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Understanding HCC Coding in Home-based

Primary Care

RICHARD O. SCHAMP MD GEORGE W. BRET T MD

CHIEF EXECUT IVE OFF ICER CH IEF MEDICAL OFF ICER

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Presenter: Richard Schamp, MD

• Family Medicine & Geriatrics x 30 yrs (rural PA with active home care practice, then urban St. Louis)

• Clinical Professor of FM & Geriatrics at Saint Louis University School of Medicine – started home visit program for residents & students

• Medical Director experience: Hospice, Home Health, Long Term Care and PACE

Disclosures• CEO of Capstone Performance Systems -- support

organizations/providers that care for vulnerable patients

• Risk Adjustment training for providers, Managed Care & PACE organizations x 10 yrs

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• Discuss the Risk Adjustment methodology and relevance to home-based primary care practice

• Understand how complete and accurate documentation and coding supports good patient care

• Introduction to Official Coding Guidelines and comments on ICD-10

• Tips for accurate and complete documentation and coding of common conditions seen in typical home-based primary care practice

Objectives for Today

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• NEVER submit false data or data (codes) that are not supported by documentation

• ALWAYS seek to be complete and accurate

• NEVER attempt to game the system

• ALWAYS attempt to systemize your game

Honesty is the best Policy

Disclaimer

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Triple Aim: 3 Value Vectors

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Quality vs. Quantity Value-based compensation Healthcare is shifting from FFS model to

pay-for-performance methods Payers will reward value and care

coordination- rather than volume and duplication

HHS testing and expanding new healthcare payment models

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HHS Payment Models

Category 1: FFS no link to quality Category 2: FFS with quality link Category 3: Alternative Models built on

FFS architecture Category 4: Population Based Payment

Value-Based Payment is Here to Stay

Source:

http://www.hhs.gov/news/press/2015pres/01/20150126a.html

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FFS Museum

Shifting Provider Payment Environment Two Shifts1. Increasing accountability for quality and total

cost of care2. Timeline:

1. 30% of Medicare payments in alternative payment models (categories 3 & 4) by the end of 2016

2. 50% of Medicare payments in alternative payment models (categories 3 & 4) by the end of 2018

3. Overall, 85% of payments in categories 2 through 4 by 2016 and 90% by 2018

3. Most contracted arrangements will involve risk-adjusted payments

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Payment Mechanism Shift

FFS

Time

Shared Risk/Savings

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How does this make you feel so far?

How Does Risk-based Payment Model Work?CMS MONTHLY MEDICARE PAYMENT

• Capitated Payment for A&B costs• Benchmarks established for each County

~$750 -- $1300/mo

• Risk Adjusted amount for each member/enrollee

• Amount Changes Yearly

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Significance to Providers•Traditional: seriousness and severity of patient care indicated by E&M CPT® codes

•Higher level E&M codes identify serious encounters•utilizing more medical decision making•reimbursed at a higher rate

•In Risk Adjustment scenarios, these CPT® codes have no significance•Instead, diagnosis codes communicate the seriousness of medical decision-making

Risk-adjusted Plans are paid based on ICD-9 Codes,

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Significance to Providers Documenting involves three main points:① Identify diagnosis as a current problem as opposed to a previous condition② Choose specific ICD-9 diagnosis code and ③ Support the diagnosis fully by documentation

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• Medicare pays based on severity of illness for each enrollee

• ICD-9 is the specific language that is used to inform CMS the extent and severity of disease present

• Like any language, ICD-9 must be spoken properly.

• Failure to document and code correctly can lead to ◦ underpayment for your plan; i.e., Lost Revenue

◦ overpayment and violations of the False Claims Act

ICD-9 (10) is its own Language

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Risk Adjustment and

The False Claims Act

The False Claims Act prohibits: a) knowingly presenting (or causing to be

presented) to the federal government a false or fraudulent claim for payment or approval; and

b) knowingly concealing or knowingly and improperly avoiding or decreasing an obligation to pay or transmit money or property to the Government.

31 U.S.C. §3729(a)(1)

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The False Claims Act

• Any person who violates the FCA is liable for a civil penalty of up to $11,000 for each violation, plus three times the amount of the damages sustained by the United States.

31 U.S.C. §3729(a)(1)

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• Coding from a problem list (not current problems)• Submitting diagnoses (e.g. cachexia) with no support in

medical records for existence in that year.• Claiming current treatment for conditions better

characterized by “history of.” (e.g. acute stroke)• Submitting diagnostic codes from Labs/Radiology

Rpts/Rx’s without further documentation• Improperly linking complications and conditions to

increase risk score (e.g. linking diabetes and CKD without proper documentation)

• Targeted Coding: Pressuring coders to focus on high value diagnoses (e.g. malnutrition, Major Depression)

Improper Upcoding

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ICD-10• The ICD-10 transition date is October 1, 2015.

