Risk Adjustment Training

Transcription

1 Risk Adjustment Training HCC, CDPS, and Hybrid models 2014 National Conference Education provided by: Brian Boyce, BSHS, CPC, CPC-I Proprietor & Managing Consultant, ionhealthcare, LLC 1 1

2 No part of this presentation may be reproduced or transmitted in any form or by any means (graphically, electronically, or mechanically, including photocopying, recording, or taping) without the expressed written permission of AAPC or ionhealthcare, LLC. 2 What is Risk Adjustment? Foundations of RA Models 3 2

3 Introduction Risk Adjustment is a methodology of adjusting estimated or perceived risks as they relate to diagnosis codes of patients Understanding each current illness or diagnosis a patient has helps to estimate needed funding for future years and in some models, applies to payments for treating those illnesses There are different forms of risk adjustment models, to include: HCC CDPS Hybrid 4 Introduction Within risk adjustment models, there are usually two branches of risk reviewed: 1. Diagnosis-based risk adjustment examples: Chronic illness and Disability Payment Systems (CDPS) Medicaid Hierarchical Co-Existing Conditions (HCC-C) Medicare Diagnosis Related Groups (DRG) Inpatient Adjusted Clinical Groups (ACG) Outpatient 2. Prescription-based risk adjustment examples: MedicaidRx (UCSD) RxGroups (DxCG) Hierarchical Co-Existing Conditions (HCC-D) 5 3

4 Why It Matters For Medicare Advantage Plans 1 Risk Adjustment (RA) identifies patients who may need disease management interventions and 2 RA establishes the financial allotment from CMS toward the annual care of each patient; with more dollars allocated for those with higher risk scores For Medicaid and Commercial Plans 1 Risk Adjustment (RA) identifies patients who may need disease management interventions and 2 RA establishes the overall state of the population by aggregating diagnoses; which assists in financial forecasting for future medical need 6 General RA Guidelines These programs operate on similar rules and guidelines to include: Specific diagnoses must be documented in a face-toface visit by the treating licensed provider (showing credentials: MD, DO, PA, NP, OT, CRNA, MSW, and similar master s level providers) and the documentation must be signed by the treating provider to be accepted Diagnoses must be clearly stated on the DOS (Date Of Service) as a current problem Diagnoses must be documented each year, ongoing as each year is evaluated without historical context influence 4

5 Acceptable Provider Specialties CODE SPECIALTY CODE SPECIALTY CODE SPECIALTY 01 General Practice 25 Physical Medicine & Rehabilitation 67 Occupational 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 Addiction Medicine 08 Family Practice 35 Chiropractic 80 LCSW 09 Interventional Pain Management (IPM) 36 Nuclear Medicine 81 Critical Care (Intensivists) 10 Gastroenterology 37 Pediatric Medicine 82 Hematology 11 Internal Medicine 38 Geriatric Medicine 83 Hematology/Oncology 12 Osteopathic Manipulative Therapy 39 Nephrology 84 Preventative Medicine 13 Neurology 40 Hand Surgery 85 Maxillofacial Surgery 14 Neurosurgery 41 Optometry (optometrists) 86 Neuropsychiatry 15 Speech Language Pathologist 42 Certified Nurse Midwife 89 Certified Clinical Nurse Specialist 16 Obstetrics/Gynecology 43 CRNA 90 Medical Oncology 17 Hospice and Palliative Care 44 Infectious Disease 91 Surgical Oncology 18 Ophthalmology 46 Endocrinology 92 Radiation Oncology 19 Oral Surgery (Dentists only) 48 Podiatry 93 Emergency Medicine 20 Orthopedic Surgery 50 Nurse Practitioner 94 Interventional Radiology 21 Cardiac Electrophysiology 62 Psychologist 97 Physician Assistant 22 Pathology 64 Audiologist 98 Gynecologist/Oncologist 23 Sports ionhealthcare, Medicine LLC All rights reserved. For education & discussion 65 Physical purposes. Therapist Permitted use via contractual agreement/purchase. 99 Unknown Physician Specialty 24 Plastic & Reconstructive Surgery 66 Rheumatology C0 Sleep Medicine 8 Diagnosis Code Value In risk adjustment models diagnosis codes carry a risk adjustment value (RAF or risk adjustment factor in the HCC model) This is similar to the concept of RVU (Relative Value Units) assigned to CPT codes The more severe or complex a diagnosis, the higher its value If two or more diagnoses are documented from the same category, the diagnosis that is more severe or complex will trump any others 9 5

6 No Conditions Coded (Demographics Only) Financial Matters Some Conditions Coded (Claims Data Only) All Conditions Coded (Chart Review by Certified Coder) 76 year old female year old female year old female.468 Medicaid Eligible.177 Medicaid Eligible.177 Medicaid Eligible.177 DM Not Coded DM (no manifestations).118 DM with Vascular.368 Manifestations Vascular Disease Vascular Disease.299 Vascular Disease.41 not coded without complication with complication CHF not coded CHF not coded CHF coded.368 No interaction No interaction + Disease Interaction.182 bonus RAF (DM + CHF) Patient Total RAF.645 Patient Total RAF Patient Total RAF PMPM Payment for Care $452 PMPM Payment for Care $743 PMPM Payment for Care $1,381 Yearly Reserve for Care $ 5,418 Yearly Reserve for Care $8,921 Yearly Reserve for Care $16,573 Hierarchical Categories Families or hierarchical groups/categories are used in risk adjustment More severe or complicated illnesses (by ICD code) in the family or hierarchy will trump all others in the category or family Sometimes codes which are trumped by others from a medical management perspective (Part C) may still carry value from a prescription drug perspective (Part D) This leads to a strong need for coders to always code diagnoses to their highest specificity so that all current diagnoses are accounted for each encounter ICD guidelines instruct coders to code for a principal diagnosis, but also all other comorbidities during each encounter 11 6

