Risk Adjustment, HCC, & Stars Ratings 101 2013.14...

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Risk Adjustment, HCC Model, & Stars Ra=ngs 101 An Overview for Coders

& Providers

Risk Adjustment (RA) •  Risk Adjustment is a method of analysis using diagnoses for financial forecas=ng that has been growing in popularity in healthcare

•  Medicaid plans began using Risk Adjustment modeling in 1996 and has con=nued to update that model

•  Medicare Advantage Plans have been using the HCC/ Risk Adjustment model since 2004 and is expanding the program

•  Commercial Plans are now looking at Risk Adjustment as a valuable method to iden=fy and plan for high risk pa=ents

3/17/13 © ionHealthcare, LLC All rights reserved. For educa=on & discussion purposes. PermiVed use via contractual agreement/purchase. 2

RA & Affordable Care Act •  “The Affordable Care Act calls for a risk adjustment program that aims to eliminate incen=ves for health insurance plans to avoid people with pre-‐exis=ng condi=ons or those who are in poor health. Risk adjustment ensures that health insurance plans have addi=onal money to provide services to the people who need them most by providing more funds to plans that provide care to people that are likely to have high health costs. Insurance plans then compete on the basis of quality and service, and not on the basis of whether they can aVract healthy people” (Larsen, 2011)


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Different Programs, Same Goal •  Whether Risk Adjustment is being u=lized for Medicaid, Medicare, or Commercial pa=ents, the main ingredients used are Diagnosis Codes (ICD codes)

•  Diagnoses are collected and their specificity drives risk score or categoriza=on

•  The worse, or more serious a condi=on, or diagnosis, the higher the risk scoring

•  Risk Scores either affect incoming payment or the future financial forecas=ng for each pa=ent


Why It MaVers •  For Medicare Advantage Plans

① Risk Adjustment (RA) iden=fies pa=ents who may need disease management interven=ons and

② RA establishes the financial allotment allowed from CMS toward the annual care of each pa=ent; with more dollars allocated for those with higher risk scores

•  For Medicaid and Commercial Plans ① Risk Adjustment (RA) iden=fies pa=ents who may need

disease management interven=ons and ② RA establishes the “overall state of the popula=on” by

aggrega=ng diagnoses; which assists in financial forecas=ng for future medical need


General RA Guidelines •  These programs operate on similar rules and guidelines to include: – Specific diagnoses must be documented in a face-‐to-‐face visit by the trea=ng licensed provider (showing creden=als: MD, DO, PA, NP, OT, CRNA, MSW, and similar

master’s level providers) and the documenta=on must be signed by the trea=ng provider to be accepted

– Diagnoses must be clearly stated on the DOS (Date Of Service) as a current problem if audited

– Diagnoses must be documented each year, ongoing as each year is evaluated without historical context influence


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Significance to Providers •  Providers have long aVempted to establish the seriousness and severity of the pa=ents they treat through the use of E&M CPT codes

•  Higher level E&M codes iden=fy serious encounters, u=lizing more medical decision making, and are reimbursed at a higher rate

•  In Risk Adjustment scenarios, these CPT codes have no significance

•  Instead, specific diagnosis codes communicate the seriousness of medical decision making


Significance to Providers •  Using specific ICD Diagnosis Codes will help convey the true seriousness of the condi=ons being addressed in each visit

•  Documen=ng these carefully involves two main focal points: ① Iden=fying the Diagnosis as a current or ongoing

problem as opposed to a PMH (Past Medical History) or previous condi=on

② Choosing the most specific Diagnosis Code while also being sure documenta=on supports it


Origins of Medicare Advantage & the HCC Model

•  Sub=tle A of the Balanced Budget Act of 1997 created Medicare Choice for pa=ents. This allowed pa=ents to choose the original Medicare FFS program or a Medicare + Choice program.

•  The Medicare Moderniza=on Act of 2003 changed Medicare + Choice to Medicare Advantage

•  The new Medicare risk adjustment model was gradually phased into Medicare advantage payment calcula=ons star=ng in 2004 (with full implementa=on in 1/2007)

•  Developed by researchers at RTI Interna=onal, Boston University and Harvard medical school, Hierarchical Condi=on Categories, uses ambulatory and inpa=ent diagnosis to create a valid risk adjustment methodology to help predict individual expenditure varia=on among Medicare pa=ents


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The HCC Model is Ever-‐Changing

•  The original DCG/HCC model in 2000 iden=fied 804 costly diagnosis groups, mapped to 189 HCC codes

•  Created a repor=ng model for reimbursement based on ICD codes within families of condi=ons. (Hierarchal Categories)

•  There are 2,944 ICD codes carrying Part C HCC value. –  The program began with over 3,000 in 2004

•  There are 1,475 ICD codes carrying Part D HCC value. –  The program began with over 3,000 in 2004

•  978 ICD codes carry both Part C and Part D HCC value. –  The program began with ~ 1500 in 2004

•  Major Changes are due for 2014 (new HCC’s, split values, etc.) 3/17/13 © ionHealthcare, LLC All rights reserved. For educa=on & discussion purposes. PermiVed use via contractual agreement/purchase. 10

How ICD Codes Carry Value

•  Most of the ICD diagnosis codes which are in the model are chronic condi=ons

•  Risk Adjustment is based on adjus=ng the es=mated risk of each pa=ent based on known diagnoses

•  Part C HCC (HCC-‐C) are those diagnoses which are costly to manage from a medical perspec=ve

•  Part D HCC (HCC-‐D) are those diagnoses which are costly to manage from a prescrip=on drug perspec=ve