Get ready now for ICD-10.

• You don’t have to use 68,000 codes.As you do now, your practice will use a very small subset of the codes.

• You will look up ICD-10 codes just like you look up ICD-9.Alphabetic index and electronic tools available to help with code selection.

• Outpatient procedure codes aren’t changing.Transition to ICD-10 does not affect the use of CPT for outpatient coding.

• All FFS providers can conduct testing before ICD-10 transition.Contact Medicare Administrative Contractor for details about testing plans.

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ICD-10 v ICD-9 Comparison

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Tobacco Abuse

ICD-9-CM: 1 Code

ICD-10-CM: 5 Codes

Diabetes Mellitus

ICD-9-CM: 10 Codes

ICD-10-CM: 318 Codes

Fracture of Radius

ICD-9-CM: 33 Codes

ICD-10-CM: 1,818 Codes

Source: AHLA Institute on Medicare and Medicaid Payment issues

Coder’s Employment Relief Act? Between ICD-10 and the changes

associated with changing payment models, medical coding has never been more valuable.

Should your practice use a coder?◦ Depends on provider interest, skills and time◦ Out-sourcing coder is an option◦ Fresh models bring fresh scrutiny – compliance

with rules and regulations supported by coder/audits

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“Close Enough for Gummint Work” Doesn’t Cut it Anymore

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Under the Hood of RA How does the Risk Adjustment Model work? What are the key characteristics of the

Model? How is a risk score calculated? How much impact does a risk score have? How does incomplete documentation affect

it?

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• RA is a mathematical model designed for more accurate payments to Medicare Advantage and other capitated health plans

• Payment based upon health status of enrollees plus demographic data.

• Designed to predict illness costs covered by Parts A and B (Part C)

• Sicker members generate higher payments (to cover the costs of care)

Big Picture of Risk Adjustment

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• In March 2002, CMS chose CMS Hierarchical Condition Category Model (“CMS-HCC Model”) groups similar serious chronic medical conditions with similar costs of treatment into Hierarchical Condition Categories (HCCs), each with a “risk score”

• RA methodology has two inputs: ◦ Demographics◦ Diagnoses

• One output = HCCs (driving risk scores) • MA Plans and most other models (except PACE /

ESRD) use Version 22 (79 HCCs) for 2016 payments

Big Picture of Risk Adjustment

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CMS HCC Model is Prospective

• CURRENT demographics and diagnoses predict FUTURE expenses.

• Ultimately, payment in a given year is based on diagnoses submitted the PREVIOUS year.

• ICD-9 codes for dates of service in CY 2015 will be basis of payment in CY 2016

• (Health Exchanges use a concurrent model.)

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Risk Adjustment System (RAS)

All RAS factors are regressed SO THATAverage Medicare Risk Score = 1.000

(Based on FFS costs)

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Demographics: (approx. 0.330)◦ Gender◦ Age◦ How entered Medicare (disabled or age)◦ Medicaid status

HCC Component: (approx. 0.670)◦ Determined by diagnosis codes (ICD-9)

Risk Score ComponentsAverage Risk Score = 1.000

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Demographic FactorsDescription Score

Female70-74 Years 0.348 75-79 Years 0.437 80-84 Years 0.539 85-89 Years 0.667 90-94 Years 0.815

Male 70-74 Years 0.356 75-79 Years 0.442 80-84 Years 0.543 85-89 Years 0.683 90-94 Years 0.848

Medicaid Female Aged 0.151 Medicaid Female Disabled 0.085

Medicaid Male Aged 0.177 Medicaid Male Disabled 0.086

Originally Disabled Female 0.239 Originally Disabled Male 0.163

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• Gender• Age• OREM (disabled or

age)• Medicaid status

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Where do HCCs come from?

ICD-9 Codes(13,000)

Qualifying Dx Codes(~3400)

Diagnostic Groups(804)

Condition Categories

(189)

HCCs (79) Hierarchies

imposed

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Examples of HCCsHCC Description Score

1 HIV/AIDS 0.470 2 Septicemia, Sepsis, SIRS/Shock 0.535 8 Metastatic Cancer and Acute Leukemia 2.484

12Breast, Prostate, and Other Cancers and Tumors 0.154

18 Diabetes with Chronic Complications 0.368 19 Diabetes without Complication 0.118 21 Protein-Calorie Malnutrition 0.713 22 Morbid Obesity 0.365 55 Drug/Alcohol Dependence 0.420 57 Schizophrenia 0.490