7 Hierarchical Categories in the HCC Model Infection 2014 Hierarchical Categories in the HCC Model 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 Disability Status Musculoskeletal Heart Injury 12 Hierarchical Categories in the CDPS Model 2014 CDPS Major Categories Psychiatric Skin Metabolic Skeletal Renal Pregnancy Central Nervous System Substance Abuse Eye Pulmonary Cancer Cerebrovascular Gastrointestinal Developmental Disability AIDS/Infectious Disease Diabetes Genital Hematological 13 7

8 Trump Examples (HCC) If this HCC is found **2014 Disease Group Label** Then Drop these HCC s: 8 Metastatic Cancer and Acute Leukemia 9,10,11,12 9 Lung and Other Severe Cancers 10,11,12 10 Lymphoma and Other Cancers 11,12 11 Colorectal, Bladder, and Other Cancers 12 If this HCC is found **2014 Disease Group Label** Then Drop these HCC s: 17 Diabetes with Acute Complications 18,19 18 Diabetes with Chronic Complications Trump Examples (CDPS) Cardiovascular Category (4 levels) 1. CARVH includes 3 Stage 1 groups and 7 diagnoses 2. CARM includes 13 Stage 1 groups and 53 diagnoses 3. CARL includes 26 Stage 1 groups and 314 diagnoses 4. CAREL includes 2 Stage 1 groups and 35 diagnoses Where the suffix of the Cardiovascular Category (CAR) establishes its place in the hierarchy. For example: VH (Very High) (weight 2.037): heart transplants, valves, etc. M (Medium) (weight 0.805): heart attacks, etc. L (Low) (weight 0.368): heart disease, etc. EL (Extra Low): hypertension etc. 15 8

9 The HCC Model is Ever-Changing The original DCG/HCC model in 2000 identified 804 costly diagnosis groups, mapped to 189 HCC codes Created a reporting model for reimbursement based on ICD codes within families of conditions. (Hierarchal Categories) There are 2,944 ICD codes carrying Part C HCC value (over 3,000 in 2004) There are 1,475 ICD codes carrying Part D HCC value (over 3,000 in 2004) 978 ICD codes carry both Part C and Part D HCC value (~ 1500 in 2004) Major Changes are due for 2014 Many Part C s dropped to Part D only Blended model in 2014 (mixing values from 2013 model and 2014 model) Many new interactions If this HCC is found **2013 Disease Group Label** Then Drop these HCC s: 5 Opportunistic Infections Metastatic Cancer and Acute Leukemia 8, 9, 10 8 Lung, Upper Digestive Tract, and Other Severe Cancers 9, 10 9 Lymphatic, Head and Neck, Brain and Other Major Cancers Diabetes with Renal Manifestations or Peripheral Circulatory Manifestation 16, 17, 18, Diabetes with Neurologic or Other Specified Manifestation 17, 18, Diabetes with Acute Complication 18, Diabetes with Ophthalmologic or Unspecified Manifestations End Stage Liver Disease 26, Cirrhosis of Liver Drug/Alcohol Psychosis Schizophrenia Quadriplegia/Other Extensive Paralysis 68, 69, 100, 101, Paraplegia 69, 100, 101, Spinal Cord Disorders/Injuries Respirator Dependence/Tracheotomy Status 78, Respiratory Arrest Acute Myocardial Infarction 82, Unstable Angina and Other Acute Ischemic Heart Disease Cerebral Hemorrhage Hemiplegia/Hemiparesis Vascular Disease with Complications 105, Cystic Fibrosis Aspiration and Specified Bacterial Pneumonias Dialysis Status 131, Renal Failure Decubitus Ulcer of Skin Severe Head Injury 75, Traumatic Amputation 177 9

10 If this HCC is found **2014 Disease Group Label** Then Drop these HCC s: 8 Metastatic 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 Diabetes with Acute Complications 18,19 18 Diabetes with Chronic Complications End-Stage Liver Disease 28,29,80 28 Cirrhosis of Liver Severe Hematological Disorders Drug/Alcohol Psychosis Schizophrenia Quadriplegia 71,72,103,104, Paraplegia 72,104, Spinal Cord Disorders/Injuries Respirator Dependence/Tracheostomy Status 83,84 83 Respiratory Arrest Acute Myocardial Infarction 87,88 87 Unstable Angina and Other Acute Ischemic Heart Disease Cerebral Hemorrhage Hemiplegia/Hemiparesis Atherosclerosis of the Extremities with Ulceration or Gangrene 107,108,161, Vascular Disease with Complications Cystic Fibrosis 111, Chronic Obstructive Pulmonary Disease Aspiration and Specified Bacterial Pneumonias Dialysis Status 135,136, Acute Renal Failure 136, Chronic Kidney Disease (Stage 5) Pressure Ulcer of Skin with Necrosis Through to Muscle, Tendon, or Bone 158, Pressure Ulcer of Skin with Full Thickness Skin Loss Severe Head Injury 80,167 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-Existing Conditions (HCC-C) - Medicare Diagnosis Related Groups (DRG) Inpatient Adjusted Clinical Groups (ACG) Outpatient Prescription based programs: MedicaidRx (UCSD) RxGroups (DxCG) Hierarchial Co-Exisiting Conditions (HCC-D) Some add: Patient Functional Abilities (ADL s) 10

