The Centers for Medicare and Medicaid Services (CMS) have ... · 2018 ICD-10 Code Count by...

2018 ICD-10 Code Count by Specialty The changes include 360 new codes, 200 revisions, and 108

deleted codes; now a total of 71,704 ICD-10-CM codes available for use.

NOTE: New codes may be listed in multiple specialties. Not all specialties are listed above.

The Centers for Medicare and Medicaid Services (CMS) have published the 2018 ICD-10-CM

updates. The 2018 ICD-10-CM codes are to be used for services and encounters occurring from

October 1, 2017 through September 30, 2018.

2018 ICD-10 Updates Newsletter

In this issue… ICD-10-CM Guidelines and Terminology Revisions ............... pg 2 & 3

7th Character ‘S’ Sequela ............................................................ pg 4

MEDWEB Diagnosis Master ........................................................ pg 4

MEDTRON 2018 ICD-10-CM Code Resource Grid ...................... pg 5

Resource Grid - ICD-10 2018 Code List ...................................... pg 5

Resource Grid - 2018 New ICD-10-CM Codes ............................ pg 7

Resource Grid - 2018 Deleted ICD-10-CM Codes ....................... pg 7

Resource Grid - 2018 Revised ICD-10-CM Codes ....................... pg 7

Resource Grid - MEDPM ICD Abbreviations .............................. pg 8

CMS 1500 Claim Form - Diagnosis Codes ................................... pg 9

Healthcare Effectiveness Data and Information Set (HEDIS) ....... pg 10

Risk Adjustment (RA) and Hierarchical Condition

Categories (HCC) ................................................................ pg 11

Clinical Documentation Integrity (CDI) ...................................... pg 12

CMS General Equivalence Mappings (GEM)

Files - Retiring in 2019!

2018 is the last year that CMS will provide the General

Equivalence Mapping (GEM) files for ICD-9-CM to

ICD-10-CM. These files assisted providers and coders

with finding corresponding diagnosis codes between

ICD-9 and ICD-10 diagnosis code sets.

The 2018 files and guidelines are available via:

https://www.cms.gov/Medicare/Coding/ICD10/2018-

ICD-10-CM-and-GEMs.html

See the MEDTRON 2016 Summer Newsletter for ICD-10 Basics, i.e., Structure/Design, 7th Character Usage, Code First, etc.

https://www.medtronsoftware.com/pdf/2016/2016_SUMMER_NEWSLETTER.pdf

Specialty New Deleted Revised

Allergy 7 - -

Cardiovascular 49 - 2

Dermatology 76 - 8

Endocrinology 2 - -

Gastroenterology 26 - -

Maternity Care & Delivery 45 - -

Medicine 85 - 5

Musculoskeletal 138 35 116

Neoplasms 22 - -

Neurology 7 72 -

Obstetrics 79 - -

Opthalmology 55 - -

Pediatrics 19 - -

Psychiatry 13 - -

Radiology 89 36 -

Respiratory 1 - -

Surgery 15 108 -

Vascular 0 48 -

**IMMEDIATE ACTION IS NEEDED** Immediately identify any deleted or revised ICD-10 codes that are referenced or used in any of your practice resources, i.e., charge tickets/superbills, EHR templates, conditions/rules, and update to a new default diagnosis codes. Example: ICD-10 code Z36 has been deleted in 2018 and replaced with 17 new codes to identify more specificity. To assist, MEDTRON has created a 2018 ICD-10 Code Resource Grid available via:

https://www.medtronsoftware.com/pdf/Documents/MSI_ICD-10-CM_Code_Resource_Grid.xlsx

See page 5 of this newsletter for further details!

https://www.cms.gov/Medicare/Coding/ICD10/2018-ICD-10-CM-and-GEMs.html





ICD-10-CM GUIDELINES AND TERMINOLOGY REVISIONS

For a complete list of revisions please review the 2018 Coding Guidelines available via the CMS website: https://www.cms.gov/Medicare/Coding/ICD10/2018-ICD-10-CM-and-GEMs.html

2018 Updates are in RED.

“WITH” The word “with” or “in” should be interpreted to mean “associated with” or “due to” when it appears in a code title, the Alphabetic Index, or an instructional note in the Tabular List. The classification presumes a causal relationship between the two conditions linked by these terms in the Alphabetic Index, or Tabular List. These conditions should be coded as related even in the absence of provider documentation explicitly linking them, unless documentation clearly states the conditions are unrelated or when another guideline exists that specifically requires a documented linkage between the two conditions (i.e., sepsis guideline for “acute organ dysfunction that is clearly not associated with the sepsis”). For conditions not specifically linked by these relational terms in the classification or when a guideline requires that a linkage between two conditions be explicitly documented, provider documentation must link the conditions in order to code them as related.

