Conditions of the Heart. (For Risk Adjustment Purposes)

Transcription

1 Conditions of the Heart (For Risk Adjustment Purposes)

2 Disclaimer The information presented herein is for information purposes only. HIMS BMG Coding and Compliance Education has prepared this education using Banner Health Ethics and Compliance approved regulatory and industry authoritative resources. It is designed to provide accurate and authoritative information on the subject matter. Every reasonable effort has been made to ensure its accuracy. Nevertheless, the ultimate responsibility for correct use of the coding system and the publication lies with the user. Any codes are to be used for easy reference; however, the CPT code book and the ICD-10-CM code books and the Official Guidelines for Coding and Reporting are the authoritative references for accurate and complete coding. HIMS BMG warrants that the information contained herein is accurate and up to date according to the approved authoritative resources, but may not be free from defects. 2

3 Objectives Conditions of the Heart Documentation of Heart Conditions ICD-10-CM documentation and coding guidelines. 3

4 Cardiovascular Disease 4

5 Cardiovascular Disease Cardiovascular disease (CVD) is the leading cause of death in the United States, according to the CDC. CVD covers a range of cardiovascular problems, for example: Coronary artery disease (CAD) Heart rhythm abnormalities (arrhythmia) Atherosclerosis (Harding of the arties) Congenital heart defects Heart infections

6 CMS Preventative Services Cardiovascular disease There are a number of CMS Preventative Services that involve cardiovascular disease: Intensive Behavioral Therapy (IBT) for Cardiovascular Disease (CVD) Cardiovascular Disease Screening Tests 6

7 CMS Preventative Services Cardiovascular disease 7

8 CMS Preventative Services Cardiovascular disease 8

9 Documentation for cardiovascular disease Clinical suggestion: Prior to this visit, ensure that the patient has had a fasting lipid profile and glucose and review the patient s most recent screening EKG. Physical examination: Document blood pressure, heart rate, height, weight and BMI during clinic visit. Head and neck: JVD, carotid bruits, chest, heart, abdomen, lower extremity: peripheral edema, pedal pulses Labs: Review lipid profile, diabetes screening and bring pertinent findings into body of progress note. EKG: Report results from screening EKG. Perform every 1 2 years Assessment: Document all pertinent diagnoses Document all pertinent risk factors for cardiovascular disease 9

10 Document Risk Factors New for ICD-10-CM is guidance to use additional codes, if applicable, to indicate: Personal history of nicotine dependence Current tobacco dependence Tobacco use Exposure to environmental tobacco smoke (acute) (chronic) Occupational exposure 10

11 Document Risk Factors Body mass index (BMI) Angina Coronary artery bypass graft (CABG) Arrhythmia/Dysrhythmia (specify type) Hypertension Hypertensive heart disease Hypertensive chronic kidney disease Hypertensive heart and chronic kidney disease Diabetes Peripheral vascular disease Hypercholesterolemia Exercise tolerance, shortness of breath on exertion Family history of CVD 11

12 Coronary Disease Coronary artery disease (CAD) develops when the coronary arteries become damaged or diseased. Plaque in the arteries and inflammation are usually to blame for CAD. As plaques build up coronary arteries become narrow, decreasing blood flow to the heart. Ultimately, the decreased blood flow may cause shortness of breath or angina or other coronary artery disease symptoms. A complete blockage of the arteries can cause a heart attack. 12

13 Coronary Disease Atherosclerotic Coronary Artery Disease and Angina ICD-10-CM has combination codes for atherosclerotic heart disease with angina pectoris. The subcategories for these codes are: I25.11x Atherosclerotic heart disease of native coronary artery with angina pectoris I25.7x Atherosclerosis of coronary artery bypass graft(s) and coronary artery of transplanted heart with angina pectoris 13