11 History of CDPS Model Started in 1996 to tailor current risk adjustment models to better apply to Medicaid programs. Development started using claims from disabled beneficiaries information 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 information. Based on combining from the Chronic Disease Score (CDS) developed by Von Korff and associates and the RxRisk model by Fishman and associates History of CDPS Model In 2008, CDPS and MRX models were updated using Medicaid data from 44 states in 2001 and Another model was developed employing both diagnostic and pharmacy data called CDPS + Rx Data was supplied by CMS from Medicaid Analytic extract (MAX) data system. MAX data consists of patient-level data files with information on Medicaid eligibility, utilization of services, and payments for services More on CDPS: University of California, San Diego website: 11

12 How Does CDPS & MRX Work? Mapping of diagnoses and/or pharmaceutical 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 patient utilization to 45 Medicaid Rx categories This leads to Stage 1 Groups (build CDPS) Groups ICD codes, typically at 3-digit level (for ICD-9) Sometimes grouped at 4 th or 5 th digit when that extra digit describes a more serious condition or version of a diagnosis Predictive Modeling Diagnosis with no complications DME; Rx; CPT; Labs; HCPCS; etc. Diagnosis with some complication? 12

13 Quality Improvement CMS defines the star ratings 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 Variable weights are given to each measure with those related to outcomes being weighted highest, followed by patient experience measures in the middle, and process measures being lowest Quality Improvement Medicare Part C Domains for 2014: Quality of Care Domain 1 Domain 2 Domain 3 Domain 4 Domain 5 Staying Healthy Screenings, Test, & Vaccines Managing Chronic Conditions Ratings of Plan Responsiveness & Care Member Complaints, Problems Getting Services, & Choosing to Leave the Plan Health Plan Customer Service Medicare Part D Domains for 2014: Quality of Care Domain 1 Domain 2 Domain 3 Domain 4 Staying Healthy Screenings, Test, & Vaccines Managing Chronic Conditions Ratings of Plan Responsiveness & Care Member Complaints, Problems Getting Services, & Choosing to Leave the Plan 13

14 Significance to Providers Providers have long attempted to establish the seriousness and severity of the patients they treat through the use of E&M CPT codes Higher level E&M codes identify serious encounters, utilizing more medical decision making, and are reimbursed at a higher rate In Risk Adjustment scenarios, these CPT codes have no significance Instead, specific diagnosis codes communicate the seriousness of medical decision making Significance to Providers Using specific ICD Diagnosis Codes will help convey the true seriousness of the conditions being addressed in each visit Documenting these carefully involves two main focal points: 1 Identifying the Diagnosis as a current or ongoing problem as opposed to a PMH (Past Medical History) or previous condition 2 Choosing the most specific Diagnosis Code while also being sure documentation supports it fully 14

15 Diagnosis Documentation & Coding Coding for Risk Adjustment Documentation Documentation is the only key to collect appropriate diagnosis codes for encounters When appropriate, coders should query the treating provider if possible, however many coders working in risk adjustment cannot query the providers, thus they must only code to the best of their ability based on documentation given ICD guidelines state to code for all existing comorbidities for each encounter that are a part of MDM (Medical Decision Making) 29 15

16 Documentation Providers and Coders are equally guilty of choosing generic, non-specific codes because they are memorized and easier than stopping to look up a more specific diagnosis code supported by the documentation Documenting complications and comorbidities is also important for risk adjustment purposes Many providers still do not realize that the coding guidelines largely prohibit medical coders from assuming any cause and effect relationships and if these are not clearly documented in the medical record, they are lost in translation 30 For example: Documentation 1. A diabetic patient who comes in for a sore throat and is diagnosed with strep throat: Many offices will only use the strep diagnosis code, yet diabetes is still a current diagnosis, and one that surely was considered during treatment options as a part of the Medical Decision Making 2. A hypertensive patient with CHF comes in to the office for follow up: Many providers do not know that if the CHF and hypertension are related, they must state this, otherwise coders are left to only code them as separate diagnoses. CHF alone and HTN alone may risk adjust in models, but Hypertensive Heart Disease is more serious 31 16

17 Documentation 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 Hepatitis B vs. Hepatitis B Chronic Bronchitis vs. Bronchitis Chronic cor pulmonale vs. cor pulmonale 32 Documentation Avoid homegrown abbreviations and document all cause and effect relationships 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, & credential (MD, DO, NP, PA, etc.) Document history of heart attack, any amputations, hypoxia, status codes, ostomy, etc., when factual Only document diagnoses as history of or PMH when they no longer exist or are a current condition 33 17

18 Documenting Diabetes Many providers have memorized the ICD-9-CM code of for diabetes, yet this is often NOT the correct code for many patients Diabetes codes in both ICD-9 and ICD-10 have specific codes to identify diabetes-related manifestations In both: The 4 th digit tells manifestation and 5 th digit tells if controlled or uncontrolled Only diabetics with no manifestations should utilize the generic diabetes ICD code ICD-9 Code Diabetes in ICD-9-CM Manifestation by 4 th digit; Stated as: Due to, with, etc x DM, no mention of complication 250.1x DM, with Ketoacidosis 250.2x DM, with hyperosmolarity 250.3x DM, with coma/insulin coma 250.4x DM, with renal manifestations 250.5x DM, with ophthalmic manifestations 250.6x DM, with neurological manifestations 250.7x DM, with peripheral circulatory disorders 250.8x DM, with other specified manifestations 250.9x DM, with unspecified complications Cause & Effect relationships must be documented by the provider when DM is the reason for any manifestation. (Only exception is gangrene in DM may be assumed related.) 18