•  Some diagnoses carry both part D and Part D value •  These ICD codes have a “RAF” (risk adjustment factor), similar

in concept to the “RVU” value of procedure codes


HCC Hierarchal Categories Used

2014 Hierarchal Categories in the HCC Model

INFECTION

BLOOD CEREBROVASCULAR DISEASE

COMPLICATIONS

NEOPLASM

SUBSTANCE ABUSE

VASCULAR TRANSPLANT

DIABETES PSYCHIATRIC

LUNG OPENINGS

METABOLIC

SPINAL EYE AMPUTATION

LIVER NEUROLOGICAL

KIDNEY DISEASE INTERACTIONS

GASTROINTESTINAL

ARREST SKIN DISABLED/DISEASE INTERACTIONS

MUSCULOSKELETAL

HEART INJURY


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If this HCC is found… **2013 Disease Group Label** …Then Drop these HCC’s:

5 OpportunisMc InfecMons 112

7 MetastaMc Cancer and Acute Leukemia 8, 9, 10

8 Lung, Upper DigesMve Tract, and Other Severe Cancers 9, 10

9 LymphaMc, Head and Neck, Brain and Other Major Cancers 10

15 Diabetes with Renal ManifestaMons or Peripheral Circulatory ManifestaMon 16, 17, 18, 19

16 Diabetes with Neurologic or Other Specified ManifestaMon 17, 18, 19

17 Diabetes with Acute ComplicaMon 18, 19

18 Diabetes with Ophthalmologic or Unspecified ManifestaMons 19

25 End Stage Liver Disease 26, 27

26 Cirrhosis of Liver 27

51 Drug/Alcohol Psychosis 52

54 Schizophrenia 55

67 Quadriplegia/Other Extensive Paralysis 68, 69, 100, 101, 157

68 Paraplegia 69, 100, 101, 157

69 Spinal Cord Disorders/Injuries 157

77 Respirator Dependence/Tracheotomy Status 78, 79

78 Respiratory Arrest 79

81 Acute Myocardial InfarcMon 82, 83

82 Unstable Angina and Other Acute Ischemic Heart Disease 83

95 Cerebral Hemorrhage 96

100 Hemiplegia/Hemiparesis 101

104 Vascular Disease with ComplicaMons 105, 149

107 CysMc Fibrosis 108

111 AspiraMon and Specified Bacterial Pneumonias 112

130 Dialysis Status 131, 132

131 Renal Failure 132

148 Decubitus Ulcer of Skin 149

154 Severe Head Injury 75, 155

161 TraumaMc AmputaMon 177

If this HCC is found… **2014 Disease Group Label** …Then Drop these HCC’s:

8 Metasta=c Cancer and Acute Leukemia 9,10,11,12

9 Lung and Other Sever Cancers 10,11,12

10 Lymphoma and Other Cancers 11,12

11 Colorectal, Bladder, and Other Cancers 12

17 Diabetes with Acute Complica=ons 18,19

18 Diabetes with Chronic Complica=ons 19

27 End-‐Stage Liver Disease 28,29,80

28 Cirrhosis of Liver 29

46 Severe Hematological Disorders 48

54 Drug/Alcohol Psychosis 55

57 Schizophrenia 58

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 Infarc=on 87,88

87 Unstable Angina and Other Acute Ischemic Heart Disease 88

99 Cerebral Hemorrhage 100

103 Hemiplegia/Hemiparesis 104

106 Atherosclerosis of the Extremi=es with Ulcera=on or Gangrene 107,108,161,189

107 Vascular Disease with Complica=ons 108

110 Cys=c Fibrosis 111,112

111 Chronic Obstruc=ve Pulmonary Disease 112

114 Aspira=on and Specified Bacterial Pneumonias 115

134 Dialysis Status 135,136,137

135 Acute Renal Failure 136,137

136 Chronic Kidney Disease (Stage 5) 137

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

158 Pressure Ulcer of Skin with Full Thickness Skin Loss 161

166 Severe Head Injury 80,167

Acceptable Provider Special=es


CODE SPECIALTY CODE SPECIALTY CODE SPECIALTY

01 General Prac=ce 25 Physical Medicine & Rehabilita=on 67 Occupa=onal Therapist

02 General Surgery 26 Psychiatry 68 Clinical Psychologist

03 Allergy/Immunology 27 Geriatric Psychiatry 72 Pain Management

04 Otolaryngology 28 Colorectal Surgery 76 Peripheral Vascular Disease

05 Anesthesiology 29 Pulmonary Disease 77 Vascular Disease

06 Cardiology 33 Thoracic Surgery 78 Cardiac Surgery

07 Dermatology 34 Urology 79 Addic=on Medicine

08 Family Prac=ce 35 Chiroprac=c 80 LCSW

09 Interven=onal Pain Management (IPM) 36 Nuclear Medicine 81 Cri=cal Care (Intensivists)

10 Gastroenterology 37 Pediatric Medicine 82 Hematology

11 Internal Medicine 38 Geriatric Medicine 83 Hematology/Oncology

12 Osteopathic Manipula=ve Therapy 39 Nephrology 84 Preventa=ve Medicine

13 Neurology 40 Hand Surgery 85 Maxillofacial Surgery

14 Neurosurgery 41 Optometry (optometrists) 86 Neuropsychiatry

15 Speech Language Pathologist 42 Cer=fied Nurse Midwife 89 Cer=fied Clinical Nurse Specialist

16 Obstetrics/Gynecology 43 CRNA 90 Medical Oncology

17 Hospice and Pallia=ve Care 44 Infec=ous Disease 91 Surgical Oncology

18 Ophthalmology 46 Endocrinology 92 Radia=on Oncology

19 Oral Surgery (Den=sts only) 48 Podiatry 93 Emergency Medicine

20 Orthopedic Surgery 50 Nurse Prac==oner 94 Interven=onal Radiology

21 Cardiac Electrophysiology 62 Psychologist 97 Physician Assistant

22 Pathology 64 Audiologist 98 Gynecologist/Oncologist

23 Sports Medicine 65 Physical Therapist 99 Unknown Physician Specialty

24 Plas=c & Reconstruc=ve Surgery 66 Rheumatology C0 Sleep Medicine

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What May Be Coded & SubmiVed