58Major Depressive, Bipolar, and Paranoid Disorders 0.330

75 Polyneuropathy 0.408 108 Vascular Disease 0.299 137 Chronic Kidney Disease, Moderate (Stage 4) 0.224 Note: these are not diagnoses, but categories that contain

diagnoses

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Hierarchical◦ Payment based on more severe form of disease when

less severe form is also present in reporting period (e.g., PVD vs PVD w/complications)

Interactive◦ When certain diseases coexist, the model assigns

additional payment to recognize higher morbidity and costs than just adding the separate conditions

Additive◦ When unrelated diseases co-exist, the risk factors are

added together

The HCC model rewards: specificity and completeness

HCC Model Characteristics

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Hierarchy (Trump) Examples

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• 78 yo woman,• Lives in 2-story row home

for past 50 years• Bi-polar daughter lives in

home with her (with her 2 children)

• Oxygen dependent• Personally catered annual

block party x 20 years• Multiple cats with fleas• Personal goal to survive to

80th birthday

Example of the HCC Model

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Example of the HCC Model

o 491.21 COPDo 518.83 Respiratory Fail.

with O2o 327.3 Sleep Apneao 440.2 PVDo 585.4 CKD 4o 404.11 HTN w/CKD and HFo 416.8 Pulmonary Htno 428.3 Diastolic CHFo 427.89 SVTo 358.8 Neuropathyo 274.0 Gouto 285.29 Anemia o 721.9 Cervical spondylosiso 295.30 Major Depressiono 366.9 Cataracto 530.81 GERDo 389.9 Hearing losso 250.00 Diabetes Mellituso 250.40 Diabetes w. CKDo 250.70 Diabetes w PVDo 250.60 Diabetes w/Neuro

HCC Version 22

111 - COPD

84 - Cardiorespiratory Failure

108 - Peripheral Vascular Disease

137 – CKD Stage IV

85 - Congestive Heart Failure

96 - Specified Heart Arrhythmia

58 - Major Depression

18 - Diabetes With Complications

19 - Diabetes W/O Complications

Acti

ve P

rob

lem

s

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Risk Score Calculatio

n

Version 22Coefficients

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Adjusted HCC Risk Score: 4.053 Beaver County Rate $790.24

PAYMENT/MO: ($750 * 4.053) =$3,040

Calculating Her PaymentAssume our Patient is living in Beaver County, PA, enrolled in MA Plan with a 4.5 Star Rating and a bid of $750

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Financial Impact Example

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DIAGNOSISICD9 CODE

RXHCC NUMBER

RXHCC Score

Hypertension 401.9 88 0.244

Hypothyroidism 244.0 20 0.056

Hyperlipidemia 272.4 23 0.150

Osteoporosis 733.0 45 0.121

Depression (NEC) 311.0 62 0.122

Glaucoma (NOS) 365.00 113 0.232

Coronary Artery DisHistory of MI

414.01412.0

8989

0.1800.180

Diagnoses Unique to RxHCC Model(Document and submit all active diagnoses)

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RA Model Run Timetable

Practical Matter – need to submit ALL diagnoses/year Only room for 4 codes on paper claim (or 8

if file electronically) Key – maintain good active problem list

and track which are submitted in calendar year

Annual assessment is another way – the MA plan collects the diagnoses on separate form and submits (no limit)

MA Plan may perform chart review and collect codes (no limit)

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Face-to-Face To be eligible for risk adjustment, a

diagnosis must be documented in the context of a face-to-face visit.

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Documentation Guidelines What are CMS expectations for medical

records? How do Official Coding Guidelines impact

us? Which common documentation pitfalls?

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• Importance of clear, complete, accurate documentation cannot be overstated.

• Each visit note • Reason for the visit• Findings from physical exam• Diagnosis (single or multiple) established with

medical decision making• Plan of care

• Note dated and signed by PCP w/credentials.• SOAP note form is common and acceptable • “Impression/Plan” approach better for

comprehensive assessments

Documentation in Medical Records

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Question 1 The following assessment is found in a note:

What is/are the proper code(s) for the assessment above?

a) 305.1, 272.4, 401.9, 250.00b) 272.4, 401.9, 250.00c) 272.4, 401.9d) 401.9

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Answer 1

1. Answer: d) 401.9

Rationale: The HTN is only code that can be obtained from this example. Positive history of smoking cannot translate to tobacco

dependence (it must be stated), so 305.1 is incorrect. Diabetes is questionable due to legibility, so not coded.

The cholesterol is listed as “↑ chol”. (Cannot code from arrows)

This example illustrates coding clinic rules on up and down arrows, illegible notes, and clinical documentation specificity.