19 Diabetes in ICD-10-CM Type 1 Type 2 Other Specified (*No Unspecified code) E10.1x-[Check 5 th ] with ketoacidosis E10.2x-[Check 5 th ] w/kidney complications E10.3x-[Check 5-6 th ] w/ ophthalmic comp. E10.4x-[Check 5 th ] w/ neuro. complications E10.5x-[Check 5 th ] w/ circulatory comp. E10.6x-[Check 5-6 th ] w/ other spec. comp. E10.8 w/ unspecified complications E11.0x-[Check 5 th ] with hyperosmolarity E11.2x-[Check 5 th ] w/kidney complications E11.3x-[Check 5-6 th ] w/ ophthalmic comp. E11.4x-[Check 5 th ] w/ neuro. complications E11.5x-[Check 5 th ] w/ circulatory comp. E11.6x-[Check 5-6 th ] w/ other spec. comp. E11.8 w/ unspecified complications E13.0x--[Check 5 th ] w/ hyperosmolarity E13.2-[Check 5 th ] w/kidney complications E13.3-[Check 5-6 th ] w/ ophthalmic comp. E13.4-[Check 5 th ] w/ neuro. complications E13.5-[Check 5 th ] w/ circulatory comp. E13.1x--[Check 5 th ] w/ ketoacidosis E13.6-[Check 5-6 th ] w/ other specified complications E13.8 w/ unspecified complications E10.9 without complications E11.9 without complications E13.9 without complications Documenting & Coding Diabetes Under-documenting DM communicates a less serious DM case, which affects value of care Any manifestations must be documented as a cause and effect relationship, for example: 1 Assessment: 1. DM 2. Polyneuropathy Can only code: and (ICD-9-CM) E11.9 and G62.9 (ICD-10-CM) [Lower Value DM] 2 Assessment: 1. DM with Polyneuropathy Can code: and E11.42 (ICD-10-CM) [Higher Value DM] 19

20 Documenting & Coding HTN Under-documenting HTN communicates a less serious HTN case, which affects value of care Any manifestations must be documented as a cause and effect relationship (CKD is an exception) Hypertension Type ICD-9-CM ICD-10-CM HTN (primary, benign, essential, 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 Documenting & Coding Cancers Per guidelines, cancers are coded by their location and may only be coded as active when current treatment is being directed to the cancer, or if the cancer is active and treatment was refused Radiation, Chemotherapy, and Hormonal treatments used specifically for a given cancer qualify as current treatment Without current treatment, the patient only has a personal history of cancer (V code) and these typically do not risk adjust Helpful to know if cancer is primary, metastatic, and what treatments are ongoing in order to code 20

21 Documenting & Coding Depression Patients who are on anti-depressant therapy are considered to have major depression clinically Providers rarely document it this way, often only noting depression Coders can only code what is documented and depression alone defaults to situational depression such as bereavement or job loss or other temporary depression Depression assessment tools are often used to validate or support moderate to severe or major depression but when patients are receiving therapy these scores may not reflect the diagnosis and this should be noted Provider Signatures Providers must always sign or authenticate their records CMS has clarified that this may be a full signature or initials or other mark, however is the signature or mark is illegible, then there must be some other way to determine the providers name, such as a printed name on the encounter, such as on letterhead When more than one provider is listed on letterhead, the treating provider should be marked in some fashion Documentation which lacks proper signature or credential of the treating provider may still be coded, as this can be obtained later 41 21

22 Choosing Diagnoses From Various Portions of the Encounter Where Current Diagnoses May Be Documented Current Diagnoses While most will readily agree that the assessment and plan portions of any encounter will have solid documentation on current diagnoses, these areas may be missing diagnoses, or combined data that may be found elsewhere In most all other forms of coding, ICD codes are selected by choosing those diagnoses which were addressed or fit the primary diagnosis, or even the local coverage determination for a procedure When coding for risk adjustment purposes, it is appropriate to code for all current diagnoses in each encounter 43 22

23 Current Diagnoses Some organizations may choose a conservative approach and prefer that there be some form of treatment or acknowledgment of the diagnosis in the encounter, however there are many diagnoses in risk adjustment models which may never be treated or acknowledged because they just exist: Old MI (having had an heart attack) carries value Amputations carry value Drug Addiction codes carry value Family and personal history of codes carry value in the CDPS model Etc. 44 Code for All Diagnoses Risk adjustment models allow for collection of diagnoses from face-to-face visits from outpatient and inpatient encounters Diagnoses should not be collected from radiological or other diagnostic test orders or reports or laboratory requests or results with the exception of pathology, which is considered a consult When diagnoses are noted within the face-to-face encounter, such as a summary of findings or results noted, then those diagnoses may be collected 45 23

24 Code for All Diagnoses Some coders may confuse E&M guidelines for diagnosis reporting as it pertains to the selection of the E&M level of service codes When choosing a level of service for E&M, diagnosis codes should only be counted toward the level of service when they are documented how they were evaluated or addressed This is entirely related to selection of level of service for E&M purposes, and does not change the fact that ICD coding guidelines instruct coders to include all comorbidities for each encounter 46 ICD-9 Coding Guidelines ICD-9-CM: Section IV. Diagnostic Coding and Reporting Guidelines for Outpatient Services H. ICD-9-CM code for the diagnosis, condition, problem, or other reason for encounter/visit List first the ICD-9-CM code for the diagnosis, condition, problem, or other reason for encounter/visit shown in the medical record to be chiefly responsible for the services provided. List additional codes that describe any coexisting conditions. In some cases the first-listed diagnosis may be a symptom when a diagnosis has not been established (confirmed) by the physician. (ICD- 9-CM, 2013) K. Code all documented conditions that coexist Code all documented conditions that coexist at the time of the encounter/visit and require or affect patient care treatment or management. Do not code conditions that were previously treated and no longer exist. However, history codes (V10-V19) may be used a secondary codes if the historical condition or family history has an impact on current care or influences treatment. (ICD-9-CM, 2013) 47 24