“CODE ALSO” NOTE A “code also” note instructs that two codes may be required to fully describe a condition, but this note does not provide sequencing direction. The sequencing depends on the circumstances of the encounter.

Multiple Coding for a Single Condition In addition to the etiology/manifestation convention that requires two codes to fully describe a single condition that affects multiple body systems, there are other single conditions that also require more than one code. “Use additional code” notes are found in the Tabular List as codes that are not part of an etiology/manifestation pair where a secondary code is useful to fully describe a condition. The sequencing rule is the same as the etiology/manifestation pair, “use additional code” indicates that a secondary code should be added, if known.

Chapter 2: Neoplasms (C00-D49) Malignant neoplasms of ectopic tissue are to be coded to the site of origin mentioned, e.g., ectopic pancreatic malignant neoplasms involving the stomach are coded to malignant neoplasm of pancreas, unspecified (C25.9).

Guideline 2.a Treatment directed at the malignancy: The only exception to this guideline is if a patient admission/encounter is solely for the administration of chemotherapy, immunotherapy, or external beam radiation therapy assign the appropriate Z51.– Encounter for other aftercare and medical care code as the first - listed or principal diagnosis, and the diagnosis or problem for which the service is being performed as a secondary diagnosis.

Guideline 2.e.2 If a patient admission/encounter solely for administration of chemotherapy, immunotherapy and radiation therapy: If a patient admission/encounter is solely for the administration of chemotherapy, immunotherapy or external beam radiation therapy assign code Z51.0, Encounter for antineoplastic radiation therapy, or Z51.11, Encounter for antineoplastic chemotherapy, or Z51.2, Encounter for antineoplastic immunotherapy as the first-listed or principal diagnosis. If a patient receives more than one of these therapies during the same admission more than one of these codes may be assigned, in any sequence. If a patient admission/encounter is for the insertion or implantation of radioactive elements (e.g., brachytherapy) the appropriate code for the malignancy is sequenced as the principal or first-listed diagnosis. Code Z51.0 should not be assigned.

Guideline 2.e.3 Patient admitted for radiation therapy, chemotherapy or immunotherapy, and develops complications: When a patient is admitted for the purpose of external beam radiotherapy, immunotherapy or chemotherapy and develops complications such as uncontrolled nausea and vomiting, or dehydration, the principal or first-listed diagnosis is Z51.0, Encounter for antineoplastic radiation therapy, or Z51.11, Encounter for antineoplastic chemotherapy, or Z51.12, Encounter for antineoplastic immunotherapy followed by any codes for the complications. When a patient is admitted for the purpose of insertion or implantation of radioactive elements (e.g., brachytherapy) and develops complications such as uncontrolled nausea and vomiting or dehydration, the principal or first-listed diagnosis is the appropriate code for the malignancy followed by any codes for the complications.



ICD-10-CM GUIDELINES AND TERMINOLOGY REVISIONS(cont.) 2018 Updates are in RED.

Guideline 4.a.3 Diabetes Mellitus and the use of insulin and oral hypoglycemic: If the documentation in a medical record does not indicate the type of diabetes but does indicate that the patient uses insulin, code E11.-, Type 2 diabetes mellitus should be assigned. An additional code should be assigned from category Z79 to identify the long-term (current) use of insulin or oral hypoglycemic drugs. If the patient is treated with both oral medications and insulin, only code Z79.4 Long-term (current) use of insulin should be assigned. (Code Z79.4 Long term (current) use of insulin should not be assigned if the insulin is given temporarily to bring a Type 2 patient’s blood sugar under control during an encounter.)