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Problem Lists

Problem list should be maintained to include:◦ Each condition and the start date.◦ The end date if the condition no longer exists.◦ The reason why the patient is disabled (Medicare

beneficiary and under 65 years).

Current (active) problem list important ◦ Other providers can know patient’s condition ◦ Reminder to address each chronic condition at least

once a year

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Show a clear, causal relationship between any condition and its respective manifestation(s).

Use linking verbiage such as “due to,” “because of” or “related to” to establish this relationship. The word “with” does not establish a cause-and-effect relationship except in the case of “diabetes with neuropathy”

Coding guidelines prohibit medical coders from assuming any cause and effect relationships

Document Causality if possible

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Official ICD-9 Coding Guidelines Diagnosis may only coded when

explicitly spelled out in medical record Medical record documentation that

supports each coded diagnosis must be obtainable

Must demonstrate adherence to coding guidelines

Documentation Critical in Capturing Risk Adjustment Data

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http://www.cdc.gov/nchs/icd/icd9cm_addenda_guidelines.htm

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Mantra #1 - All conditions documented by a PCP that co-exist at the time of the encounter/visit, and require or affect patient care or management should be coded.

• Do not continue to code conditions that were previously treated and no longer exist.

• History codes may be used as secondary codes IF the historical condition or family history has an impact on current care or influences treatment (V10-V19 are not in HCC model but are important).

Official Coding Guidelines

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Mantra #2 - Documentation should reflect medical decision-makingExamples:◦ DM currently stable on medication◦ Condition worsening - medications adjusted◦ Reviewed history and use of inhaler

w/patient◦ Condition improving◦ Interpret test results/confirm diagnosis in

note

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Official Coding Guidelines

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Monitored: current or planned

Evaluated: testing, physical finding or symptom

Assessed: conclusion that describes diagnosis

Treated: medications, exercise, advice, diet, etc

Put MEAT in your notes

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Best if each problem/diagnosis is addressed explicitly with an “Impression/Plan” format, instead of SOAP format for complex patients.

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Mantra #3 – Treatment is prima facie evidence of a diagnosis

◦ If treating, then a working diagnosis has usually been made, so write it down

◦ Don’t state “rule out” and then start treatment ◦ Document as “will treat for _______” or similar◦ Clinician should be as specific as possible when

documenting to allow for the most accurate/highest level code to be assigned (especially for ICD-10).

Coding Guidelines

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Avoid Qualifiers, if Possible

Using qualifying language disqualifies codes◦ OK to use qualifying terms, if diagnosis not established◦ If treating condition, diagnose/code for what you are treating

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Cannot Code in Outpatient Records: May Code in Outpatient Records:

Suggestive of / Symptoms of / Likely Early / Underlying

Consistent With / Compatible With Evidence of

Suspicious for / Pending Element of

Probable / Suspect / Tendency / Possible Component of

Presumed / Sign(s) of / Suspect Significant

Pre‐ / or vs. Compensated

Rule‐Out / Perhaps / Questionable Results show

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Incomplete Diagnoses Work-up in progress? Fine to state “rule-

out”, etc When results point to either firm/working

diagnosis OR when treating definitively (not symptoms only), then record the working diagnosis for coding.

Addendum to original face-to-face visit note is fine to record new diagnosis based on work-up.

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Question 2Ms. Maibock came in for follow up visit with her PCP. A full SOAP note was documented and signed by the treating MD.CC/HPI: Ms. Maibock is here for follow-up of RLL painMedications: CoumadinPMH: Compartmental syndrome status post surgery 2 years ago.Assessment: 1. Rt. Leg pain (NOTE: Duplex Doppler report of lower extremities from radiologist shows findings of: “consistent with DVT”.May the coder code DVT mentioned as an active diagnosis?a) Yesb) No

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Answer 2

2. Answer: b) No

Rationale: A Coding Clinic* ruling states that any diagnosis described as “consistent with” cannot be coded as active or current as a specific diagnosis is not being made with this wording choice.

This example highlights the rules around coding unspecific diagnoses when described as “consistent with”.

*The Coding Clinic (a department within the AHA‐ American Hospital Association) issues rulings on diagnosis coding.

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• Diagnosis specificity is paramount.• E.g., “chronic” can change the chosen

diagnosis code (and its risk score value)•Chronic Renal Disease vs. Renal insufficiency•Chronic Hepatitis B vs. Hepatitis B•Chronic Bronchitis vs. Bronchitis•Chronic cor pulmonale vs. cor pulmonale

Specificity Matters

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Evaluate and document chronic quiescent conditions, such as:

o Amputation, toe loss (V-code) (Z89.4xxx)

o Ostomy (V-code) (Z93.x)o HIV status (V-code) (B20)o Dialysis status (V-code) (Z99.2)

Each of these triggers an HCC.