25 ICD-10 Coding Guidelines ICD-10-CM: Section IV. Diagnostic Coding and Reporting Guidelines for Outpatient Services G. ICD-10-CM code for the diagnosis, condition, problem, or other reason for encounter/visit List first the ICD-10-CM code for the diagnosis, condition, problem, or other reason for encounter/visit shown in the medical record to be chiefly responsible for the services provided. List additional codes that describe any coexisting conditions. In some cases the first-listed diagnosis may be a symptom when a diagnosis has not been established (confirmed) by the physician. (ICD- 10-CM, 2013 Draft) J. Code all documented conditions that coexist Code all documented conditions that coexist at the time of the encounter/ visit and require or affect patient care treatment or management. Do not code conditions that were previously treated and no longer exist. However, history codes (categories Z80-Z87) may be used as secondary codes if the historical condition or family history has an impact on current care or influences treatment. (ICD-10-CM, 2013 Draft) 48 CMS Guidelines Medicare has also recommended that coders follow official coding guidelines, as well as Coding Clinic determinations The Coding Clinic is a division of the AHA (American Hospital Association) and they make all final determinations on the appropriate utilization of diagnosis codes The Coding Clinic has several rules that pertain to Risk Adjustment that will be covered later The CMS Risk Adjustment Participant Guide also supports coding for all current diagnoses 49 25

26 CMS Participant Guide Excerpts Co-Existing and Related Conditions : The instructions for risk adjustment implementation refer to the official coding guidelines for ICD-9-CM, published at and in the Coding Clinic. Physicians should code all documented conditions that co-exist at the time of the encounter/visit, and require or affect patient care treatment or management. Do not code conditions that were previously treated and no longer exist. However, history codes (V10-V19 not in HCC model) may be used as secondary codes if the historical condition or family history has an impact on current care or influences treatment. Co-existing conditions include chronic, ongoing conditions such as diabetes (250.XX, HCCs 15-19), congestive heart failure (428.0, HCC 80), atrial fibrillation (427.31, HCC 92), chronic obstructive and pulmonary disease (496, HCC 108). These diseases are generally managed by ongoing medication and have the potential for acute exacerbations if not treated properly, particularly if the patient is experiencing other acute conditions. It is likely that these diagnoses would be part of a general overview of the patient s health when treating co-existing conditions for all but the most minor of medical encounters. 50 CMS Participant Guide Excerpts Co-existing conditions also include ongoing conditions such as multiple sclerosis (340, HCC 72), hemiplegia (342.9X, HCC 100), rheumatoid arthritis (714.0, HCC 38) and Parkinson s disease (332.0, HCC 73). Although they may not impact every minor healthcare episode, it is likely that patients having these conditions would have their general health status evaluated within a data reporting period, and these diagnoses would be documented and reportable at that time. MA organizations must submit each required diagnosis at least once during a risk adjustment reporting period. Therefore, these co-existing conditions should be documented by one of the allowable provider types at least once within the data reporting period. (CMS Participant Guide, 2008) The above excerpts give several examples on how to review diagnoses for Risk Adjustment purposes CMS also acknowledges the common issue of diagnoses marked as history of 51 26

27 CMS Participant Guide Excerpts Use of history of. In ICD-9-CM, history of means the patient no longer has the condition and the diagnosis often indexes to a V code not in the HCC models. A physician can make errors in one of two ways with respect to these codes. One error is to code a past condition as active. The opposite error is to code as history of a condition when that condition is still active. Both of these errors can impact risk adjustment. (CMS Participant Guide, 2008) Because the purpose is to code for all known diagnoses for each patient in risk adjustment models, diagnoses from any portion of the record should be valid, provided that they are accurately documented as current diagnoses This includes current diagnoses from the CC (Chief Complaint) or HPI (History of Present Illness); PMH (Past Medical History) when still current; Current, Ongoing, or Active Problem Lists; ROS (Review of Systems); Exam; and Assessment and Plan portions 52 Coding from Chief Complaint or HPI Entries from the CC/HPI portion of any record should be carefully evaluated by the wording used by the treating provider All documented diagnoses should be coded and any that are only noted as historical, should be left as PMH (Past Medical History) or questionable (which is covered later in this chapter) In the next slide there are two examples of how wording can influence the selection of current diagnoses from the CC or HPI portion of the record Coders must carefully review how diagnoses are documented, a history of statement can be interpreted as historical only and no longer existing, or can also be interpreted as a current ongoing problem that has been present for a long time for the patient 53 27