14 Coronary Disease When using one of these combination codes it is not necessary to use an additional code for angina pectoris. A causal relationship can be assumed in a patient with both atherosclerosis and angina pectoris Unless the documentation indicates the angina is due to something besides atherosclerosis If a patient with coronary artery disease is admitted due to an acute myocardial infarction (AMI), the AMI should be sequenced before the coronary artery disease. 14

15 Myocardial Infarction 15

16 Myocardial Infarction (MI) A heart attack occurs when the blood flow that brings oxygen to the heart muscle is severely reduced or cut off completely. When the heart muscle is starved for oxygen and nutrients, it is called ischemia. A heart attack or myocardial infarction occurs when damage or death of part of the heart muscle occurs as a result of ischemia. Approximately every 43 seconds, someone in the United States has a myocardial infarction 16

17 Documentation MI1 ST elevation(stemi) o Other o o Requires site and specific artery Anterior Wall Left Main coronary artery Left anterior descending artery Other coronary artery of anterior wall Inferior Wall Right coronary artery Other coronary artery of inferior wall Left circumflex coronary artery Other Specified Non-ST elevation MI (NSTEMI) o Requires episode of care reporting only 17

18 Documentation of MI2 Document date of any recent acute MIs within 28 days of admission Document whether or not the current MI has occurred within 28 days of a previous MI Document if the patient has a history of an MI (older than 28 days) Document any associated diagnoses/conditions 18

19 Myocardial Infarction Patient admitted with AMI Note: sequencing depends on circumstances of admission Previous MI? Yes No Older than 28 days? Code I21-Initial MI YES, I21 Initial MI and I25.2 Old MI NO, I22-Subsequent MI and I21 Initial 19

20 Aftercare for MI For encounters after the 4 week time frame and the patient is still receiving care related to the MI, the appropriate after care code should be assigned. I25.2 may be assigned for an old MI. 20

21 Heart Failure 21

22 Heart Failure Heart failure (HF), a clinical syndrome in which a variety of symptoms, physical signs or laboratory abnormalities are due to disordered cardiac function. Clinical manifestations generally include dyspnea, fatigue and fluid retention, in most individuals cardiac function declines and symptoms progress over time. Congestive heart failure (CHF) CHF defines the mechanical inability to pump blood efficiently, consequently compromising circulation which then causes systemic complications due to fluid build-up in the lung and other tissues. 22

23 Documentation Heart Failure Document type- systolic, diastolic, or combined Document acuity- acute, chronic, acute on chronic Due to or associated with- Is there an underlying cause? TIP- If the patient is being seen for a condition other than heart failure but the heart failure is documented in the record and the patient is receiving treatment for it, or the patients care, treatment and/or management is affected by the heart failure, the heart failure should be coded as a secondary condition. 23

24 Additional dx documented/coded Exposure to environmental tobacco smoke (Z77.22) Occupational (Z57.31) History of tobacco use (Z87.891) Tobacco use (Z72.0) Tobacco dependence (F17.-) 24

25 Documentation Best Practices 25

26 CMS Accurate chart documentation and diagnosis reporting determines reimbursement for the CMS Medicare Advantage Plans under the Risk Adjustment Program 26

27 Meet the M.E.A.T! One of the Top 10 coding errors for risk adjustment: Documentation does not indicate that the diagnoses are being monitored, evaluated, assessed/addressed, or treated (MEAT). 27

28 M.E.A.T. Documentation must show how chronic condition is being treated, managed or assessed on EACH date of service. Each diagnosis should have an assessment and a plan. Assessment Stable Improved Tolerating Meds Deteriorating Uncontrolled Language Samples Plan Monitor D/C Meds Continue Current Meds Refuses Treatment Refer If the documentation is unclear, physician clarification may be necessary to assist in accurate code assignment 28

29 Examples 29

30 Case Study 1 This 54 year old female is being treated for an acute non- ST anterior wall myocardial infarction which she suffered 5 days ago. She also has atrial fibrillation. What are the correct diagnosis codes? I21.4 Infarct, Infarction, myocardium, myocardial (acute) (with stated duration of 4 weeks or less),non ST elevation (NSTEMI) I48.91 Unspecified, atrial fibrillation 30