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“Status” Conditions

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Standard abbreviations

Avoid abbreviations in medical record documentation

Use only standard abbreviations

Do not create abbreviations Check with local hospital for

list if your organization doesn’t have an approved standard

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Use “history of” only when appropriate

Per ICD-9-CM guidelines, the term “history of” means the patient no longer has the condition

Examples:◦ “history of congestive heart failure” to indicate

compensated congestive heart failure◦ “history of atrial fibrillation” to indicate atrial

fibrillation controlled by medication Avoid using the words “history of” to

document a current condition

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Signature Issues

Unacceptable Signature/ Authentication

Acceptable Signature/ Authentication

“Signed but not read”Handwritten signature or initials of treating provider

“Dictated but not signed/ read”, etc.

Electronic signature/ authentication (e.g. “authenticated by”, “completed by”, “finalized by”, “validated by”, “attested by”, “sealed by”, etc.

Signed by someone other than the treating provider (nurse, transcriptionist, etc.) on providers behalf

Signature stamps were phased out effective 12/31/2008. (EMR systems that affix a JPEG that looks like a signature stamp are approved)

EHR Shortcuts Beware “copy and paste” without updates Auditors are not stupid

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• Diabetes & complications• Vascular Disease• Chronic Kidney Disease• Chronic Heart Failure

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Common Documentation and Coding Issues in Home-

based Primary Care• Malnutrition• Stroke & Sequela• Major Depression• Dependencies

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• There are two HCC’s for Chronic Diabetes Mellitus◦Uncomplicated

HCC 19 (Community) 0.182◦Complicated

HCC 18 (Community) 0.368• Most patients with diabetes for a long time

have complications • Evaluating and documenting diabetic

complications does increase revenue, and is just plain Good Medicine.

Documenting Diabetes Mellitus

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Coding Diabetes Mellitus

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Documenting Diabetic Complications• Common Diabetic Complications include

• Nephropathy (250.4x) (E11.22)

• Neuropathy (250.6x) (E11.4x)

• Diabetic Vascular Disease/angiopathy (250.7x) (E11.5x)

• Diabetic retinopathy (250.5x) (E11.3x)

• Lipidemiopathies (250.8x) (E11.69)

• Each diabetic complication represents a separate diagnosis itself

• Support both diagnoses in your narrative – signs, symptoms, test results and link the two together.

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Coding Diabetes Mellitus First, document DM type with 250.xx code(s) These codes always require a 4th and 5th character

◦ 4th Character: Diabetic Complication◦ 5th Character: Type I v Type II and controlled (actually is “not stated as

uncontrolled”) v uncontrolled 0 = type 2, not stated as uncontrolled 1 = type 1, not stated as uncontrolled 2 = type 2, uncontrolled 3 = type 1, uncontrolled

Type 2 is default, if documentation doesn’t state Type 1 Uncomplicated diabetes requires just one code Multiple complications require multiple (250.xx) codes

◦ Example: DM2 with renal and neuro manifestations: 250.40 and 250.60 (E11.21 and E11.4x)

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Coding Diabetes Mellitus

Second, document/code all complications◦ Document/code at least one manifestation for

each 250.xx code that applies.◦ Ex: DM2 with diabetic retinopathy & diabetic

neuropathy would be coded as: 250.50, 250.60, 366.41, 357.2 (E11.36, E11.42)

◦ Document the linkages between complications and Diabetes (“due to”, “caused by”, etc)

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Question 3Ms. Lager came in for follow up visit with her PCP. A SOAP note is documented and signed by the treating MD.Assessment: 1. Diabetes (DM) Type II 2. Peripheral Neuropathy 3. HypertensionWhat are the proper codes for the diabetes & neuropathy above?a) 250.00, 357.2 -- DM2, uncompl + Polyneuropathy in diabetes

b) 250.60, 356.9 – DM2 w/neuro manif + Unspec peripheral neuropathy

c) 250.00, 356.9 -- DM2, uncompl + Unspec peripheral neuropathy

d) 250.60, 357.2 -- DM2 w/neuro manif + Polyneuropathy in diabetes

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Answer 3

3. Answer: c) 250.00, 356.9

Rationale: In this example, cause & effect is not demonstrated between the diabetes and the peripheral neuropathy. If the provider had documented the cause & effect relationship such as: “DM with peripheral neuropathy”, “Peripheral neuropathy due to diabetes”, “Diabetic peripheral (or poly) neuropathy”, etc., then the codes would be justified for 250.60 and 357.2.