Guideline 4.a.6.a Secondary diabetes mellitus and the use of insulin or oral hypoglycemic drugs: For patients with secondary diabetes mellitus who routinely use insulin or oral hypoglycemic drugs, an additional code should be assigned from category Z79 to identify the long-term (current) use of insulin or oral hypoglycemic drugs. If the patient is treated with both oral medications and insulin, only code Z79.4 Long-term (current) use of insulin should be assigned. (Code Z79.4 should not be assigned if insulin is given temporarily to bring a Type 2 patient’s blood sugar under control during an encounter.)

Guideline 7.a.6 ~ New for 2018! If “blindness” or “low vision” of both eyes is documented but the visual impairment category is not documented, assign Code H54.3, Unqualified visual loss, both eyes. If “blindness” or “low vision” in one eye is documented but the visual impairment category is not documented, assign a code from range H54.60-H54.62, Unqualified visual loss, ? eye(s). If “blindness” or “visual loss” is documented without any information about whether one or both eyes are affected, assign Code H54.7 Unspecified visual loss.

Guideline 9.a.10 ~ New for 2018! Pulmonary Hypertension is classified to category I27, Other pulmonary heart diseases. For secondary pulmonary hypertension assign code from ranges I27.1 Kyphoscoliotic heart disease and I27.20-I27.29 Other Secondary Pulmonary Hypertension. The ’Code Also’ notes advise to code any associated conditions or adverse effects of drugs or toxins. The sequencing is based on the reason for the encounter.

Guideline 9.e.5 ~ New for 2018! Other types of Myocardial Infarction (MI): The ICD-10-CM provides codes for different types of MI. Type 1 MI’s are assigned to codes I21.01-I21.4 ST elevation (STEMI) Myocardial Infarction. Type 2 MI’s, and MI due to demand ischemia or secondary to ischemic balance, is assigned to code I21.A1, MI Type 2 with a code for the underlying cause. Do not assign code I24.8, Other forms of acute ischemic heart disease for the demand ischemia. Sequencing of Type 2 Acute Myocardial Infarctions (AMI) or the underlying cause is dependent on the circumstances of the admission. When Type 2 AMI code is described as NSTEMI or STEMI, only assign code I21.A1. Codes I21.01-I21.4 should only be assigned for Type 1 AMIs. Type 3, 4a, 4b, 4c and 5 AMI’s are assigned to code I21.A9, Other MI type. The “Code Also” and Code First” notes should be followed related to complications, and for coding the postprocedural MI’s during or following cardiac surgery.

Guideline 13.c Coding of Pathologic Fractures: 7th character A is for use as long as the patient is receiving active treatment for the fracture. While the patient may be seen by a new or different provider over the course of treatment for a pathologic fracture, assignment of the 7th character is based on whether the patient is undergoing active treatment and not whether the provider is seeing the patient for the first time. 7th character D is to be used for encounters after the patient has completed active treatment for the fracture and is receiving routine care for the fracture during the healing or recovery phase. The other 7th characters, listed under each subcategory in the Tabular list, are to be used for subsequent encounters for treatment of problems associated with the healing, such malunions, nonunions, and sequelae (see next page).

For a complete list of revisions please review the 2018 Coding Guidelines available via the CMS website: https://www.cms.gov/Medicare/Coding/ICD10/2018-ICD-10-CM-and-GEMs.html




The 7th character ‘S’, Sequela (Late Effect), is used for complications or conditions that arise as a direct result of a Condition after the acute phase of an illness or injury has terminated, such as scar formation after a burn. The scars are the sequela of the burn. The 7th character ‘S’ identifies the injury responsible for the sequela. The specific type of sequela, i.e., scar, is sequenced first, followed by the injury code with the 7th character ‘S’. Coding guidelines for sequela: There is no time limit on when a sequela code can be used The residual effect may present early or may occur months or years later Two codes are generally required: one describing the nature of the sequela and one for the sequela The code for the acute phase of the illness or injury is never reported with a code for the late effect,

i.e., S’ is only added to the injury code. Example 1: A patient suffers a low back injury that heals on its own. The patient isn’t seeking intervention for the initial injury, but for the pain that persist later. The chronic pain is sequela of the injury. The visit is reported using G89.21 (Chronic pain due to trauma) and S39.002S (Unspecified injury of muscle fascia and tendon of lower back, sequela). Example 2: Chronic left ankle instability following Grade III sprain of the calcaneofibular ligament six months prior. The visit is reported using M24.272 (Disorder of ligament, left ankle) and S93.412S (Sprain of calcaneofibular ligament of the left ankle, sequela). Example 3: A patient is admitted for release of scar contractures of the flexor surface of left elbow following healing of second and third degree burns of this region. The visit is reported using L90.5 (Scar conditions and fibrosis of skin) and T22.322S (Burn of third degree of left elbow, sequela).