28 Coding from Chief Complaint or HPI Example 1: CC: Ms. Jones is a 70 year old female who comes in today for her follow up of her diabetes and COPD. She has a history of DVT and peripheral vascular disease. She has had no issues or complaints since her last visit to the office. RATIONALE: The CC clearly states the patient is here for the diabetes and COPD, while the DVT and PVD are merely mentioned as historical in nature and are not clear to be current conditions. Additionally, these 2 conditions are not known to be permanent and life-long and therefore should not be coded as current. Example 2: CC: Ms. Jones is a 70 year old female with a history of diabetes and COPD and she is here today for a follow up on her blood sugar control and to evaluate her inhaler effectiveness. RATIONALE: This CC lists both conditions as historical yet it also affirms that they are current conditions being treated and therefore are appropriate to code as current. 54 Coding from PMH (Past Medical History) PMH (Past Medical History) is one of the biggest areas of contention when reviewing medical records CMS (per the above excerpt) has even recognized that providers may sometimes incorrectly list a current diagnosis as PMH or vice versa. One error is to code a past condition as active. The opposite error is to code as history of a condition when that condition is still active (CMS Participant Guide, 2008). Per our coding guidelines, as well as CMS guidance, coder cannot code for conditions that were previously treated and no longer exist. If a condition is not listed as current and only as historical, there must be a way to identify those diagnoses that are still valid separate from those which are truly historical

29 Past Medical History (PMH) 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 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 56 Coding from PMH (Past Medical History) If a coder believes any diagnosis is current, but it is only listed as PMH or historical, coders should ask themselves: Did the provider TAMPER (Treatment, Assessment, Monitor/Medicate, Plan, Evaluate, or Referral) with the diagnosis in that DOS (date of service)? 57 29

30 Coding from PMH (Past Medical History) Most organizations collect diagnoses, even if they are PMH only so that they might have something to send in case of a RADV audit CMS has said in RADV training that they accept diagnoses listed in PMH listings when they are interpreted as still being current or ongoing for the patient There are some diagnoses, however that should never be collected as PMH only because they have their own history of codes: Fractures CVA HIV Anything noted as resolved Cancers MI Amputations Anything noted as repaired 58 Coding from Lists (Current, Ongoing, Active, Chronic, etc.) Coders must use caution when given diagnosis lists While it is appropriate to code for all known current diagnoses, caution should be exercised to avoid improperly coding any diagnosis in such a list which could not be current, is not believed to be current, or appears to be mistakenly brought forward from a past visit documentation In general, if diagnoses are listed as current, ongoing, active, chronic, etc., they may be coded, especially if there is another specific separate listing of PMH diagnoses Conditions that resolve and have no additional mention in the record should not be coded unless TAMPER guidance is met 59 30

31 Coding from Lists (Current, Ongoing, Active, Chronic, etc.) Example: Chronic Problems: A-Fib (on Coumadin) Acute Pancreatitis (admitted 2002) Old MI CVA (2000) CKD (Followed by Dr. Jones, nephrology) Prostate CA RATIONALE: The above list may be titled as chronic conditions, but not all of the conditions listed are current. This is a common problem for coders. The A-Fib is clearly current as there is current medical treatment, the acute pancreatitis appears to be historical only, the Old MI may be coded as factual, the CVA is not only historical (one could code a history of code and any related residual conditions if noted, but an active CVA code cannot be coded once a patient has been discharged for the CVA anyway, CKD is clearly still under treatment, and Prostate CA lacks any current ongoing treatment that would be necessary to code a cancer as current. 60 Coding from ROS (Review of Systems) Some coders have voiced concerns about coding diagnoses from the ROS (Review of Systems) portion of the record and this hesitation can be related back to the E&M coding guidelines While this portion of the medical record documentation s intention is for the purpose of documenting any talking points with the patient for feedback on how they are doing by systems, many providers will still document accurate diagnoses in this section of a record The main warning in this area is to avoid coding for any patient-stated conditions Conditions or diagnoses that are only reported by the patient as recounting to the current provider are not acceptable without provider validation

32 Coding from ROS (Review of Systems) Example 1: ROS: Respiratory: COPD, Hypoxia, on inhaler and home oxygen Cardiovascular: no complaints of SOB, no palpitations, MI 1992 RATIONALE: The above ROS annotates that the patient is on current treatment for the COPD and there is a valid Old MI noted during the ROS as well that is valid. Example 2: ROS: Respiratory: patient states her PCP told her she has COPD RATIONALE: The above ROS merely annotates a patient stated condition that is not confirmed by the current treating provider. It is diagnosis hearsay and should not be coded. 62 Coding from the Exam The exam portion of the medical record s purpose is a placeholder to document the actual physical exam portion of the encounter between the patient and the treating provider Many providers may still also list valid diagnoses in this section of the record and any diagnoses documented, as current should be coded appropriately Often this may be the only area where amputations, an ostomy, or other important factors may be noted 63 32

33 Coding from the Exam Example 1: Exam: Extremities: Good Lt. pedal pulses; Rt. Above Knee Amputation (2006). RATIONALE: In the above exam, the provider merely uses the exam portion to annotate that there is a above the knee amputation. The code for amputation status would be appropriate to code. Example 2: Exam: Appearance: Appears cachectic. RATIONALE: In the above exam, the provider is merely annotating an appearance and not making a diagnosis of cachexia. Appears is the same as likely which is not a diagnosis. 64 Coding from the Assessment & Plan The assessment and plan portions of any record are the final portions of documentation for each encounter These should generally always be coded, with one word of caution, in that many providers will list items in the assessment, which have resolved or are no longer current. Examples of potential improper diagnoses in assessment/plan: Stroke: Should only be coded as current up to discharge of care for stroke in inpatient setting. Outpatient follow up visits should be coded as history of stroke Cancers: Many providers are unclear if cancers are still current and cancers may only be coded as current if there is current ongoing chemo, radiation, or hormonal treatment toward the cancer, or if the cancer id present and the patient has refused treatment or watchful waiting has been chosen 65 33