This example illustrates the importance of documenting all cause & effect relationships, especially in diabetes.

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DM w/Renal Manifestations 250.4x (E11.2-)

Most common Renal Manifestations: CKD with Nephropathy in DM (583.81) (N05.9)

◦ DM and Microalbuminuria (>30mg in 24 hr or urine albumin/Cr> 30 x 2 in >3 mo), or

◦ Proteinuria (evidence of protein on UA >/=1+)◦ Nephrotic syndrome (581.81) sometimes present

and/or

CKD (585.x ) (N18.x) without Nephropathy(stage based on eGFR alone if <60ml/min/1.83m2)

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CKD Documentation & Coding CKD 1 - 2◦ eGFR> 60, requires documented evidence

of renal disease◦ document microalbuminuria, polycystic

kidney, hydronephrosis, etc. CKD 3 - 5

◦ eGFR <60 is presumed CKD (at least stage 3)

If >70 y/o, use Cockcroft-Gault equation (age, ideal wt, Cr) vs lab report (MDRD: age, gender, race Cr, BUN, Albumin)Example: 79 y/o BM, Cr 1.4, BUN 20, Alb 4.0

MDRD = 63but CG = 53

Don’t forget about Renal Hyperparathyroidism (588.81) – common in CKD 3 or worse – order PTH

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DX eGFR ICD-9

CKD I 90+ 585.1CKD 2 60-89 585.2CKD 3 30-59 585.3

CKD 4 15-29 585.4CKD 5 0-15 585.5

ESRD Dialysis 585.6

CKD unspecified

NOS 585.9

Question 4

Mr. Dubble came in for follow up visit with his PCP. A SOAP note was documented and signed by the treating MD.Assessment: 1. Diabetes, 2. Hypertension, 3. Kidney Disease

What is (are) the right code(s) for kidney disease noted above?a)585.9 Chronic kidney disease, unspecifiedb)593.9 Unspecified disorder of kidney and ureterc)584.9 Acute Kidney Failure, unspecifiedd)585.1 CKD Stage 1

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Answer 44. Answer: b) 593.9 Unspecified disorder of kidney and ureter

Rationale: Provider did not use specific documentation for the kidney disease. Had the provider noted it as “chronic”, then 585.9 would be correct for unspecified. Without the description of the kidney disease, default code is 593.9, “unspecified disorder of kidney and ureter”. This is the same default code when “chronic” is not used to describe a renal insufficiency as well.

This example covers the needed specificity in kidney disease coding.

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DM w/Neuro Manifestations 250.6x (E11.4)

Document and code:

• Polyneuropathy in diabetes (357.2) (E11.42)

• Peripheral autonomic neuropathy (337.1) (E11.43)

• Mononeuropathy (354.0 - 355.9) (E11.41)

• Diagnosis does not require NCT, etc. Can document • Positive findings on physical exam• Numbness• Tingling• Burning sensations • Gastroparesis• What about ED?

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Diabetes Mellitus with Peripheral Circulatory Disease 250.7x (E11.51)

Document and code manifestations, such as arterial insufficiency: Peripheral angiopathy due to other disease

(443.81) (Preferred over unspecified PVD - 443.9)

(I70.209)

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Documenting Vascular Disease Easy to diagnose, but over-looked, since not symptomatic in

early/middle stages. Look for:◦ Claudication if present

◦ Diminished pedal pulses common (avoid documenting pulse “present” or “palpable” – use gradations like“+2”

◦ Other stigmata Ankle-Brachial Index (ABI) is preferred diagnostic study if

claudication or other manifestations absent Document ulceration/gangrene if present. Also Large vessel disease – AAA, atherosclerotic aorta, etc

◦ May be discovered on CXR, for example◦ Is usually being treated (risk factor modification)◦ So, add to assessment/problem list

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Vascular Disease

HCC 108 – Atherosclerosis of Extremities ◦ 440.20 (I70.20x) Atherosclerosis of Extremities, unspecified◦ 443.9 (I73.9) PVD, unspecified◦ 443.81 Angiopathy in diabetes

HCC 107 – Vascular w/complications ◦ 454 (I83.0) Document varicose veins of LE w/ulcer◦ Renovascular disorders, ruptured aneurysms, arterial emboli

HCC 106 - Atherosclerosis of Extremity with Ulcer/Gangrene

◦ 785.4 (I96) Gangrene◦ 440.24 (I70.269) Atherosclerosis of ext artery w/gangrene ◦ 440.23 (I70.2x) Atherosclerosis of ext artery w/ulcer

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DM with Ophthalmic Manifestations 250.5x (E11.3xx)