•  Diagnosis codes from Inpa=ent Hospital, Outpa=ent Hospital, and Outpa=ent Physician/ Provider visits

•  Encounters must be face-‐to-‐face by an acceptable provider specialty. (Note includes: OT, PT, RN-‐CNS, LCSW, PA, NP, OD)

•  The documenta=on must have the signature and creden=al of the trea=ng provider.

•  All diagnoses documented in each DOS (date of service) which is related to the MDM (medical decision making) of the encounter as a current or ac=ve problem

•  Chronic condi=ons (paraplegia, old MI, loss of limb, etc.) that never resolve should be re-‐documented and coded yearly


What Is Excluded? (Counted Elsewhere)

•  Skilled Nursing Facili=es & Intermediate Care Facili=es (ICF’s) •  Hospice •  Home Health/Home Care •  Lab Visits (except Pathology Codes, which are allowed) •  Radiology Visits (except for therapeu=c radiology codes) •  Ambulance •  DME, Prosthe=cs, Ortho=cs, Supplies •  Ambulatory Surgical Centers •  Free-‐Standing Renal Dialysis Facili=es •  Documenta=on by an approved physician specialty that did not result

from a face-‐to-‐face encounter. Note: Pa=ents with ESRD, Hospice, and/or are Dual Eligible (Medicare and Medicaid) are calculated using extra measures already.


Lab & Radiology Related Diagnoses

•  Providers should update each face to face visit documenta=on to reflect any suspect or rule out diagnosis that is confirmed by lab or radiology which is newly known from the last visit

•  Diagnosis Codes associated with the following CPT Radiology Codes are not permiVed if not therapeu=c or a treatment –  70010-‐76999 are Excluded –  78000-‐78999 are Excluded

•  Diagnosis Codes associated with the following CPT Pathology Codes are Allowed –  80500-‐80502 –  88000-‐88199 –  88300-‐88399


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Calcula=ng Risk & RAF


Each year’s risk score is based on: Demographic score plus risk from the prior year’s diagnosis codes These scores are added to calculate the pa=ent’s RAF. Example: Pa=ents get a report from CMS showing their HCC codes:

John Doe, age 65, male HCC 15 (0.6) HCC 7 (1.648) HCC 83 (0.23) Demographic score (0.330) Total individual score = (2.808)

RAF is for the whole plan. This affects monthly payment. Based on projected cost to cover member’s Part A & Part B services. • Goal of HCC use is to increase the RAF score

• RAF Example: =$650 PMPM x RAF $650 x 0.5 RAF = $325 $650 x 2.5 RAF = $1,625

The Importance of Trained Cer=fied Coders


No CondiMons Coded Some Coded-‐ Not Specific From Claims Submission

All CondiMons Coded Chart Review by CerMfied Coder

76 year old Female .468 76 year old Female

.468 76 year old Female

.468

Medicaid Eligible .177 Medicaid Eligible

.177 Medicaid Eligible

.177

DM not coded DM w/o complica=on .181 DM w Vascular Complica=on .608

Vascular Disease not coded

Vascular w/o complica=on

.324 Vascular w complica=on .645

CHF Not coded CHF not coded CHF coded .395

No interac=on No interac=on Disease interac=on (DM + CHF)

.204

TOTAL RAF .645 TOTAL RAF 1.15 TOTAL RAF 2.497

PMPM Payment $585 PMPM Payment $1,042 PMPM Payment $2,263

Yearly Payment $7,015 Yearly Payment $12,508 Yearly Payment $27,159

How Suspect Logic Is Used


DME

Rx

CPT

Lab

HCC 15

Diabetes w Renal Manifest or Peripheral Circ d/o

[250.40-‐250.43 & 250.70-‐250.73] HCC 16

Diabetes w Neuro Manifest or Other Specified

[250.60-‐250.63 & 250.80-‐250.83] HCC 17

Diabetes w coma or ketoacidosis [250.10-‐250.33]

HCC 18 Diabetes w Opthal Manifest or

Unspecified [250.50-‐250.53 & 250.90-‐250.93]

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CMS Submission Timetable


RADV Risk Adjustment Data Valida=on

Part 2

RADV: Risk Adjustment Data Valida=on

Ø  RADV is a process used by CMS to verify that diagnosis codes submiVed by the plan are supported by documenta=on in the beneficiary’s (pa=ent) medical record

Ø  RADV audits are designed to validate the accuracy of the payment data submiVed by the plan and ul=mately the accuracy of payments to the plan

Ø  RADV audits involve the review of hospital inpa=ent, hospital outpa=ent, and physician medical records

Ø  Annually CMS conducts RADV audits on targeted plans and randomly-‐selected plans

Ø  The sample is stra=fied, randomly choosing members with low, medium and high risk scores within each plan

Ø  The plans must provide wriVen documenta=on of each HCC paid


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Ø  Best Record means finding any acceptable documenta=on of any diagnosis code that supports the HCC submiVed that needs valida=ng in the RADV audit