Source: ICD-10 Guidelines and ICD-10 Monitor: https://www.icd10monitor.com/icd-10-cm-coding-for-sequelae-of-injuries.

7TH CHARACTER ‘S’ SEQUELA

To Access the MEDWEB Diagnosis Code Master: At the Dashboard, click ‘Setup and Support’ Click ‘Diagnosis’ Search is available via Diagnosis Code (no decimal), Description, or ICD-10 Code. Below is an example of a search for ‘lesion’ in the ‘Description’.

MEDWEB DIAGNOSIS SUPPORT FILE

https://www.icd10monitor.com/icd-10-cm-coding-for-sequelae-of-injuries

MEDTRON has created a 2018 ICD-10 Code Resource Grid available via: https://www.medtronsoftware.com/pdf/Documents/MSI_ICD-10-CM_Code_Resource_Grid.xlsx The ICD-10-CM Resource Grid is an excel spreadsheet that contains: Chapter List-Index: ICD-10-CM Chapter List and Index of available tabs/worksheets. ICD-10 2018 Code List: Full ICD-10-CM Code List with Code, Long Description, MEDPM Short

Description and several code indicators, i.e., Non-Primary Dx, Code Additional, Gender Specific, Age Specific, and more!

2018 New Codes: New code list with specialty indicator. 2018 Deleted Codes: Deleted code list with specialty indicator. 2018 Revised Codes: Revised code list with specialty indicator. MEDPM Abbreviations: Abbreviations used in MEDPM for diagnosis descriptions.

MEDTRON 2018 ICD-10-CM CODE RESOURCE GRID


ICD-10 2018 Code List tab has filters applied so users can easily manage/search for data/information needed. All codes listed are active codes with the current description. The MEDPM ICD-10 Short Description column represents the information as it presents in the MEDPM Diagnosis Master (see sample on page 5).

To Access the MEDPM Diagnosis Code Master: Identify Practice Master Menu

#2 Setup and Support #3 Diagnosis Codes

The Diagnosis Master screen offers ‘Position To’ search by ‘Dg Code’, ’Diagnosis Description’ and ‘ICD-Code’ fields. Users can also search for a ‘data string’ by placing ‘=‘ in lead characters, i.e., =LESION. Refer to User Guide: Setup/Maintain Setup and Support Files

RESOURCE GRID - ICD-10 2018 CODE LIST

= <to scan>


https://www.medtronsoftware.com/User%20Guides/Setup_Maintain_Setup_&_Support_Files.pdf

https://www.medtronsoftware.com/User%20Guides/Setup_Maintain_Setup_&_Support_Files.pdf


ICD-10 2018 Code List tab contains Indicator columns that identifies ICD-10 codes with restrictions.

Column Legend: NOTE: The above Legend is available by hovering over the column description.

MDS/MSI will be constantly growing this resource, i.e., we have composed lists for Maternity Diagnosis supporting C-Section < 39 weeks and Abortion Diagnosis requiring Medical Necessity by LA Medicaid.

RESOURCE GRID - ICD-10 2018 CODE LIST (cont)

Column Column Description

ICD-10 Code ICD-10 code with decimal

Dg Code ICD-10 code without decimal

ICD-10 Long Description Long code description per the CPT book/CMS file

MEDPM ICD-10 Description 35 character code description in MEDPM, see MEDPM ICD Abbreviation tab of the MSI ICD-10-CM Resources Grid.