34 Clinical Documentation Barriers For Risk Adjustment Purposes Provider Signatures Most organizations flag signature issues so that they can improve provider documentation with feedback to providers The lack of a signature or credential does not make the diagnosis untrue and should still be captured when appropriate In a RADV (Risk Adjustment Data Validation) audit by CMS, the printed name, credential, and signature may all be validated during the audit via an attestation Diagnoses themselves however cannot be authenticated during such an audit 67 34

35 Signature Issues Unacceptable Signature/ Authentication Signed but not read Dictated but not signed/ read, etc. Signed by someone other than the treating provider (nurse, transcriptionist, etc.) on providers behalf Signature stamps were phased out effective 12/31/2008. (Note that some EMR systems affix a JPEG that may look like a signature stamp and these are approved) Acceptable Signature/ Authentication Handwritten signature or initials of treating provider Electronic signature/ authentication (e.g. authenticated by, completed by, finalized by, validated by, attested by, sealed by, etc. 68 Using Signs and/or Symptoms instead of making a Diagnosis Coding guidelines instruct it may be appropriate to code for signs and or symptoms, when the treating provider has not yet established a diagnosis ICD-9-CM: Section IV. Diagnostic Coding and Reporting Guidelines for Outpatient Services E. Codes that describe symptoms and signs Codes that describe symptoms and signs, as opposed to diagnoses, are acceptable for reporting purposes when a diagnosis has not been established (confirmed) by the provider. Chapter 16 of the ICD-9-CM, Symptoms, Signs, and Ill-Defined Conditions (Codes ) contain many, but not all codes for symptoms. (ICD-9-CM, 2013) ICD-10-CM: Section IV. Diagnostic Coding and Reporting Guidelines for Outpatient Services D. Codes that describe symptoms and signs Codes that describe symptoms and signs, as opposed to diagnoses, are acceptable for reporting purposes when a diagnosis has not been established (confirmed) by the provider. Chapter 18 of the ICD-10-CM, Symptoms, Signs, and Abnormal Clinical and Laboratory Findings Not Elsewhere Classified (Codes R00 R99) contain many, but not all codes for symptoms. (ICD-10-CM, 2013 Draft) 69 35

36 Uncertain Diagnosis - Outpatient Cannot Use in Outpatient Records: Suggestive of / Symptoms of / Likely Consistent With / Compatible With Suspicious for / Pending Probable / Suspect / Tendency / Possible Presumed / Sign(s) of / Suspect Pre- / or vs. Rule-Out / Perhaps / Questionable May Use in Outpatient Records: Early / Underlying Evidence of Element of Component of Significant Compensated Results show 70 Uncertain Diagnosis - Inpatient Uncertain diagnoses are handled differently in the inpatient vs. outpatient settings Diagnoses that are still uncertain in an inpatient encounter, and are still uncertain at the time of discharge may be reported, however, if during the inpatient stay, tests and other evaluation determine that the diagnosis is not accurate then it may not be coded Thus, a probable or possible heart attack, if still uncertain at the time of discharge, may be coded as a heart attack and a possible heart attack that was ruled out by discharge cannot be coded as a heart attack 71 36

37 Consistent with Many providers, especially in pathology use the phrase consistent with when describing a diagnosis or condition The provider may feel that they are diagnosing the condition to the best of their ability based on known data and therefore use this phrase to establish their relative certainty with a very small margin of error However, The Coding Clinic has ruled that this terminology means the same as suspected and that the provider is still unsure of the diagnosis and therefore it is not acceptable wording to establish a diagnosis Consistent with diagnoses may be coded in inpatient settings if the diagnosis is still uncertain at the time of discharge 72 Use of Up and Down Arrows [ or ] Coding Clinic issued a 2011 answer on the use of up and down arrows for diagnosis coding purposes (e.g. cholesterol, thyroid) and per the Coding Clinic, it is not appropriate for the coder to report a diagnosis based upon up and down arrows Diagnosing a patient s condition is solely the responsibility of the provider Up and down arrows can have variable interpretations and do not necessarily mean abnormal. They could simply be indicating change (including improvement) over past results. (Coding Clinic, 2011) 73 37

38 Overview Risk Adjustment is a method to collect all known current diagnoses for each patient to improve disease management, forecast for financial needs, and establish payment in some cases Coders should follow ICD coding guidelines to code for all coexisting conditions while also following Coding Clinic determinations Some entities may only be focused on HCC relevant codes, while others may be more global, such as CDPS Some entities may choose a conservative approach in the collection of codes, while being mindful of costs 74 Risk Adjustment Coding Risk Adjustment coding takes a slightly different mindset from coding for Fee-For-Service encounters There are often difficult decisions that can be encountered in risk adjustment diagnosis collection, but if coders adhere to the TAMPER guideline, these can become easier There may be other entities with policies and procedures that may be inconsistent with this teaching, however this presentation is congruent with the concepts and purposes of risk adjustment data collection Look for more information on Risk Adjustment from AAPC and ionhealthcare in the future 75 38

39 Brian Boyce, BSHS, CPC, CPC-I Proprietor and Managing Consultant THANK YOU Contact Us at: 76 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 treating MD. Assessment: 1. DM with polyneuropathy 2. Hypertension 3. Heartburn Can the coder document GERD in the above note? a) Yes b) No 39

40 Applying Concepts Quiz 1. Answer: b) No Rationale: The documentation 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 documenting actual diseases as opposed to their symptoms if they are a current true diagnosis. Applying Concepts Quiz 2. Ms. Smith came in for follow up visit with her PCP. A full SOAP note was documented and signed by the treating MD. Assessment: 1. Diabetes (DM) Type II 2. Peripheral Neuropathy 3. Hypertension What are the proper codes for the diabetes & neuropathy listed above? a) , b) , c) , d) ,