Document and code, such as:• Proliferative Diabetic Retinopathy  (362.02) * (E11.35)

• Vitreous hemorrhage (379.23)* (H43.10)

• Microaneurysm/background retinopathy (362.01) (E11.329)

• Macular edema (362.07), (must include a diabetic retinopathy code also) (E11.311 only code needed)

If linked by specialist…• Diabetic Cataract (366.41) (rare: not senile cataract) (e11.36)

• Glaucoma with systemic syndromes (365.44) (E34.9)

*generates separate HCC (122)

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Diabetic Coding Examples A person with documented controlled diabetes

with the following diabetic complications: ◦ Polyneuropathy◦ Nephropathy (microalbuminuria x 2 over 3 mo)◦ Stage III chronic kidney disease (eGFR = 30-60 x 3 mo)

Would use the following diagnosis codes:◦ 250.40 (DM2 w/renal manifestations) (E11.22)

◦ 250.60 (DM2 w/neuro manifestation) (E11.4x)

◦ 357.2 (Neuropathy in DM) (no code in ICD10)

◦ 583.81 (nephropathy in oth dis) (E11.21)

◦ 585.3 (CKD 3) (N18.3)

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Diabetic Coding ExampleUnder-documenting DM communicates a less serious DM case, which affects value of careAny manifestations must be documented as a cause and effect relationship, for example:

①Assessment: 1. DM 2. Polyneuropathy

Can only code: 250.00 and 356.9 (ICD-9)

E11.9 and G62.9 (ICD-10)

[Lower Value DM]

②Assessment: 1. Diabetic Polyneuropathy

Can code: 250.60 and 357.2

E11.42 (ICD-10)

[Higher Value DM]

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Chronic Heart Failure Many new patients have quiescent disease Develop high index of suspicion for CHF

◦ Clue: May be on diuretic, ACEI, Beta-blocker, etc◦ Abnormal EKG should prompt echocardiogram

EF and PA Pressure Diastolic dysfunction is common

◦ (Normal EKG =high predictive value for normal Echo) Remember: Stage B CHF = anatomic

changes without symptoms; e.g.,◦ Non-valvular AF ◦ LVH, wall motion abnormalities◦ Diastolic dysfunction◦ Elevated PA Pressure

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Ischemic Cardiomyopathy Clinicians use this term to refer to CHF from

various forms of coronary artery disease◦ 414.xx (I25.89) “Other forms of Ischemic Heart

Disease.”◦ 414.8 (I25.5): Ischemic Cardiomyopathy◦ Also includes Chronic Coronary Insufficiency, and

Chronic Ischemia, myocardial This Presents a Problem: None of the ICD9

414.xx (I25.x) codes map to the HCC 85 CHF.

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Documenting Ischemic Cardiomyopathy Does the patient have history/evidence of

coronary artery disease (CAD) or old MI? Does the participant have evidence

of CHF documented? In your medical opinion, is CHF a

result from the CAD? If “yes” to all three, then document and code

BOTH◦414.8 (I25.5) Ischemic Cardiomyopathy

(Genotype)◦428.xx (I50.xx) Heart Failure (Phenotype)

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Stable AnginaCAD (414.0x) (I25.10) and ASCVD (429.2) (I25.x)

do not risk-adjust Angina Pectoris does risk adjust (HCC 88)Document Stable Angina:◦Known diagnosis of CAD?◦Current use of Nitrates or beta-blockers?◦Past history of chest pain, now controlled?◦Treatment is prima facie evidence of disease

If definitively treated with CABG/stent and no further medical Tx, then Dx is “History of” Angina.

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AMI

Unstable

Angina

Stable Angina

CAD/ASCVD

Hierarchy of HCCs:

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COPD Be specific if possible, otherwise

use “COPD” 496 (J44.9)

Code pneumoconiosis separately Be careful how document/code

Asthma◦ 493.9x (J45.90x) – Unspecified Asthma

(is non-specific)◦ 493.2x (J44.9) – Chronic Obstructive

Asthma (abnormal PFTs between exacerabations)

Look for rescue inhalers, etc as clue to dx

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Respiratory Failure

TWO types – Hypercapnic or Hypoxemic If requiring continuous O2 (hypoxemic)

then also document Chronic Resp Failure (518.83)◦ Oxygen dependence (>15 hrs/day)◦ Document Hypoxemia at rest (not only with

exercise or sleep)◦ Usually CHF or COPD as etiology

ICD10 Respiratory failure (NEC) (J96.xx) ◦ Acute and Chronic Resp Failure map to the same HCC◦ Can designate Hypoxia (J96.11) vs Hypercapnia (J96.12)

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Nutritional  Diagnoses

Malnutrition generally under-diagnosed ◦ No clear diagnostic criteria for community-

dwelling elders◦ Acute hospitalization often causes malnutrition◦ Common with end-stage conditions like COPD,

CA, Dementia◦ Are you treating it with supplements, etc?