Non-Primary Dx Codes that can NOT be used as Primary Diagnosis, i.e., not ‘A’ pointer, any code marked "Code First" in the ICD-10 book

(blanks = may be used as Primary) X = Can NOT be used as Primary Diagnosis

L = Must be listed as Last Diagnosis

Code Additional (+) Codes that require additional Diagnosis added; i.e., any code marked "Use Additional" or "Code Also" in the ICD-10 Book

Acute Manifestation Codes that are classified as acute manifestation codes, used with Code Additional column codes

Gender Specific (M/F) Codes that are gender specific:

M = Male

F = Female

Age Specific (A/M/N/P) Codes with age restrictions:

A = Adult

M = Maternal

N = Newborn

P = Pediatric

Low Age Youngest age of patient for code

High Age Highest age of patient for code

Take Charge Plus Family Planning Codes used for the Take Charge Plus Family Planning LA Medicaid Program

Multi Fetus Codes relating to more than one fetus in the same pregnancy

Cause Codes External Causes of Morbidity Codes, i.e., not used as primary ‘A’ pointer

Mental Health Mental, Behavioral and Neurodevelopmental Disorders

Version CMS Version # for source file

Code Effective Date Effective date of code

The 2018 New Codes tab of the MEDTRON 2018 ICD-10-CM CODE RESOURCE GRID contains a list of the 360 new ICD-10-CM codes for 2018. Indicators have been added to enable users to filter by Specialty.

The 2018 Deleted Codes tab of the MEDTRON 2018 ICD-10-CM CODE RESOURCE GRID contains a list of the 108 deleted ICD-10-CM codes for 2018. Indicators have been added to enable users to filter by Specialty.

The 2018 Revised Codes tab of the MEDTRON 2018 ICD-10-CM CODE RESOURCE GRID contains a list of the 200 revised ICD-10-CM codes for 2018. Indicators have been added to enable users to filter by Specialty. 2017 full descriptions and revised descriptions for 2018 are listed.

RESOURCE GRID - 2018 NEW ICD-10-CM CODES


RESOURCE GRID - 2018 DELETED ICD-10-CM CODES

RESOURCE GRID - 2018 REVISED ICD-10-CM CODES


The MEDPM Abbreviations tab of the MEDTRON 2018 ICD-10-CM CODE RESOURCE GRID contains a list of abbreviations used in the MEDPM Diagnosis Code Master file to satisfy the 35 character ’Description’ field requirements. Below is an excerpt of abbreviations; for a full list see the MSI ICD-10-CM Resource Grid.