41 Applying Concepts Quiz 2. Answer: c) , Rationale: In this example, There is no cause & effect demonstrated between the diabetes and the peripheral neuropathy. If the provider has documented the cause & effect relationship such as: DM with peripheral neuropathy, Peripheral neuropathy due to diabetes, Diabetic peripheral (or poly) neuropathy, etc., then the codes would be justified for a and a This example illustrates the importance of documenting all cause & effect relationships, especially in diabetes. Applying Concepts Quiz 3. Mr. Chung came in for follow up visit with his PCP. A full SOAP note was documented and signed by the treating MD. CC/HPI: Mr. Chung is here for follow up of his COPD, Diabetes, HTN. He has a history of prostate cancer. Medications: 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 active diagnosis? a) Yes b) No 41

42 Applying Concepts Quiz 3. Answer: b) No Rationale: 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 active prostate cancer code. Guidelines require that in order for cancers to be coded as current/active, there must be treatment directed to the cancer. If the patient had been on radiation, 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. 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 treating MD. CC/HPI: Ms. Hernandez is here for follow up of her Diabetes, HTN, and Depression with anxiety. Medications: 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) , b) , 311 c)

43 4. Answer: c) Applying Concepts Quiz Rationale: In this example, the documentation only states depression with anxiety. Even though she is on an anti-depressant medication, the diagnosis of major depression has not been made, and coders may not assumptive 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 combination code would be correct for these two together. This example highlights depression vs. major depression & anxiety coding. 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 treating MD. Assessment: 1. Diabetes, 2. Hypertension, 3. Kidney Disease What is (are) the right code(s) for kidney disease noted above? a) b) c) d)

44 5. Answer: b) Applying Concepts Quiz Rationale: In this example, the provider did not use specific documentation for the kidney disease. Had the provider noted it as chronic, then a code would be correct for unspecified staging. Without the description 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. 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 treating MD. CC/HPI: Ms. White is here for follow up of her Atrial Fibrillation, COPD, HTN, and Depression. She has a past history of DVT. Medications: Coumadin, Singulair, Advair, Actos, HCTZ, Tarka, Abilify. Assessment: 1. Depression, 2. COPD, 3. Hypertension, 4. A-Fib May the coder code for the DVT mentioned above as an active diagnosis? a) Yes b) No 44

45 Applying Concepts Quiz 6. Answer: b) No Rationale: 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 patient is on Coumadin, often used for DVT treatment, however she also has A-Fib., and it is more likely that this medication is being used for the ongoing atrial fibrillation. This example illustrates the critical thinking necessary for reviewing current medications as they pertain to PMH diagnoses in order to identify them as current or active problems. 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 treating MD. CC/HPI: Mr. Green is here for follow up of his hypertension. Medications: Digoxin, HCTZ, Nitrostat Sublingual, prn PMH: Angina Assessment: 1. HTN May the coder code angina mentioned above as an active diagnosis? a) Yes b) No 45

46 Applying Concepts Quiz 7. Answer: a) Yes Rationale: While angina is listed as PMH (Past Medical History), the patient is currently on nitro-stat (which is used to manage angina) and this makes the angina recognized as a current or active condition. The provider should have annotated the angina in the assessment to remove any question of the diagnosis, but under this situation, the code may still be captured. This example illustrates the use of PMH to identify active diagnoses when specific medications support the diagnosis as ongoing or current. 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 treating MD. CC/HPI: Ms. Fudd is here for follow up of Rt. Lower leg pain. Medications: Coumadin PMH: Compartmental syndrome status post surgery 2 years ago. Assessment: 1. Rt. Leg pain (NOTE: Duplex Doppler report of lower extremities from radiologist shows findings of: consistent with DVT. May the coder code DVT mentioned above as an active diagnosis? a)yes b)no 46

47 Applying Concepts Quiz 8. Answer: b) No Rationale: The Coding Clinic (a department within the AHA- American Hospital Association) issues formal rulings on diagnosis coding. One of those rulings states that any diagnosis described as consistent with cannot be coded as active or current as the description is too vague and a specific diagnosis is not being made with this wording choice. [Similar wordings which pose problems include: appears to be, is likely, probable, suspect, may be, etc. This example highlights the rules around coding unspecific diagnoses when described as consistent with. Applying Concepts Quiz 9. Mr. Bird came in for follow up visit with his PCP. A full SOAP note was documented and signed by the treating MD. CC/HPI: Mr. Bird is here for follow up weakness in left 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) b) c) d) ,

48 Applying Concepts Quiz 9. Answer: b) Rationale: In this example, there is only a left weakness noted. Another Coding Clinic determination 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 conditions 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 afterward only a personal history of CVA may be coded. This example shows the importance of both cause and effect documentation as well as specific wording to code correctly. It also highlights the rule for CVA coding. Applying Concepts Quiz 10. The following assessment is found in a Hand-written note: What is/are the proper code(s) for the assessment above? a) 305.1, 272.4, 401.9, b) 272.4, 401.9, c) 272.4, d)

49 10. Answer: d) Applying Concepts Quiz Rationale: The HTN is the only code that can be obtained from this example. Positive history of smoking cannot translate to tobacco dependence (it must be stated), so the code is incorrect. The diabetes is very questionable due to legibility, so it should not be coded. The cholesterol is listed as chol. The Coding Clinic has a determination that coders may not code from up and down arrows or, as these are not definitive 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 documentation specificity. Brian Boyce, BSHS, CPC, CPC-I Proprietor and Managing Consultant [email protected] THANK YOU Contact Us at: