Risk%Adjustment,%HCC%Model,%&% Stars%Rangs%101%

Risk Adjustment, HCC Model, & Stars Ra8ngs 101 An Overview for Coders & Providers

Risk Adjustment (RA) •  Risk Adjustment is a method of analysis using diagnoses for financial forecas8ng that has been growing in popularity in healthcare •  Medicaid plans began using Risk Adjustment modeling in 1996 and has con8nued 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 iden8fy and plan for high risk pa8ents 3/17/13

© ionHealthcare, LLC All rights reserved. For educa8on & discussion purposes. PermiUed use via contractual agreement/purchase.

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RA & Affordable Care Act •  “The Affordable Care Act calls for a risk adjustment program that aims to eliminate incen8ves for health insurance plans to avoid people with pre-‐exis8ng condi8ons or those who are in poor health. Risk adjustment ensures that health insurance plans have addi8onal 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 aUract healthy people” (Larsen, 2011) 3/17/13


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Different Programs, Same Goal •  Whether Risk Adjustment is being u8lized for Medicaid, Medicare, or Commercial pa8ents, the main ingredients used are Diagnosis Codes (ICD codes) •  Diagnoses are collected and their specificity drives risk score or categoriza8on •  The worse, or more serious a condi8on, or diagnosis, the higher the risk scoring •  Risk Scores either affect incoming payment or the future financial forecas8ng for each pa8ent 3/17/13


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Why It MaUers •  For Medicare Advantage Plans ①  Risk Adjustment (RA) iden8fies pa8ents who may need disease management interven8ons and ②  RA establishes the financial allotment allowed from CMS toward the annual care of each pa8ent; with more dollars allocated for those with higher risk scores •  For Medicaid and Commercial Plans ①  Risk Adjustment (RA) iden8fies pa8ents who may need disease management interven8ons and ②  RA establishes the “overall state of the popula8on” by aggrega8ng diagnoses; which assists in financial forecas8ng for future medical need 3/17/13


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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 trea8ng licensed provider (showing creden8als: MD, DO, PA, NP, OT, CRNA, MSW, and similar

master’s level providers) and the documenta8on must be

signed by the trea8ng 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 3/17/13


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Significance to Providers •  Providers have long aUempted to establish the seriousness and severity of the pa8ents they treat through the use of E&M CPT codes •  Higher level E&M codes iden8fy serious encounters, u8lizing 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 3/17/13


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Significance to Providers •  Using specific ICD Diagnosis Codes will help convey the true seriousness of the condi8ons being addressed in each visit •  Documen8ng these carefully involves two main focal points: ① Iden8fying the Diagnosis as a current or ongoing problem as opposed to a PMH (Past Medical History) or previous condi8on ② Choosing the most specific Diagnosis Code while also being sure documenta8on supports it 3/17/13


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Origins of Medicare Advantage & the HCC Model •  Sub8tle A of the Balanced Budget Act of 1997 created Medicare Choice for pa8ents. This allowed pa8ents to choose the original Medicare FFS program or a Medicare + Choice program. •  The Medicare Moderniza8on Act of 2003 changed Medicare + Choice to Medicare Advantage •  The new Medicare risk adjustment model was gradually phased into Medicare advantage payment calcula8ons star8ng in 2004 (with full implementa8on in 1/2007) •  Developed by researchers at RTI Interna8onal, Boston University and Harvard medical school, Hierarchical Condi8on Categories, uses ambulatory and inpa8ent diagnosis to create a valid risk adjustment methodology to help predict individual expenditure varia8on among Medicare pa8ents 3/17/13


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The HCC Model is Ever-‐ Changing •  The original DCG/HCC model in 2000 iden8fied 804 costly diagnosis groups, mapped to 189 HCC codes •  Created a repor8ng model for reimbursement based on ICD codes within families of condi8ons. (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


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How ICD Codes Carry Value •  Most of the ICD diagnosis codes which are in the model are chronic condi8ons •  Risk Adjustment is based on adjus8ng the es8mated risk of each pa8ent based on known diagnoses •  Part C HCC (HCC-‐C) are those diagnoses which are costly to manage from a medical perspec8ve •  Part D HCC (HCC-‐D) are those diagnoses which are costly to manage from a prescrip8on drug perspec8ve •  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 3/17/13