RESOURCE GRID - MEDPM ICD ABBREVIATIONS

Full Word/Term MEDPM Abbreviations Full Word/Term MEDPM Abbreviations

ABDOMINAL ABDOM CONTRACEP CNTRCP

ABLATIVE ABLAT CONTRACEPTIVE CONTRACEP

ABNORMAL ABN COUNSELING CNSLING

ABUSE ABU CRYOPYRIN-A SSOCIATED CRYOPYR-ASSOC

ACQUIRED ACQD DEFICIT DFCT

ACTIVATION ACT DEGENERATION DGENR

ADHESIONS ADH DEGENERATIVE DGEN

ADMINISTRATION ADM DELIVERY DELVRY

ADMISSION ADM DERMATOLOGIC DERM

ADMIT ADM DESENSITIZATION DESENS

AGENT AGNT DETACH DTCH

AGE-RELATED AGE_REL DEV/IMPL/GRFT DVC

AGGRESSIVE AGRSV DEVICE IMPL/GRAFT DVC

AND & DIAB DM

ANESTH ANES DIABETES DIAB

ANESTHESIA ANES DIABETIC DIAB

ANTERIOR ANTR DISEASE DIS

AROUND ARND DISEASES DSIS

ARTERIES ART DISLOCATION DISCLOC

ARTHROSCOPIC ARTHROS DISORDER DIS

ASYMMETRIC ASYM DISPLACEMENT DISPLAC

AT @ DISSECTION DISSECT

ATTENTION ATTN DOCUMENTED DOC

ATYPICAL ATYP DRUG/CHEM DRUG

AWKWARD AWKWD DURING @

BEHAVIOR BEHV DYSFUNCTION DSYF

BILATERAL BIL DYSREGULATION DSYR

BREAKDOWN BRKDWN ELEVATED HIGH

BULKING BULK ELSEWHERE E/W

CATHETER CATH EMBOLISM EMBO

CENTRAL CNTL ENCOUNTER ENC

CEREBRAL CEREB ENLARGEMENT ENLRG

CEREBROVASCULAR CEREBVASC EXAMINATION EXAM

CERVICAL CERV EXCESSIVE EXC

CESAREAN C-sec EXPOSURE EXPSR

CHILDBIRTH CHLDBRTH FAILURE FAILUR

CHOROIDAL CHOROIDAL FALLOPIAN FALLOP

The CMS-1500 hard copy (Version 02/12) claim form was updated to include compatible entries for ICD-10 diagnosis codes; these same principles apply to electronic media claims (EMC). Although twelve diagnosis codes are allowed per claim, only four diagnosis codes are allowed per service line item via the use of alpha diagnosis pointers. Example: If your claim has only one service (charge), then ONLY four diagnosis codes may be reported. If your claim contains more than one service (charge), then MORE THAN FOUR diagnosis codes may be reported, but only up to four diagnosis codes will be reported for each service/charge/CPT code.

At MEDPM FD Default Entry Screen key all applicable diagnosis codes: In the above example, charge line for 06/13/17 date of service; CPT 99214 is assigned diagnosis codes N40.1, M10.00, E66.1, J11.0.

If greater than 4 diagnosis codes are needed to convey additional ICD-10 codes for additional risk factors; users can use the $0 HEDIS CAT II (P4P) code, i.e., HEDIS code G8417 is assigned diagnosis codes Z68.33, E11.29, E51.9 and N28.82. Additional $0 HEDIS charge codes (numerators) can be on a claim as each HEDIS code can provide an additional 4 ICD-10 codes, see charge lines 3-6 in the above example. NOTE: Humana allows use of CPT 99299 and 99499 to report additional diagnosis codes.

Remember to setup with Revenue Center P4P if no dollar value assessed. Please review the 071417 News Blast: Reporting MIPS and HEDIS via MEDPM for $0 Encounters, available via https://www.medtronsoftware.com/pdf/2017/071417_Reporting_MIPS_and_HEDIS_via_MEDPM_for_$0_Encounters.pdf


CMS 1500 FORM ~ DIAGNOSIS CODES

Diagnosis Code Selections with Alpha Diagnosis Pointers

Charge Lines

Diagnosis Pointers

HEDIS $0 Charges

https://www.medtronsoftware.com/pdf/2017/071417_Reporting_MIPS_and_HEDIS_via_MEDPM_for_$0_Encounters.pdf


HEALTHCARE EFFECTIVENESS DATA AND INFORMATION SET (HEDIS) The Healthcare Effectiveness Data and Information Set (HEDIS) is a widely used set of performance measures in the managed care industry, developed and maintained by the National Committee for Quality Assurance (NCQA). HEDIS results are increasingly used to track year-to-year health plan performance on important dimensions of care and service for more than 90% of America’s health plans. An incentive for many health plans to collect HEDIS data is a Centers for Medicare and Medicaid Services (CMS) requirement that Health Maintenance Organizations (HMOs) submit HEDIS data in order to provide HMO services. The “reporting year” after the term “HEDIS” is one year following the year reflected in the data, i.e., HEDIS 2017 reports, contain analysis of data collected from “measurement year” January - December 2016. HEDIS data is collected through surveys, medical records and insurance claims. Periodically carriers conduct a HEDIS program audit of supplemental data. Practice’s are required to participate and submit all requested supplemental documentation typically within one week of the delivery date or specified time frame. For example, if a mammogram screening has been supplied as supplemental data, the practice would submit a copy of the mammogram result from the radiologist as proof the service was rendered. Practices/Providers are scored by their compliance. A compliance score of less than 95% accuracy will result in an additional audit of medical records. Depending on audit results sanctions against the practice may also be considered. MEDTRON/MEDDATA publish News Blasts for provider and office staff education. We encourage all providers and key office staff to review to confirm their understanding and ultimately their compliance with HEDIS requirements. News Blasts: 081116 EHR News: New Features - HEDIS https://www.medtronsoftware.com/pdf/2016/081116_EHR_NEWS_-_New_Features_HEDIS.pdf 081116 HEDIS Reporting - More Information https://www.medtronsoftware.com/pdf/2016/081116_HEDIS_Reporting_-_More_Information.pdf 071417 Reporting MIPS and HEDIS via MEDPM for $0 Encounters https://www.medtronsoftware.com/pdf/2017/071417_Reporting_MIPS_and_HEDIS_via_MEDPM_for_$0_Encounters.pdf