31 Rationale: Case Study 1 Rationale: Per the Official Coding Guidelines, Code I21.4, Non-ST elevation (NSTEMI) myocardial infarction, is used for Non-ST elevation myocardial infarction and nontransmural MI s. 31

32 Case Study 2 Assign the correct diagnosis codes: Acute cerebrovascular infarction, embolism of the left cerebellar artery with dysphagia and right hemiplegia. I Infarct, infarction, cerebellar see Infarct, cerebral. I Dysphagia following CVA. I Hemiplegia following CVA. 32

33 Rationale: Case Study 2 Rationale: ICD-10-CM provides specific codes to identify the involved artery in a cerebrovascular infarction. There is a note under code I to use additional code to identify type of dysphagia, if known (R13.1-). Right dominant side (I69.351) was selected based on Coding Guideline I.C.6.a which states should the affected side be documented, but not specified as dominant or nondominant, and the classification system does not indicate a default, code selection is as follows: if the right side is affected the default is dominant. 33

34 Case Study 3 Assign the code for Stage 3 chronic kidney disease with congestive heart failure (CHF) due to hypertension. I13.0 Hypertension, hypertensive, (accelerated) (benign) (essential) (idiopathic) (malignant) (systemic), cardiorenal (disease), with heart failure, with stage 1-4 CKD I50.9 Failure, failed, heart (acute) (senile) (sudden), congestive (compensated) (decompensated) N18.3 Disease, diseased, kidney (functional) (pelvis), chronic, stage 3 (moderate) 34

35 Rationale: Case Study 3 Rationale: In ICD-10-CM, a combination code is used to identify those diagnoses that include hypertensive heart and kidney disease. Under I13.0 there is a use additional code note to identify both the type of heart failure and the stage of chronic kidney disease. I 35

36 Rationale: Case Study 3 ICD-10-CM assumes a cause-and-effect relationship and classifies chronic kidney disease with hypertension as hypertensive chronic kidney disease, when both hypertension and chronic kidney disease are present. 36

37 Case Study 4 This 63 year old male is being seen for treatment of his unstable angina. This gentleman has a history of 2 vessel coronary artery bypass approximately 18 months ago. A recent cardiac catheterization shows continued evidence of coronary arteriosclerosis but both of the bypass grafts are patent. Also of note, is that this patient suffered a cerebrovascular infarction three years ago which resulted in right side (dominant) hemiparesis. What is the correct diagnosis codes? I Angina (attack) (cardiac) (chest) (heart) (pectoris) (syndrome) (vasomotor), with atherosclerotic heart disease see Arteriosclerosis, coronary (artery), native vessel with angina pectoris, unstable I Hemiparesis see Hemiplegia, following, cerebrovascular disease, cerebral infarction Z95.1 Status (post), aortocoronary bypass 37

38 Rationale: Case Study 4 Rationale: The coronary artery disease of the native vessel is coded because the previous cardiac catheterization showed that the bypass grafts are patent. Also, per the Official Coding Guidelines, ICD-10-CM has combination codes for atherosclerotic heart disease with angina pectoris. When using one of these combination codes it is not necessary to use an additional code for angina pectoris. A causal relationship can be assumed in a patient with both atherosclerosis and angina pectoris, unless the documentation indicates the angina is due to something other than atherosclerosis. 38

39 References: ICD-10-CM Official Guidelines for Coding and Reporting Effective October 1, 2015, Module Plans/MedicareAdvtgSpecRateStats/Downloads/Advance2014.pdf Items/Prelim-IDC10Mappings.html?DLPage=1&DLSort=0&DLSortDir=descending echart_1.pdf CMS 2014 Payment Year Risk Adjustment Model 39

40 Contact RAF Team: 38