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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

3/17/13


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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

Metasta8c 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 Complica8ons

18,19

18

Diabetes with Chronic Complica8ons

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 Infarc8on

87,88

87

Unstable Angina and Other Acute Ischemic Heart Disease

88

99

Cerebral Hemorrhage

100

103

Hemiplegia/Hemiparesis

104

106

Atherosclerosis of the Extremi8es with Ulcera8on or Gangrene

107,108,161,189

107

Vascular Disease with Complica8ons

108

110

Cys8c Fibrosis

111,112

111

Chronic Obstruc8ve Pulmonary Disease

112

114

Aspira8on 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

Acceptable Provider Special8es CODE

SPECIALTY

CODE

SPECIALTY

CODE

SPECIALTY

01

General Prac8ce

25

Physical Medicine & Rehabilita8on

67

Occupa8onal 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

Addic8on Medicine

08

Family Prac8ce

35

Chiroprac8c

80

LCSW

09

Interven8onal Pain Management (IPM)

36

Nuclear Medicine

81

Cri8cal Care (Intensivists)

10

Gastroenterology

37

Pediatric Medicine

82

Hematology

11

Internal Medicine

38

Geriatric Medicine

83

Hematology/Oncology

12

Osteopathic Manipula8ve Therapy

39

Nephrology

84

Preventa8ve Medicine

13

Neurology

40

Hand Surgery

85

Maxillofacial Surgery

14

Neurosurgery

41

Optometry (optometrists)

86

Neuropsychiatry

15

Speech Language Pathologist

42

Cer8fied Nurse Midwife

89

Cer8fied Clinical Nurse Specialist

16

Obstetrics/Gynecology

43

CRNA

90

Medical Oncology

17

Hospice and Pallia8ve Care

44

Infec8ous Disease

91

Surgical Oncology

18

Ophthalmology

46

Endocrinology

92

Radia8on Oncology

19

Oral Surgery (Den8sts only)

48

Podiatry

93

Emergency Medicine

20

Orthopedic Surgery

50

Nurse Prac88oner

94

Interven8onal 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

Plas8c & Reconstruc8ve Surgery

66

Rheumatology

C0

Sleep Medicine

3/17/13


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What May Be Coded & SubmiUed •  Diagnosis codes from Inpa8ent Hospital, Outpa8ent Hospital, and Outpa8ent 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 documenta8on must have the signature and creden8al of the trea8ng 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 ac8ve problem •  Chronic condi8ons (paraplegia, old MI, loss of limb, etc.) that never resolve should be re-‐documented and coded yearly 3/17/13


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What Is Excluded? (Counted Elsewhere) Skilled Nursing Facili8es & Intermediate Care Facili8es (ICF s) Hospice Home Health/Home Care Lab Visits (except Pathology Codes, which are allowed) Radiology Visits (except for therapeu8c radiology codes) Ambulance DME, Prosthe8cs, Ortho8cs, Supplies Ambulatory Surgical Centers Free-‐Standing Renal Dialysis Facili8es Documenta8on by an approved physician specialty that did not result from a face-‐to-‐face encounter. Note: Pa8ents with ESRD, Hospice, and/or are Dual Eligible (Medicare and Medicaid) are calculated using extra measures already. •  •  •  •  •  •  •  •  •  • 

3/17/13


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Lab & Radiology Related Diagnoses •  Providers should update each face to face visit documenta8on 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 permiUed if not therapeu8c 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

3/17/13


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Calcula8ng 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 pa8ent s RAF. Example: Pa8ents 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) 3/17/13

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


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The Importance of Trained Cer8fied Coders No CondiMons Coded

Some Coded-‐ Not Specific From Claims Submission

All CondiMons Coded Chart Review by CerMfied Coder

76 year old Female .468



Medicaid Eligible .177



DM not coded

DM w/o complica8on .181

DM w Vascular Complica8on .608

Vascular Disease not coded

Vascular w/o .324 complica8on

Vascular w complica8on .645

CHF Not coded

CHF not coded

CHF coded .395

No interac8on

No interac8on

Disease interac8on (DM .204 + CHF)

