Coding to be more efficient and accurate

Transcription

1 Why we need to code well! Coding to be more efficient and accurate Diabetes without Complication Diabetes with opthamologic or unspecified complication Diabetes with acute complication $1833 $2931 $3836 Diabetes with Neurologic complication Diabetes with renal or cirulatory complication $4617 $5749 Two parts to diabetic coding CPT Coding CPT codes in order entry area allow for Medicare payment and for population studies by Kaiser E & M coding in the LOS area allows for patient mix payment (the other 70% of our patients) Efficiency and accuracy are paramount for maximal legal reimbursement 1

2 What is Diabetic Dyslipidemia? Diabetic dyslipidemia is the elevated triglycerides and reduced HDL-cholesterol in the blood caused by diabetes. It is not an abnormality of LDL-C C level. How to define it NCEP ATP III definitions: Triglycerides Normal: < 150 mg/dl Borderline-high: mg/dl High: > 200 mg/dl HDL-Cholesterol Low: < 40 mg/dl in both men and women We will use a conservative definition for diabetic dyslipidemia: TG > 200 mg/dl AND HDL-C C < 40 mg/dl How to define it How to code it Mixed dyslipidemia is a genetic disease that often co- exists with diabetes and has both elevated triglycerides and elevated LDL-C. TG > 200 and HDL-C C < 40 = DM Dyslipidemia TG > 150 and LDL-C > 100 = Mixed Dyslipidemia (is not caused by diabetes) Both conditions should be treated with a statin to lower LDL-C C to < 100 mg/dl. Both diagnoses can be coded if present in the same individual. Compound Code : DM 2 W LOW HDL AND HIGH TRIGLYCERIDE DUE TO DM (DIABETIC DYSLIPIDEMIA) Type DM L to bring up the diagnosis Reports both ICD-9 9 codes: and Compound Code also exists: DM 2 W DIABETIC DYSLIPIDEMIA Type DM DYSL to bring up the diagnosis Reports the same codes and pays the same as

3 HealthConnect Codes Four relevant codes in HealthConnect: CORRECT: DM 2 W LOW HDL AND HIGH TRIGLYCERIDE DUE TO DM (DIABETIC DYSLIPIDEMIA) DM 2 W DIABETIC DYSLIPIDEMIA HYPERLIPIDEMIA, MIXED NOT CORRECT: DM 2 W DIABETIC HYPERLIPIDEMIA, MIXED What is DM MAU? Why should I care? DM microalbuminuria: Definition: 30-<300 mcg albumin/mg creatinine in urine x 2 in 24 months in past (even if suppressed with ACEI etc later) Have not met criteria for overt CKD: MACROalbuminuria in urine >=300 x 2 for CKD 1/2 OR with GFR low enough to qualify for CKD (GFR < 2 SD for age). One of 1st manifestations of systemic end organ damage in DM Quality Implications: 2X CVD risk for death, 4x risk for ESRD Amenable to ALL therapy: lower risk for ESRD, lower risk of death at 13 years 65yo+: over 15,000 missed pts with DM renal manifestations DM MAU on the continuum before DM CKD DM 2 KIDNEY DIAGNOSES KPHC Proactive Care KPHC description code 'CKD' Explanation DM 2 w/ Diabetic Microalbuminuria DM MAU NO CKD stage & urine MAU/CR 1 >=30 but <300 x DM 2 w/ Diabetic CKD Stage 1 STG 1 GFR >=90 & MAU/CR >=300 x DM 2 w/ Diabetic CKD Stage 2 STG 2 GFR & MAU/CR>=300 x DM 2 w/ Diabetic CKD Stage 3 STG 3 GFR >3 months 4, DM 2 w/ Diabetic CKD Stage 4 STG 4 GFR >3 months DM 2 w/ Diabetic CKD Stage 5 STG 5 GFR <15 > 3 months DM 2 w/ Diabetic End Stage Renal on hemodialysis or peritoneal Hemo or PD Disease on dialysis dialysis 1 MAU/CR=microalbumin/creatinine in mcg/mg creatinine with results during pregnancy excluded. 2' "x 2" means on 2 separate occasions in past in 24 month window even if more recent values are normalized with treatment of blood pressure or use of angiotensin converting enzyme inhibitors, angiotensin receptor blockers, renin inhibitors, aldosterone inhibitors, or diabetic control. 3 or urine protein/creatinine ratio >0.3 or 24 urine protein >300 mg/day on 2 sequential occasions in past even if normalized with treatment. 4 Added specificity for CKD in this range of GFR per POINT algorithm is GFR +1/2 age <85 OR proteinuria as in definition for CKD stage 1&2 5 Up to 30% of DM with GFR <60 lack both retinopathy and microalbuminuria (NHANES III,JAMA 2003; 289: ). Using the chronic disease form Helps with both types of coding Is populated from the problem list Will populate the encounter diagnosis section of the order entry screen when completed Completing at least three chronic diagnosis allows for higher level of LOS There is no definitive biopsy data to say whether CKD is due to DM so clinician may decide. 3

4 The chronic disease form Completed Chronic Disease Form Completed encounter Diagnosis form.diag completes the documentation 4

5 Maximizing Reimbursement Manifestations in order of reimbursement: 1. Renal or Peripheral Circulatory 2. Neurologic or other specified 3. Diabetes with acute complications 4. Ophthamologic or unspecified 5. Diabetes without complication Remember Many of the diagnosis are additive? Renal Manifestations due to DM CKD DM2 w/ other unspecified manifestations (for mixed hyperlipidemia) These payments add together from medicare,, but they must be linked to diabetes to get maximimum payment: use codes (combined codes) * This payment is actually downcoded due to being a secondary diagnosis, but there is still an additional payment Codes codes: examples The codes automatically combine Diabetes with complications. They attribute the complication to diabetes which upcodes the payment. You should never be coding a diabetic without using the codes. I keep them in my diabetes coding preference list along with codes for foot exam and smoking histories so that I can just click down all the diabetic diagnoses. 5

6 Just the additional coding of mixed hyperlipidemia or erectile dysfunction increases the payment by $3500. Of course, you must actually ask about these complications, include them in your note and in your assessment and plan Do you ask your patients to roll up their pant legs? Diabetic Dermopathy has a separate code: DM2 w Diabetic Dermopathy This gets paid like diabetes with an unspecified manifestation: (this is NOT additive to the mixed hyperlipidemia or any of the neuropathies) 6

7 USE CORRECT LINK TO LOOK FOR MICROALBUMIN/CREATININE RESULTS IN KPHC.brieflab[malbcreat:100 MICROALBUMIN/CREATININE /26/2009 MICROALBUMIN/CREATININE /23/2008 MICROALBUMIN/CREATININE /09/2007 MICROALBUMIN/CREATININE /10/2007 MICROALBUMIN/CREATININE /23/2006.LASTMICROALBPANEL MICROALB /26/2009 MICROALBUMIN/CREATININE /26/2009 PROT/CREAT UR /07/2006.LASTMICROALB.BRIEFLAB[MICROALB:1 MICROALB /26/2009 LOS form 7

8 The problem list: one way to add chronic diseases 8