not Coded CHF not coded CHF Coded 0.368
No Interaction No interaction *Disease Interaction Bonus RAF (DM and CHF) 0.182
Patient total RAF: 0.468 Patient total RAF 0.885 Patient total RAF 1.018 PMPM Payment for care: $452
PMPM Payment for Care: $743 PMPM Payment for Care $1,381
HCC Financial Difference in Coding Specificity
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1. Document thoroughly 2. Code to the highest specificity 3. Evaluate patients with chronic/complex
conditions annually 4. Code all conditions that are supported in
documentation 5. Ensure that codes make it to the claim 6. Review medication lists with patient as often as
possible 7. Utilize PMH and Active condition lists
appropriately 8. Don’t copy and paste 9. Review your documentation and verify it
supports the codes 10. Don’t forget to sign the note!
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Questions?
035235 (11-2015)