Ø  DOS (Date of Service) does not maVer as long as within audit year (and each HCC may be proven on separate DOS)

Ø  Proving your HCC alone is great, but proving your HCC plus addi=onal Part C HCC’s in the same DOS is beVer

Ø  A solid find of HCC without missing creden=al or signature is ideal, but CMS has allowed their specific aVesta=ons for missing creden=als or signatures

Ø  If the HCC needed cannot be found CMS will accept any other HCC’s of higher or lower value in lieu of that HCC (the higher the beVer)




• Valid HCC + Extra HCC’s with no Issues • Valid HCC alone with no Issues First Choice

• HCC with Cred/Sig Issues + Extra HCC’s • HCC alone with Cred/Sig Issues

Second Choice

• Any Other Higher Valued HCC • Any Other Lower Valued HCC

Third Choice

Typical RADV Timeline


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Stars Ra=ngs

Part 3

The CMS rates Medicare Advantage plans on a scale of one to five stars, with five stars represen=ng the highest quality. The CMS defines the star ra=ngs in the following manner:

5 Stars Excellent performance 4 Stars Above average performance 3 Stars Average performance 2 Stars Below average performance 1 Star Poor performance

These are based on individual quality metrics.

For 2012, there were 35 measures for MA plans and 17 measures for PDP plans which are weighted with the above overall measure scoring system.

CMS Star Ratings

•  CMS has assigned the highest weight to outcomes and intermediate outcomes measures, followed by pa=ent experience/complaints and access measures. Process measures are weighted the least

•  Plans are measured on mul=ple domains, each of which is compose of a series of individual measures. Part C plans have 5 domains, and Part D plans have 4 domains

CMS Star Ratings

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Part C: 5 Domains Part D: 4 Domains

CMS Star Ratings

Domain 1 Staying Healthy – Screenings, Test, & Vaccines

Domain 2 Managing Chronic Condi=ons

Domain 3 Ra=ngs of Plan Responsiveness & Care

Domain 4 Member Complaints, Problems Gexng Services, & Choosing to Leave the Plan

Domain 5 Health Plan Customer Service

Domain 1 Drug Plan Customer Service

Domain 2 Member Complaints, Problems Gexng Services, & Choosing to Leave the Plan

Domain 3 Member Experience with Drug Plan

Domain 4 Drug Pricing & Pa=ent Safety

•  Star=ng in 2014, plans which do not obtain at least 4 stars will lose a percentage of their PMPM revenue

•  Likewise, plans can achieve higher payments for higher quality ra=ngs

•  CMS is highligh=ng plans that have achieved an overall quality ra=ng of 5 stars with a high performer or “gold star” icon so people with Medicare can easily find high quality plans. People with Medicare can switch to an available 5-‐star plan at any =me during the year

CMS Star Ratings

CDPS Chronic Illness & Disability

Payment Systems Part 4

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How Does HCC Compare to CDPS?

There are various systems using Risk Adjustment beyond HCC for Medicare HMO plans. Some of these include: Diagnosis based programs: •  Chronic Illness and Disability Payment Systems (CDPS) -‐ Medicaid •  Hierarchical Co-‐Exis=ng Condi=ons (HCC-‐C) -‐ Medicare •  Diagnosis Related Groups (DRG) – Inpa=ent •  Adjusted Clinical Groups (ACG) – Outpa=ent PrescripMon based programs: •  MedicaidRx (UCSD) •  RxGroups (DxCG) •  Hierarchial Co-‐Exisi=ng Condi=ons (HCC-‐D) Some add: PaMent FuncMonal AbiliMes (ADL’s)


History of CDPS Model •  Started in 1996 to tailor current risk adjustment models to beVer

apply to Medicaid programs. Development started using claims from disabled beneficiaries informa=on from the Disability Payment System (DPS) from Colorado, Michigan, Missouri, New York, and Ohio by Rick Kronick and associates

•  Update in 2000 to include disabled and TANF (Temporary Assistance for Needy Families) beneficiaries from California, Georgia, and Tennessee. This upgraded program was then renamed the Chronic Illness and Disability Payment System (CDPS)

•  In 2001, Todd Gilmer and associates developed the Medicaid Rx (MRX) using CDPS informa=on. Based on combining from the Chronic Disease Score (CDS) developed by Von Korff and associates and the RxRisk model by Fishman and associates


History of CDPS Model •  In 2008, CDPS and MRX models were updated using Medicaid

data from 44 states in 2001 and 2002. Another model was developed employing both diagnos=c and pharmacy data called CDPS + Rx

•  Data was supplied by CMS from Medicaid Analy=c eXtract (MAX) data system. MAX data consists of pa=ent-‐level data files with informa=on on Medicaid eligibility, u=liza=on of services, and payments for services


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How Does CDPS & MRX Work? •  Mapping of diagnoses and/or pharmaceu=cal use to a group

(vector) of disease categories •  CDPS maps 16,461 ICD codes to 58 CDPS categories which

lead up to 20 major categories related to major body systems (such as cardiovascular) or type of disease (such as diabetes)

•  MRX maps to 56, 236 NDC codes from pa=ent u=liza=on to 45 Medicaid Rx categories

This leads to “Stage 1 Groups” (build CDPS) •  Groups ICD codes, typically at 3-‐digit level (for ICD-‐9) •  Some=mes grouped at 4th or 5th digit when that extra digit

describes a more serious condi=on or version of a diagnosis


Stage 1 Groups Then Combined into Major Categories:


1)  Psychiatric 2)  Skeletal 3)  Central Nervous System 4)  Pulmonary 5)  Gastrointes=nal 6)  Diabetes 7)  Skin 8)  Renal 9)  Substance Abuse 10)  Cancer

11) Developmental Disability 12) Genital 13) Metabolic 14)  Pregnancy 15)  Eye 16)  Cerebrovascular 17)  AIDS/ Infec=ous Disease 18) Hematological

Hierarchies in CDPS


CDPS Categories are Hierarchical within Major Categories: For example: Cardiovascular Category: ( 4 levels)

-‐ CARVH includes 3 Stage 1 groups and 7 diagnoses -‐ CARM includes 13 Stage 1 groups and 53 diagnoses -‐ CARL includes 26 Stage 1 groups and 314 diagnoses -‐ CAREL includes 2 Stage 1 groups and 35 diagnoses

VH (weight 2.037) = Very High: Heart transplants, valves, etc. M (weight 0.805) = Medium: Heart aCacks, etc. L (weight 0.368) = Low: Heart disease, etc. EL (weight 0.130) = Extra Low: Hypertension, etc. * Credit only for most severe form/diagnosis in category. Each higher level takes all other lower diagnoses into considera=on already.

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What May Be Coded in CDPS


•  No Lab or Radiology (because many diagnoses from these claims are not diagnoses, but rule out or suspect diagnoses)

•  All Inpa=ent and Outpa=ent encounters. •  All diagnosis codes which are current diagnoses. •  Include known status and family history codes when

appropriate. •  Disabled model includes all pa=ent ages and all condi=ons. •  Code all diagnoses because they are o|en addi=ve. Also note that the CDPS + Rx model includes all 58 CDPS categories plus 15 MRX categories which iden=fy pa=ents who are filling prescrip=ons for medica=ons used for chronic condi=ons but have not had those diagnoses show in claims data. Goal to document all condiMons for all paMents.

Risk Adjustment & Clinical Documenta=on

Part 5

General Diagnosis Rules •  Code all current diagnoses that were a part of the medical

decision making of the visit •  Signs and symptoms should never be coded when the reasons

for the symptoms are iden=fied. For example, one would not code “shortness of breath” when a diagnosis of asthma is known, nor “heartburn” when a diagnosis of GERD is known

•  Old diagnoses which have been treated an no longer exist should not be coded unless there is a “history of” code that communicates the old condi=on (most of these do not risk adjust, but may be valuable to disease management and suspect logic)

•  Persistent diagnoses such as amputa=ons, Old MI, ostomy, quadriplegia, etc. should be re-‐documented at least yearly


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Diagnosis Specificity •  Documenta=on of diagnoses must be specific •  This is paramount not only for Risk Adjustment programs, but also for ICD-‐10 implementa=on efforts

•  Comorbidi=es; Cause and effect rela=onships of diagnoses; Loca=on; and Other modifying factors should be clearly documented

•  Examples of commonly under-‐diagnosed condi=ons are diabetes and hypertension


The word “Chronic” •  Diagnosis specificity is of paramount importance and in many diagnoses, use of the word “chronic” can change the chosen diagnosis code (and its subsequent risk value)

•  Examples include (but are not limited to): – Chronic Renal Insufficiency vs. Renal insufficiency – Chronic Hepa==s B vs. Hepa==s B – Chronic Bronchi=s vs. Bronchi=s – Chronic cor pulmonale vs. cor pulmonale


Coding Clinic Department within AHA that makes authorita=ve determina=ons on ICD code use (fresh start on ICD-‐10 determina=ons) •  Cannot code diagnoses described as “consistent

with” (includes: “suspect”, “likely”, “may be”, “rule out”, etc.) as current or ac=ve

•  Cannot code hypo or hyper condi=ons when documented with up and down arrows ↑ or ↓, must be wriVen out

•  Cannot code “hemiparesis” for “weakness on one side of the body”, provider must document “hemiparesis”

•  Should code 414.01 (na=ve artery) for CAD when no CABG Hx


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PMH (Past Medical History) •  The different ways providers document PMH or historical diagnoses is challenging for coders and auditors reviewing medical records

•  Some providers use PMH as a true list of old diagnoses, while others use this as a combined list of historical and current problems

•  This documenta=on disparity is also o|en seen in the chief complaint or HPI (History of Present Illness)


PMH Examples in CC/HPI Current vs. Hx of is not clear: CC/HPI: Mr. Jones is here today for follow up of his

diabetes, CHF, and PVD.!

PMH: MI in 2002!

CHF!

PVD!

A/P: 1. Diabetes!

Current vs. Hx is clear: CC/HPI: Mr. Jones is here today for his diabetes, he has a known CHF, and PVD.!

PMH: MI in 2002!

CHF!

PVD!

A/P: 1. Diabetes!


PMH Examples in Lists Current vs. Hx of is not clear: CC/HPI: ………!

MI in 2002!

CHF!

PVD!

Diabetes!

Allergies!

A/P: 1. Diabetes!

Current vs. Hx is clear: CC/HPI: ……….!

MI in 2002!

CHF!

PVD!

Diabetes!

Allergies A/P: 1. Diabetes!