TOTAL RAF .645 PMPM Payment $585

TOTAL RAF 1.15 PMPM Payment $1,042

TOTAL RAF 2.497 PMPM Payment $2,263

For educa8on & discussion purposes. PermiUed use via contractual agreement/purchase. 3/17/13 20 Yearly Payment © ionHealthcare, $7,015 LLC All rights reserved. Yearly Payment $12,508 Yearly Payment $27,159

How Suspect Logic Is Used Rx DME 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]

3/17/13


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CMS Submission Timetable

3/17/13


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RADV Risk Adjustment Data Valida8on Part 2

RADV: Risk Adjustment Data Valida8on

Ø  RADV is a process used by CMS to verify that diagnosis codes submiUed by the plan are supported by documenta8on in the beneficiary s (pa8ent) medical record Ø  RADV audits are designed to validate the accuracy of the payment data submiUed by the plan and ul8mately the accuracy of payments to the plan Ø  RADV audits involve the review of hospital inpa8ent, hospital outpa8ent, and physician medical records Ø  Annually CMS conducts RADV audits on targeted plans and randomly-‐selected plans Ø  The sample is stra8fied, randomly choosing members with low, medium and high risk scores within each plan Ø  The plans must provide wriUen documenta8on of each HCC paid 3/17/13


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RADV: Risk Adjustment Data Valida8on

Ø  Best Record means finding any acceptable documenta8on of any diagnosis code that supports the HCC submiUed that needs valida8ng in the RADV audit Ø  DOS (Date of Service) does not maUer 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 addi8onal Part C HCC s in the same DOS is beUer Ø  A solid find of HCC without missing creden8al or signature is ideal, but CMS has allowed their specific aUesta8ons for missing creden8als 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 beUer) 3/17/13


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RADV: Risk Adjustment Data Valida8on First Choice

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

Second Choice

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

Third Choice

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

3/17/13


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Typical RADV Timeline

3/17/13


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Stars Ra8ngs Part 3

CMS Star Ratings The CMS rates Medicare Advantage plans on a scale of one to five stars, with five stars represen8ng the highest quality. The CMS defines the star ra8ngs 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 pa8ent experience/complaints and access measures. Process measures are weighted the least

•  Plans are measured on mul8ple 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 Part C: 5 Domains Domain 1 Staying Healthy – Screenings, Test, & Vaccines Domain 2 Managing Chronic Condi8ons Domain 3 Ra8ngs of Plan Responsiveness & Care Domain 4 Member Complaints, Problems Gexng Services, & Choosing to Leave the Plan Domain 5 Health Plan Customer Service

Part D: 4 Domains 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 & Pa8ent Safety

CMS Star Ratings •  Star8ng 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 ra8ngs

•  CMS is highligh8ng plans that have achieved an overall quality ra8ng 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 8me during the year

CDPS Chronic Illness & Disability Payment Systems Part 4

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-‐Exis8ng Condi8ons (HCC-‐C) -‐ Medicare •  Diagnosis Related Groups (DRG) – Inpa8ent •  Adjusted Clinical Groups (ACG) – Outpa8ent PrescripMon based programs: •  MedicaidRx (UCSD) •  RxGroups (DxCG) •  Hierarchial Co-‐Exisi8ng Condi8ons (HCC-‐D) Some add: PaMent FuncMonal AbiliMes (ADL’s) 3/17/13


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History of CDPS Model •  Started in 1996 to tailor current risk adjustment models to beUer apply to Medicaid programs. Development started using claims from disabled beneficiaries informa8on 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 informa8on. Based on combining from the Chronic Disease Score (CDS) developed by Von Korff and associates and the RxRisk model by Fishman and associates 3/17/13


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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 diagnos8c and pharmacy data called CDPS + Rx •  Data was supplied by CMS from Medicaid Analy8c eXtract (MAX) data system. MAX data consists of pa8ent-‐level data files with informa8on on Medicaid eligibility, u8liza8on of services, and payments for services

3/17/13


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How Does CDPS & MRX Work? •  Mapping of diagnoses and/or pharmaceu8cal 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 pa8ent u8liza8on to 45 Medicaid Rx categories This leads to “Stage 1 Groups” (build CDPS) •  Groups ICD codes, typically at 3-‐digit level (for ICD-‐9) •  Some8mes grouped at 4th or 5th digit when that extra digit describes a more serious condi8on or version of a diagnosis 3/17/13


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Stage 1 Groups Then Combined into Major Categories: 1)  Psychiatric 2)  Skeletal 3)  Central Nervous System 4)  Pulmonary 5)  Gastrointes8nal 6)  Diabetes 7)  Skin 8)  Renal 9)  Substance Abuse 10)  Cancer

3/17/13

11)  Developmental Disability 12)  Genital 13)  Metabolic 14)  Pregnancy 15)  Eye 16)  Cerebrovascular 17)  AIDS/ Infec8ous Disease 18)  Hematological


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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 considera8on already. 3/17/13


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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 Inpa8ent and Outpa8ent encounters. •  All diagnosis codes which are current diagnoses. •  Include known status and family history codes when appropriate. •  Disabled model includes all pa8ent ages and all condi8ons. •  Code all diagnoses because they are o|en addi8ve. Also note that the CDPS + Rx model includes all 58 CDPS categories plus 15 MRX categories which iden8fy pa8ents who are filling prescrip8ons for medica8ons used for chronic condi8ons but have not had those diagnoses show in claims data. Goal to document all condiMons for all paMents. 3/17/13


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Risk Adjustment & Clinical Documenta8on 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 iden8fied. 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 condi8on (most of these do not risk adjust, but may be valuable to disease management and suspect logic) •  Persistent diagnoses such as amputa8ons, Old MI, ostomy, quadriplegia, etc. should be re-‐documented at least yearly 3/17/13


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Diagnosis Specificity •  Documenta8on of diagnoses must be specific •  This is paramount not only for Risk Adjustment programs, but also for ICD-‐10 implementa8on efforts •  Comorbidi8es; Cause and effect rela8onships of diagnoses; Loca8on; and Other modifying factors should be clearly documented •  Examples of commonly under-‐diagnosed condi8ons are diabetes and hypertension 3/17/13


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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 Hepa88s B vs. Hepa88s B –  Chronic Bronchi8s vs. Bronchi8s –  Chronic cor pulmonale vs. cor pulmonale 3/17/13


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Coding Clinic Department within AHA that makes authorita8ve determina8ons on ICD code use (fresh start on ICD-‐10 determina8ons) •  Cannot code diagnoses described as “consistent with” (includes: “suspect”, “likely”, “may be”, “rule out”, etc.) as current or ac8ve •  Cannot code hypo or hyper condi8ons when documented with up and down arrows ↑ or ↓, must be wriUen out •  Cannot code “hemiparesis” for “weakness on one side of the body”, provider must document “hemiparesis” •  Should code 414.01 (na8ve artery) for CAD when no CABG Hx 3/17/13


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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 documenta8on disparity is also o|en seen in the chief complaint or HPI (History of Present Illness) 3/17/13


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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! 3/17/13

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! 47


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

Current vs. Hx is clear:

MI in 2002! CHF! PVD! Diabetes! Allergies! A/P: 1. Diabetes! 3/17/13

MI in 2002! CHF! PVD!

CC/HPI: ……….!

Diabetes! Allergies A/P: 1. Diabetes!


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PMH in Prac8ce •  Remember to be very clear on what diagnoses or condi8ons are current or ongoing vs. those that are no longer present or historical •  Diagnoses which are not being treated but are s8ll current, to include ongoing monitoring should be documented as current •  Every current diagnosis being taken into considera8on for medical decision making should be documented in each visit as current and not documented as “historical” 3/17/13


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Documen8ng 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 pa8ents •  Diabetes codes in both ICD-‐9 and ICD-‐10 have specific codes to iden8fy diabetes-‐related manifesta8ons •  In both: The 4th digit tells manifesta8on and 5th digit tells if controlled or uncontrolled •  Only diabe8cs with no manifesta8ons should u8lize the generic diabetes ICD code 3/17/13


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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. 3/17/13


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Diabetes in ICD-‐10-‐CM Type 1

Type 2

E10.1x-‐[Check 5th]




with ketoacidosis

w/kidney complicaMons

with hyperosmolarity


E10.3x-‐[Check 5-‐6th] E11.3x-‐[Check 5-‐6th]

Other Specified (*No Unspecified code) E13.0x-‐-‐[Check 5th] w/ hyperosmolarity

E13.1x-‐-‐[Check 5th] w/ ketoacidosis

E13.2-‐[Check 5th]


E13.3-‐[Check 5-‐6th]

w/ ophthalmic comp.

w/ ophthalmic comp.



w/ neuro. complicaMons

w/ neuro. complicaMons



E13.5-‐[Check 5th]

w/ neuro. complicaMons w/ circulatory comp.

w/ circulatory comp.

w/ ophthalmic comp.