Additional Resources: NCQA: http://www.ncqa.org/hedis-quality-measurement NCQA HEDIS and Accreditation Standards Changes 2018 (video): https://www.youtube.com/watch?v=9SAMecA00Uk NCQA HEDIS Data Submission: http://www.ncqa.org/hedis-quality-measurement/hedis-data-submission CMS HEDIS: https://www.cms.gov/Medicare/Health-Plans/SpecialNeedsPlans/SNP-HEDIS.html NOTE: Use of HEDIS codes on claims allow providers to convey to carrier more ICD-10 codes than the ‘4 per line limitation!’


https://www.medtronsoftware.com/pdf/2016/081116_EHR_NEWS_-_New_Features_HEDIS.pdf

https://www.medtronsoftware.com/pdf/2016/081116_HEDIS_Reporting_-_More_Information.pdf



http://www.ncqa.org/hedis-quality-measurement

https://www.youtube.com/watch?v=9SAMecA00Uk

http://www.ncqa.org/hedis-quality-measurement/hedis-data-submission

https://www.cms.gov/Medicare/Health-Plans/SpecialNeedsPlans/SNP-HEDIS.html

RISK ADJUSTMENT (RA) AND HIERARCHICAL CONDITION CATEGORIES (HCC)

The Centers for Medicare and Medicaid Services (CMS) Hierarchical Condition Categories (HCC) model is a Risk Adjustment (RA) model used to adjust payments for healthcare coverage based on health conditions (risk) of the Enrollees. Health conditions are identified via the ICD-10 diagnoses that are submitted by providers via claims and medical record documentation. Risk adjustment models are based on prediction, i.e., the use of existing data to predict costs. Risk Adjustment models are used in different healthcare sectors, such as Medicare, Medicaid, and Commercial markets. Data factors such as utilization, cost, frequency, outcomes, disease progression, and more can predict many things including cost of care, resource allocation, ratios, etc. Complex data relationships are analyzed so mathematical weights can be attributed to health conditions and to determine the impact of providing more resources on outcomes. See the Medicare and Medicaid Milestones fact sheet published by the Centers for Medicare and Medicaid Services for the history that has led to Risk Adjustment: https://www.cms.gov/About-CMS/Agency-Information/History/Downloads/Medicare-and-Medicaid-Milestones-1937-2015.pdf CMS Risk Adjustment Data Technical Assistance for Medicare Advantage Organizations (MAO) Participant Guide is available via: http://www.hccuniversity.com/asset/b784177c-7b89-4dec-be72-dbb2123dd74e In the CMS-HCC model, disease groups contain major diseases and are broadly organized into body systems. For risk adjustment purposes, CMS refers to disease groups as HCCs. There are 25 disease groups (major) consisting of 79 disease/condition categories. These categories exclude those that contain diagnoses that are vague/nonspecific, i.e., symptoms, discretionary in medical treatment or coding (i.e., osteoarthritis), not medically significant, (i.e., muscle strain), or transitory/definitively treated (i.e., appendicitis). The model also excludes categories that do not empirically add to costs, as well as categories that are fully defined by the presence of procedures or durable medical equipment. This focuses the model on medical problems that are present, rather than services offered. Hierarchies are imposed among related condition categories, so that a person is coded for only the most severe manifestation among related diseases. Several HCC models are used by Medicare, Medicaid and Commercial Health Management Organizations (HMO): Medicare: CMS-HCC and CMS RxHCC (prescription drug model) Medicaid: Chronic Illness and Disability Payment System (CDPS); Clinical Risk Grouping (CRG), Medicaid Rx (MCDRx) and Diagnostic Cost Grouping (DxCG) Commercial: Dept of Health and Human Services (HHS-HCC) used in the individual and small group markets

https://www.cms.gov/mmrr/Articles/A2014/MMRR2014_004_03_a03.html CMS requires that all medical records contain sufficient information to identify the patient, support the diagnosis billed, justify the treatment and document accurately the course of treatment and results. Documentation for all reported conditions must show that the condition was Monitored, Evaluated, Assessed or Addressed, and Treated (MEAT). All chronic conditions must be evaluated and reported at least once per year. The key to risk adjustment documentation is specificity, often one word will make the difference on whether the diagnosis risk adjusts or not. HCC validation is based on the assessment (diagnosis), status of the condition and plan of action. HCC is to providers as DRG’s are to Hospitals!