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PMH in Prac=ce •  Remember to be very clear on what diagnoses or condi=ons are current or ongoing vs. those that are no longer present or historical

•  Diagnoses which are not being treated but are s=ll current, to include ongoing monitoring should be documented as current

•  Every current diagnosis being taken into considera=on for medical decision making should be documented in each visit as current and not documented as “historical”


Documen=ng Diabetes •  Many providers have memorized the ICD-‐9-‐CM code of 250.00 for diabetes, yet this is o|en NOT the correct code for many pa=ents

•  Diabetes codes in both ICD-‐9 and ICD-‐10 have specific codes to iden=fy diabetes-‐related manifesta=ons

•  In both: The 4th digit tells manifesta=on and 5th digit tells if controlled or uncontrolled

•  Only diabe=cs with no manifesta=ons should u=lize the generic diabetes ICD code


Diabetes in ICD-‐9-‐CM ICD-‐9 Code ManifestaMon by 4th digit; Stated as: “Due to, with, etc.”

250.0x DM, no menMon of complicaMon

250.1x DM, with Ketoacidosis

250.2x DM, with hyperosmolarity

250.3x DM, with coma/insulin coma

250.4x DM, with renal manifestaMons

250.5x DM, with ophthalmic manifestaMons

250.6x DM, with neurological manifestaMons

250.7x DM, with peripheral circulatory disorders

250.8x DM, with other specified manifestaMons

250.9x DM, with unspecified complicaMons


Cause & Effect relaMonships must be documented by the provider when DM is the reason for any manifestaMon. (Only excepMon is gangrene in DM may be assumed related.

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Diabetes in ICD-‐10-‐CM Type 1 Type 2 Other Specified (*No Unspecified code)

E10.1x-‐[Check 5th] with ketoacidosis

E11.0x-‐[Check 5th] with hyperosmolarity

E13.0x-‐-‐[Check 5th] w/ hyperosmolarity

E13.1x-‐-‐[Check 5th] w/ ketoacidosis

E10.2x-‐[Check 5th] w/kidney complicaMons

E11.2x-‐[Check 5th] w/kidney complicaMons

E13.2-‐[Check 5th] w/kidney complicaMons

E10.3x-‐[Check 5-‐6th] w/ ophthalmic comp.

E11.3x-‐[Check 5-‐6th] w/ ophthalmic comp.

E13.3-‐[Check 5-‐6th] w/ ophthalmic comp.

E10.4x-‐[Check 5th] w/ neuro. complicaMons

E11.4x-‐[Check 5th] w/ neuro. complicaMons

E13.4-‐[Check 5th] w/ neuro. complicaMons

E10.5x-‐[Check 5th] w/ circulatory comp.

E11.5x-‐[Check 5th] w/ circulatory comp.

E13.5-‐[Check 5th] w/ circulatory comp.

E10.6x-‐[Check 5-‐6th] w/ other spec. comp.

E11.6x-‐[Check 5-‐6th] w/ other spec. comp.

E13.6-‐[Check 5-‐6th] w/ other specified complicaMons

E10.8 w/ unspecified complicaMons



E10.9 without complicaMons




Documen=ng & Coding Diabetes •  Under-‐documen=ng DM communicates a less serious DM case, which affects value of care

•  Any manifesta=ons must be documented as a cause and effect rela=onship, for example: ①   Assessment: 1. DM 2. Polyneuropathy

§  Can only code: 250.00 and 356.9 (ICD-‐9-‐CM) §  E11.9 and G62.9 (ICD-‐10-‐CM) [Lower Value DM]

②   Assessment: 1. DM with Polyneuropathy §  Can code: 250.60 and 357.2 §  E11.42 (ICD-‐10-‐CM) [Higher Value DM]


Documen=ng & Coding HTN •  Under-‐documen=ng HTN communicates a less serious HTN case, which affects value of care

•  Any manifesta=ons must be documented as a cause and effect rela=onship (CKD is an excep=on)


Hypertension Type ICD-‐9-‐CM ICD-‐10-‐CM

HTN (primary, benign, essen=al, malignant)

401.x I10

“with” Heart Disease 402.xx I11.x

“with” CKD 403.xx I12.x

“with” heart & kidney disease 404.xx I13.x

Hypertension, secondary 405.xx I15.x

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Documen=ng & Coding Cancers •  Per guidelines, cancers are coded by their loca=on and

may only be coded as ac=ve when current treatment is being directed to the cancer, or if the cancer is ac=ve and treatment was refused

•  Radia=on, Chemotherapy, and Hormonal treatments used specifically for a given cancer qualify as current treatment

•  Without current treatment, the pa=ent only has a personal history of cancer (V code) and these typically do not risk adjust

•  Helpful to know if cancer is primary, metasta=c, and what treatments are ongoing in order to code


Documen=ng & Coding Depression

•  Pa=ents who are on an=-‐depressant therapy are considered to have “major depression” clinically

•  Providers rarely document it this way, o|en only no=ng “depression”

•  Coders can only code what is documented and “depression” alone defaults to “situa=onal depression” such as bereavement or job loss or other temporary depression

•  Depression assessment tools are o|en used to validate or support moderate to severe or “major depression” but when pa=ents are receiving therapy these scores may not reflect the diagnosis and this should be noted


Documenta=on Tips •  Avoid homegrown abbrevia=ons •  Document all cause and effect rela=onships •  Include all current diagnoses as part of the current medical decision making and carry them to the final assessment of the encounter

•  Each note needs a date, signature, & creden=al (MD, DO, NP, PA, etc.)

•  Document history of heart aVack, any amputa=ons, hypoxia, status codes, ostomy, etc., when factual

•  Only document diagnoses as “history of” or “PMH” when they no longer exist or are a current condi=on


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Ques=ons


References • Larsen, Steve. (2011). Risk adjustment and health insurance.