E13.4-‐[Check 5th] w/ circulatory comp.

E10.6x-‐[Check 5-‐6th] E11.6x-‐[Check 5-‐6th]

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

E10.8 w/ unspecified E11.8 w/ unspecified

E13.8 w/ unspecified complicaMons

w/ other spec. comp.

w/ other spec. comp.

complicaMons

complicaMons

E10.9 without

E11.9 without

complicaMons 3/17/13

complicaMons

complicaMons

E13.9 without complicaMons


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Documen8ng & Coding Diabetes •  Under-‐documen8ng DM communicates a less serious DM case, which affects value of care •  Any manifesta8ons must be documented as a cause and effect rela8onship, for example: ①  Assessment: 1. DM 2. Polyneuropathy §  § 

Can only code: 250.00 and 356.9 (ICD-‐9-‐CM) E13.9 and G62.9 (ICD-‐10-‐CM) [Lower Value DM]

②  Assessment: 1. DM with Polyneuropathy §  §  3/17/13

Can code: 250.60 and 357.2 E13.42 and (ICD-‐10-‐CM) [Higher Value DM] © ionHealthcare, LLC All rights reserved. For educa8on & discussion purposes. PermiUed use via contractual agreement/purchase.

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Documen8ng & Coding HTN •  Under-‐documen8ng HTN communicates a less serious HTN case, which affects value of care •  Any manifesta8ons must be documented as a cause and effect rela8onship (CKD is an excep8on) Hypertension Type

3/17/13

ICD-‐9-‐CM

ICD-‐10-‐CM

HTN (primary, benign, essen8al, 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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Documen8ng & Coding Cancers •  Per guidelines, cancers are coded by their loca8on and may only be coded as ac8ve when current treatment is being directed to the cancer, or if the cancer is ac8ve and treatment was refused •  Radia8on, Chemotherapy, and Hormonal treatments used specifically for a given cancer qualify as current treatment •  Without current treatment, the pa8ent only has a personal history of cancer (V code) and these typically do not risk adjust •  Helpful to know if cancer is primary, metasta8c, and what treatments are ongoing in order to code 3/17/13


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Documen8ng & Coding Depression

•  Pa8ents who are on an8-‐depressant therapy are considered to have “major depression” clinically •  Providers rarely document it this way, o|en only no8ng “depression” •  Coders can only code what is documented and “depression” alone defaults to “situa8onal 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 pa8ents are receiving therapy these scores may not reflect the diagnosis and this should be noted 3/17/13


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Documenta8on Tips •  Avoid homegrown abbrevia8ons •  Document all cause and effect rela8onships •  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, & creden8al (MD, DO, NP, PA, etc.) •  Document history of heart aUack, any amputa8ons, hypoxia, status codes, ostomy, etc., when factual •  Only document diagnoses as “history of” or “PMH” when they no longer exist or are a current condi8on 3/17/13


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Ques8ons

3/17/13


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References • Larsen, Steve. (2011). Risk adjustment and health insurance. Healthcare Blog October 13, 2011. Retrieved March 21, 2013 from hUp://www.healthcare.gov/blog/2011/10/ riskadjust10132011.html • ICD-‐9-‐CM, Official Guidelines • ICD-‐10-‐CM, Official Guidelines

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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 Prac8ce Op8miza8on -‐ Leadership Mentoring Healthcare Educa8on and Networking for Pa8ents and Professionals -‐ Risk Adjustment

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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 trea8ng MD. Assessment: 1.  DM with polyneuropathy 2.  Hypertension 3.  Heartburn Can the coder document GERD in the above note? a)  Yes b)  No

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Applying Concepts Quiz 1.  Answer: b) No

Ra8onale: The documenta8on 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 documen8ng actual diseases as opposed to their symptoms if they are a current true diagnosis.