Mini-Nutritional Assessment (MNA®) to screen or diagnose for malnutrition

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Malnutrition Diagnoses

• 263.1 (E44.1) Malnutrition of mild degree ◦BMI 16-17.9 or loss of 21% to 30% of ideal weight and mildly low albumin, 3.5g/dL, <75% of EER intake for >mo

• 263.0  (E44.0) Malnutrition of moderate degree◦BMI <16 or loss of 30% or more of ideal body weight, and moderately low albumin, 2.5g/dl◦Weight loss of 5%/mo, 7.5%/3mo or 10%/6 mo

• 262 (E43) Malnutrition of severe degree ◦Weight loss of >5%/mo, >7.5%/3 mo

• 799.4 (R64)  Cachexia

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Morbid Obesity• Morbid Obesity (BMI >40) (WHO definition)

◦ 278.01 (E66.01) Morbid Obesity

◦ 278.03 (E66.2) Obesity hypoventilation synd

◦ V85.4x (Z68.4x) BMI >40 and over

• “Overweight,” and “Obesity due to excess calories” do not risk adjust.

• Some authorities suggest BMI >35 with obesity-related complications of chronic illness or functional decline (indications for bariatric surgery) meets criteria for Morbid Obesity Dx –

• We suggest sticking with WHO definition

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Neoplasm Coding Neoplasm is coded as malignant if documented

as 1. Active (visible, measurable, growing, present)2. Receiving treatment (even if not measurable active)3. In Palliative care

History of cancer (V codes) (Z85.xx) should be used for all cancers that are not active at the time of coding.

If neoplasm has become metastatic disease carefully document and code as such (much higher RAF.)

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Cerebral Infarction, Stroke or Cerebrovascular Accident (CVA) Above terms are interchangeable = 434.91

(I63.9) = Cerebral artery occlusion, unspecified, with infarction.◦ These are ACUTE codes – not for sequelae◦ Once out of the hospital, code for late effects

Acute vs. Late Effects of CVD◦Use 438 (I69.3-) codes for neurologic deficits that persist after onset of acute condition from categories 430-437

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Late Effect

If appropriate, document presence of “plegia” or “paresis” modified with “mono” or “hemi”

◦ If associated with a CVA, document association.◦ If associated with Cerebral Hemorrhage,

subarachnoid hemorrhage◦ If present but not due to known cerebral event,

document as such◦ All of these conditions Risk Adjust (HCC 103 or HCC

104) “Weakness” and “Gait abnormality” are

symptoms, not diagnoses and code to different ICD9 codes that do not risk adjust.

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Major Depression If write “depression”, then coder must us 311 (Depressive

Disorder NEC) ◦ Non-specific◦ There are NO diagnostic criteria for 311◦ Coding convention used when there is poor documentation

Major Depression is common in home-bound population

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(Use Single Episode unless you have clear evidence of recurrent episodes.)

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Finally, Know the “Rules of the Road”

◦ Become familiar with the coding conventions and follow all instructions related to specific codes.

◦ Be aware of “includes” and “excludes” instructions and inclusion terms, as well as “use additional code” and other code-related instruction in the Official ICD-9-CM Guidelines for Coding and Reporting.

◦ If use ICD code book, locate the code first in the alphabetic index, then verify the code in the tabular index. (Reliance on only the alphabetic index or tabular index can lead to coding errors.)

◦ American Hospital Association Coding Clinic is approved resource for clarification of ICD-9-CM.

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Summary Accurate risk adjusted payment relies on

diagnosis documentation completeness and specificity

Accurate medical record documentation is essential as it leads to accurate ICD-9 coding

Document and submit all relevant codes annually at least

Prepare for ICD-10 and increased specificity Consider coding assistance

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Helpful Websites

CSSC operations- Customer Service & Support Center -- RAPS information and Prescription Drug Information Center◦ www.csscoperations.com

Official Guidelines for Coding and Reporting

http://www.cdc.gov/nchs/data/icd9/icd9cm_guidelines_2012.pdf

Medicare Advantage Website:◦

www.cms.gov/Medicare/Health-Plans/MedicareAdvtgSpecRateStats

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Questions

Capstone Performance Systems

Richard O. Schamp MD, Chief Executive OfficerGeorge W. Brett MD, Chief Medical Officer

6255 San Bonita Ave.

Saint Louis, MO 63105

314-477-3685

rschamp@cpstn.comgbrett@cpstn.com

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