Healthcare Blog October 13, 2011. Retrieved March 21, 2013 from hVp://www.healthcare.gov/blog/2011/10/ riskadjust10132011.html

• ICD-‐9-‐CM, Official Guidelines • ICD-‐10-‐CM, Official Guidelines


Contact

Brian Boyce, CPC, CPC-‐I Proprietor and Managing Consultant PO Box 14504 Richmond, VA 23221 www.linkedin.com/in/boycebrian/ [email protected]

www.ionHealthcareLLC.com

Medical Record Audit and Review -‐ Physician Prac=ce Op=miza=on -‐ Leadership Mentoring Healthcare Educa=on and Networking for Pa=ents and Professionals -‐ Risk Adjustment

3/17/13

© ionHealthcare, LLC All rights reserved. For educa=on & discussion purposes. PermiVed use via contractual agreement/purchase. 60

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Applying Concepts Quiz 1.  Mr. Jones came in for follow up visit with his PCP. A full

SOAP note was documented and signed by the trea=ng MD. Assessment:

1.  DM with polyneuropathy 2.  Hypertension 3.  Heartburn Can the coder document GERD in the above note? a)  Yes b)  No


Applying Concepts Quiz 1.  Answer: b) No

Ra=onale: The documenta=on of “heartburn” is only a symptom and does not risk adjust. The diagnosis of GERD (gastro-‐esophageal reflux disease) must be made specifically. This example illustrates the importance of documen=ng actual diseases as opposed to their symptoms if they are a current true diagnosis.


Applying Concepts Quiz 2.  Ms. Smith came in for follow up visit with her PCP. A full

SOAP note was documented and signed by the trea=ng MD. Assessment:

1.  Diabetes (DM) Type II 2.  Peripheral Neuropathy 3.  Hypertension What are the proper codes for the diabetes & neuropathy listed above? a)  250.00, 357.2 b)  250.60, 356.9 c)  250.00, 356.9 d)  250.60, 357.2


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Applying Concepts Quiz 2.  Answer: c) 250.00, 356.9

Ra=onale: In this example, There is no “cause & effect” demonstrated between the diabetes and the peripheral neuropathy. If the provider has documented the cause & effect rela=onship such as: “DM with peripheral neuropathy”, “Peripheral neuropathy due to diabetes”, “Diabe=c peripheral (or poly) neuropathy”, etc., then the codes would be jus=fied for a 250.60 and a 357.2. This example illustrates the importance of documen=ng all cause & effect rela=onships, especially in diabetes.


Applying Concepts Quiz 3.  Mr. Chung came in for follow up visit with his PCP. A full

SOAP note was documented and signed by the trea=ng MD. CC/HPI: Mr. Chung is here for follow up of his COPD, Diabetes, HTN. He has a history of prostate cancer. MedicaMons: Singulair, Albuterol inhaler, Actos, NPH insulin, sliding scale, HCTZ, Atenolol. Assessment: 1. COPD, 2. Diabetes, 3. Hypertension

Can the coder code for prostate cancer as an ac=ve diagnosis? a)  Yes b)  No


Applying Concepts Quiz 3.  Answer: b) No

Ra=onale: Prostate cancer is only listed as a “history of” in the CC/HPI of this record. In this scenario, a “Personal history of prostate cancer” would be appropriate but not an ac=ve prostate cancer code. Guidelines require that in order for cancers to be coded as current/ac=ve, there must be treatment directed to the cancer. If the pa=ent had been on radia=on, chemo, or hormonal treatment for his prostate cancer, then it could be coded as a current diagnosis. This example is a reminder of cancer coding guidelines. 3/17/13 © ionHealthcare, LLC All rights reserved. For educa=on & discussion purposes. PermiVed use via contractual agreement/purchase. 66

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Applying Concepts Quiz 4.  Ms. Hernandez came in for follow up visit with her PCP. A

full SOAP note was documented and signed by the trea=ng MD.

CC/HPI: Ms. Hernandez is here for follow up of her Diabetes, HTN, and Depression with anxiety. MedicaMons: Actos, NPH insulin, sliding scale, HCTZ, Atenolol, Prozac, Clonazepam. Assessment: 1. Depression, 2. Diabetes, 3. Hypertension

What is (are) the right code(s) for depression and anxiety above? a)  296.20, 300.00 b)  300.00, 311 c)  300.4


Applying Concepts Quiz 4.  Answer: c) 300.4

Ra=onale: In this example, the documenta=on only states depression with anxiety. Even though she is on an an=-‐depressant medica=on, the diagnosis of “major depression” has not been made, and coders may not assump=ve code. The 311 depression code would be correct if depression alone were her problem or if depression and anxiety were listed separately. However, in the example she is stated to have “depression with anxiety”. The 300.4 combina=on code would be correct for these two together.

This example highlights depression vs. major depression & anxiety coding. 3/17/13 © ionHealthcare, LLC All rights reserved. For educa=on & discussion purposes. PermiVed use via contractual agreement/purchase. 68

Applying Concepts Quiz 5.  Mr. Davis came in for follow up visit with his PCP. A full

SOAP note was documented and signed by the trea=ng MD. Assessment: 1. Diabetes, 2. Hypertension, 3. Kidney Disease

What is (are) the right code(s) for kidney disease noted above? a)  585.9 b)  593.9 c)  584.9 d)  585.1


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Applying Concepts Quiz 5.  Answer: b) 593.9

Ra=onale: In this example, the provider did not use specific documenta=on for the kidney disease. Had the provider noted it as “chronic”, then a 585.9 code would be correct for unspecified staging. Without the descrip=on of the kidney disease, the default code would be the unspecified code of 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. 3/17/13 © ionHealthcare, LLC All rights reserved. For educa=on & discussion purposes. PermiVed use via contractual agreement/purchase. 70