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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 trea8ng 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 3/17/13


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

Ra8onale: In this example, There is no “cause & effect” demonstrated between the diabetes and the peripheral neuropathy. If the provider has documented the cause & effect rela8onship such as: “DM with peripheral neuropathy”, “Peripheral neuropathy due to diabetes”, “Diabe8c peripheral (or poly) neuropathy”, etc., then the codes would be jus8fied for a 250.60 and a 357.2. This example illustrates the importance of documen8ng all cause & effect rela8onships, especially in diabetes. 3/17/13


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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 trea8ng MD. CC/HPI: Mr. Chang 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 ac8ve diagnosis? a)  Yes b)  No 3/17/13


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Applying Concepts Quiz 3.  Answer: b) No

Ra8onale: 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 ac8ve prostate cancer code. Guidelines require that in order for cancers to be coded as current/ac8ve, there must be treatment directed to the cancer. If the pa8ent had been on radia8on, 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


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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 trea8ng 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 3/17/13


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Applying Concepts Quiz 4.  Answer: c) 300.4

Ra8onale: In this example, the documenta8on only states depression with anxiety. Even though she is on an an8-‐ depressant medica8on, the diagnosis of “major depression” has not been made, and coders may not assump8ve 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 combina8on code would be correct for these two together.

This example highlights depression vs. major depression & anxiety coding. 3/17/13


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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 trea8ng 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

Ra8onale: In this example, the provider did not use specific documenta8on for the kidney disease. Had the provider noted it as “chronic”, then a 585.9 code would be correct for unspecified staging. Without the descrip8on 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


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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 trea8ng 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 men8oned above as an ac8ve diagnosis? a)  Yes b)  No

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Applying Concepts Quiz 6.  Answer: b) No Ra8onale: 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 pa8ent is on Coumadin, o|en used for DVT treatment, however she also has A-‐Fib., and it is more likely that this medica8on is being used for the ongoing atrial fibrilla8on. This example illustrates the cri8cal thinking necessary for reviewing current medica8ons as they pertain to PMH diagnoses in order to iden8fy them as current or ac8ve problems. 3/17/13


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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 trea8ng 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 men8oned above as an ac8ve diagnosis? a)  Yes b)  No

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Applying Concepts Quiz 7.  Answer: a) Yes

Ra8onale: While angina is listed as “PMH” (Past Medical History), the pa8ent is currently on nitro-‐stat (which is used to manage angina) and this makes the angina recognized as a current or ac8ve condi8on. The provider should have annotated the angina in the assessment to remove any ques8on of the diagnosis, but under this situa8on, the code may s8ll be captured.

This example illustrates the use of PMH to iden8fy ac8ve diagnoses when specific medica8ons support the diagnosis as ongoing or current. 3/17/13


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 trea8ng 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 men8oned above as an ac8ve diagnosis? a)  Yes b)  No 3/17/13


75

Applying Concepts Quiz 8.  Answer: b) No Ra8onale: The Coding Clinic (a department within the AHA-‐ American Hospital Associa8on) issues formal rulings on diagnosis coding. One of those rulings states that any diagnosis described as “consistent with” cannot be coded as ac8ve or current as the descrip8on 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”. 3/17/13


76

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 trea8ng 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

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77

Applying Concepts Quiz 9.  Answer: b) 728.87 Ra8onale: In this example, there is only a “le| weakness noted”. Another Coding Clinic determina8on 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 condi8ons 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 documenta8on as well as specific wording to code correctly. It also highlights the rule for CVA coding. 3/17/13


78

Applying Concepts Quiz 10.  The following assessment is found in a Hand-‐wriUen 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 3/17/13


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Applying Concepts Quiz 10.  Answer: d) 401.9

Ra8onale: The HTN is the only code that can be obtained from this example. Posi8ve history of smoking cannot translate to tobacco dependence (it must be stated), so the 305.1 code is incorrect. The diabetes is very ques8onable due to legibility, so it should not be coded. The cholesterol is listed as “↑ chol”. The Coding Clinic has a determina8on that coders may not code from up and down arrows ↑ or ↓, as these are not defini8ve 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 documenta8on specificity. 3/17/13


80