Provider documentation drives risk adjustment! See the Clinical Documentation Integrity article on page 12 of this newsletter!


https://www.cms.gov/About-CMS/Agency-Information/History/Downloads/Medicare-and-Medicaid-Milestones-1937-2015.pdf



http://www.hccuniversity.com/asset/b784177c-7b89-4dec-be72-dbb2123dd74e

http://www.hccuniversity.com/asset/b784177c-7b89-4dec-be72-dbb2123dd74e

https://www.cms.gov/mmrr/Articles/A2014/MMRR2014_004_03_a03.html

CLINICAL DOCUMENTATION INTEGRITY (CDI) Clinical Documentation (and coding) Integrity (CDI) is the process and effort to promote legible, clear, consistent, complete, precise, non-conflicting, and reliable provider documentation essential to the final assignment of accurate and clinically congruent HIPAA associated transaction set codes (i.e., CPT, ICD-10-CM) and their submission to intermediaries for adjudication. ICD-10-CM Official Guidelines for Coding and Reporting emphasizes CDI: A joint effort between the healthcare provider and the coder is essential to achieve complete and accurate

documentation, code assignment, and reporting of diagnoses and procedures. The importance of consistent, complete documentation in the medical record cannot be over-emphasized.

Without such documentation accurate coding cannot be achieved. Coders may not clinically interpret the medical record, the physician must state status of chronic conditions and provide appropriate documentation even if the condition is clinically obvious. Often there is a disconnect between the Clinical term and the Administrative Term, see examples below. Remember ICD-10-CM is used for classifying healthcare data for administrative purposes, including reimbursement of claims, health statistics, and other uses where data aggregation is advantageous. ICD-10 coding is based ONLY on the provider documentation, not data abstraction of the patients clinical conditions, i.e., the provider must use the proper terms for correct ICD-10-CM code assignment. Source: Decision Health Providers are encouraged to review the CMS Medlearn Matters Fact Sheet: Complying with Medical Record Documentation Requirements available via: https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/Downloads/CERTMedRecDoc-FactSheet-ICN909160.pdf Remember:

If it isn’t documented, it isn’t done!!

ICD-10 Unspecified/Laterality Denials Due to Conflicting CPT Modifier Use

MEDDATA has received denials (RARC M64, CARC 04 and RARC N57) for “unspecified” or incorrect laterality ICD-10 code selected when the laterality of the CPT, ICD-10 and CPT code modifier are mis-matched.

Examples: CPT 73080 billed with LT modifier - ICD-10 selected M70.20 Olecranon bursitis, unspecified elbow

Appropriate ICD-10 code: M70.22 CPT 69433 billed with 50 modifier - ICD-10 selected H65.21 Chronic serous otitis media, right ear H65.22 Chronic serous otitis media, left ear Appropriate ICD-10 code: H65.23


Clinical vs. Administrative Disconnect Documented Clinical Term/Consequence Alternative ICD‐10‐CM language

Urosepsis – No code Sepsis due to UTI

SIRS 2˚ infection – no code for the SIRS part Sepsis 2˚ infection

Hyperbilirubinemia – no code w/nonneonates

Jaundice

Unresponsive – no code Unconscious or coma

Pancytopenia s/p cancer chemotherapy – Only pancytopenia is coded

Pancytopenia DUE TO cancer chemotherapy A more specific code influencing the DRG

↓ K or ↓ Na – no code Hypokalemia or hyponatremia

Anemia, s/p GI bleed – only an anemia code Acute and/or chronic blood loss anemia

Reactive airway disease – codes to asthma Bronchospasm

CO2 narcosis – no code Metabolic encephalopathy 2˚ hypercapnia

Wound debridement – not specific Excisional debridement‐skin, fascia, muscle

Release of heart adhesions – not specific Release of LV, RV, LA, or RA adhesions

https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/Downloads/CERTMedRecDoc-FactSheet-ICN909160.pdf





The Centers for Medicare and Medicaid Services (CMS) have ... · 2018 ICD-10 Code Count by...

Documents

Transcript of The Centers for Medicare and Medicaid Services (CMS) have ... · 2018 ICD-10 Code Count by...