Applying Concepts Quiz 6.  Ms. White came in for follow up visit with her PCP. A full

SOAP note was documented and signed by the trea=ng MD. CC/HPI: Ms. White is here for follow up of her Atrial FibrillaNon, COPD, HTN, and Depression. She has a past history of DVT. MedicaMons: Coumadin, Singulair, Advair, Actos, HCTZ, Tarka, Abilify. Assessment: 1. Depression, 2. COPD, 3. Hypertension, 4. A-‐Fib

May the coder code for the DVT men=oned above as an ac=ve diagnosis? a)  Yes b)  No


Applying Concepts Quiz 6.  Answer: b) No Ra=onale: In this example, the DVT is only listed as a “history of” and there is a personal history code for this that would be appropriate. The pa=ent is on Coumadin, o|en used for DVT treatment, however she also has A-‐Fib., and it is more likely that this medica=on is being used for the ongoing atrial fibrilla=on. This example illustrates the cri=cal thinking necessary for reviewing current medica=ons as they pertain to PMH diagnoses in order to iden=fy them as current or ac=ve problems.


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Applying Concepts Quiz 7.  Mr. Green came in for follow up visit with his PCP. A full

SOAP note was documented and signed by the trea=ng MD. CC/HPI: Mr. Green is here for follow up of his hypertension. MedicaMons: Digoxin, HCTZ, Nitrostat Sublingual, prn PMH: Angina Assessment: 1. HTN

May the coder code angina men=oned above as an ac=ve diagnosis? a)  Yes b)  No


Applying Concepts Quiz 7.  Answer: a) Yes

Ra=onale: While angina is listed as “PMH” (Past Medical History), the pa=ent is currently on nitro-‐stat (which is used to manage angina) and this makes the angina recognized as a current or ac=ve condi=on. The provider should have annotated the angina in the assessment to remove any ques=on of the diagnosis, but under this situa=on, the code may s=ll be captured.

This example illustrates the use of PMH to iden=fy ac=ve diagnoses when specific medica=ons support the diagnosis as ongoing or current. 3/17/13 © ionHealthcare, LLC All rights reserved. For educa=on & discussion purposes. PermiVed use via contractual agreement/purchase. 74

Applying Concepts Quiz 8.  Ms. Fudd came in for follow up visit with her PCP. A full

SOAP note was documented and signed by the trea=ng MD. CC/HPI: Ms. Fudd is here for follow up of Rt. Lower leg pain. MedicaMons: Coumadin PMH: Compartmental syndrome status post surgery 2 years ago. Assessment: 1. Rt. Leg pain (NOTE: Duplex Doppler report of lower extremiNes from radiologist shows findings of: “consistent with DVT”.

May the coder code DVT men=oned above as an ac=ve diagnosis? a)  Yes b)  No


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Applying Concepts Quiz 8.  Answer: b) No Ra=onale: The Coding Clinic (a department within the AHA-‐ American Hospital Associa=on) issues formal rulings on diagnosis coding. One of those rulings states that any diagnosis described as “consistent with” cannot be coded as ac=ve or current as the descrip=on is too vague and a specific diagnosis is not being made with this wording choice. [Similar wordings which pose problems include: “appears to be”, “is likely”, “probable”, “suspect”, “may be”, etc.

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


Applying Concepts Quiz 9.  Mr. Bird came in for follow up visit with his PCP. A full SOAP

note was documented and signed by the trea=ng MD. CC/HPI: Mr. Bird is here for follow up weakness in le] leg status post CVA 2 weeks ago. Assessment: 1. Lt. leg weakness 2. insomnia

What is/are the proper code(s) for the Lt. leg weakness listed above? a)  342.80 b)  728.87 c)  438.20 d)  434.91, 438.20


Applying Concepts Quiz 9.  Answer: b) 728.87 Ra=onale: In this example, there is only a “le| weakness noted”. Another Coding Clinic determina=on states that the word “hemiplegia” must be used to gain this diagnosis code. Even with the history of CVA, the coder is unable to pair these two condi=ons without specific cause and effect as well as specific wording. Also note that CVA’s may only be coded up to the point of discharge for the treatment of the CVA and a|erward only a personal history of CVA may be coded.

This example shows the importance of both cause and effect documenta=on as well as specific wording to code correctly. It also highlights the rule for CVA coding. 3/17/13 © ionHealthcare, LLC All rights reserved. For educa=on & discussion purposes. PermiVed use via contractual agreement/purchase. 78

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Applying Concepts Quiz 10.  The following assessment is found in a Hand-‐wriVen note:

What is/are the proper code(s) for the assessment above? a)  305.1, 272.4, 401.9, 250.00 b)  272.4, 401.9, 250.00 c)  272.4, 401.9 d)  401.9


Applying Concepts Quiz 10.  Answer: d) 401.9

Ra=onale: The HTN is the only code that can be obtained from this example. Posi=ve history of smoking cannot translate to tobacco dependence (it must be stated), so the 305.1 code is incorrect. The diabetes is very ques=onable due to legibility, so it should not be coded. The cholesterol is listed as “↑ chol”. The Coding Clinic has a determina=on that coders may not code from up and down arrows ↑ or ↓, as these are not defini=ve and may only mean improved or decompensated from last visit. This example illustrates coding clinic rules on up and down arrows, illegible notes, and clinical documenta=on specificity.

What is/are the proper code(s) for the assessment above? a)  305.1, 272.4, 401.9, 250.00 b)  272.4, 401.9, 250.00 c)  272.4, 401.9 d)  401.9


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