Risk Adjustment Review Summary for Tennessee

Transcription

1 Risk Adjustment Review Summary fr Tennessee This review has been prvided fr Tennessee prviders at the request f Ingenix fr 2007 and Fr this practice, the dcumentatin fr Tennessee prviders has been reviewed by experienced cders. Careful dcumentatin is critical t accurate and cmplete data cllectin fr Risk Adjustment. This review has been separated int 3 parts. The first part cntains a list f all errrs and missins as prvided by Ingenix, alng with the ttal number f ccurrences f each E/O cde fr the entire file. The secnd part cntains a list f all new HCCs fund during the review, with the ttal number f ccurrences fr the entire file. The third part is a breakdwn, by physician, f all new HCCs and any errrs r missins. Each patient is listed separately, with each new HCC listed alng with the crrespnding ICD-9 cde and the date f service. Any errrs r missins wuld then be listed. Page 1 f 21

2 The fllwing is a list f all errr cdes identified fr Virginia EO Cde Occurences Descriptin 2 13 N prvider signature n prgress nte 3 2 Prvider's signature des nt meet CMS guidelines Prgress nte is illegible r partially illegible 5 5 N date f service n prgress nte 7 22 Abbreviatins that are nt standard 8 5 Prvider treated the patient's diagnsis, but did nt dcument it in the prgress nte r it was unclear 9 2 Prvider diagnsed the patient, but there is n prgress nte t supprt that the prvider evaluated r treated the patient's cnditin during the chart review year 12 7 Prgress nte indicates inferred diagnsis cdes. Prvider dcumented "Histry f...", but did nt diagnse nr treat the patient's cnditin 14 4 Prvider did nt dcument diagnsis cde t the highest degree f specificity Prvider dcumented unacceptable symbls assciated with a valid diagnsis cde in the prgress nte Mre inf required, request t be sent Page 2 f 21

3 The fllwing HCC cdes were identified during the review prcess fr Virginia HCC Cde Occurences Descriptin 10 5 Breast, Prstate, Clrectal and Other Cancers and Tumrs Vascular Disease with Cmplicatins Vascular Disease Chrnic Obstructive Pulmnary Disease Pneumcccal Pneumnia, Empyema, Lung Abscess Renal Failure Chrnic Ulcer f Skin, Except Decubitus Diabetes withut Cmplicatin 26 2 Cirrhsis f Liver 38 8 Rheumatid Arthritis and Inflammatry Cnnective Disease Tissue 54 5 Schizphrenia 55 1 Majr Depressive, Biplar, and Paranid Disrders 71 8 Plyneurpathy 74 2 Seizure Disrders and Cnvulsins 79 1 Cardi-Respiratry Failure and Shck Cngestive Heart Failure 9 11 Lymphatic, Head and Neck, Brain, and Other Majr Cancers Specified Heart Arrhythmias Page 3 f 21

4 The Mechanics f Chart Dcumentatin Dcumentatin validates that services were prvided, ensures cntinuity f care, supprts medical necessity and verifies that services prvided are reprted with accuracy. Gd dcumentatin supprts the level f service billed resulting in apprpriate reimbursement. The physician s signature and credentials must be n each chart entry. The patient name and the date f service must be n each page f the patient chart. The medical recrd must be cmplete and legible. Only standard medical abbreviatins shuld be used. Nte all acute and chrnic diagnses with the current status and treatment plans in the prgress nte. ICD-9-CM Guidelines and Tips Current year versin f ICD-9-CM must be used fr accurate diagnstic cding. Superbills need t be managed, updated, expanded and revised yearly. Diagnsis cdes must be accurate and specific. If a cde ffers 5 digits in ICD-9-CM, five digits must be used. Each digit adds specificity. Avid unspecified (.9) cdes unless there is nt a mre specific cde available. Avid nnspecific terminlgy such as HTN r OA, as this leads t the veruse f unspecified cdes. When there is a disease prcess alng with a manifestatin, cde bth the etilgy (underlying disease) and the manifestatin f the disease. The underlying disease wuld be cded first, with the manifestatin f the disease in 2nd place. Example: Kapsi s sarcma due t HIV 042 (HIV) underlying disease Kapsi s sarcma (manifestatin) When a cmbinatin cde is ffered in ICD-9-CM t classify tw diagnses, it must be used. Example: Malignant Hypertensive Chrnic Kidney Disease Chrnic Kidney Disease Stage V Hypertensive chrnic kidney disease, malignant, with CKD Stage V r End Stage Renal Disease Chrnic kidney disease, Stage V Careful dcumentatin is critical t accurate and cmplete data cllectin fr Risk Adjustment. The fllwing cdes have been captured accrding t the fficial CMS cding guidelines and requirements fr Risk Adjustment Validatin. The fllwing summary is a listing f HCC cnditins that were captured by experienced cders during yur recrd review fr 2007 and 2008 dates f service. CMS requires that relevant diagnses be submitted at least nce per calendar year. Page 4 f 21

5 HCC Cdes by Prvider fr Virginia Prvider Name: ROY ANDREWS Prvider ID: DOB: 8/3/1946 RICHARD BOOHER 5/5/2008 3/3/2008 OLLIE COMBOW DOB: 4/30/1940 3/25/ /17/2008 2/26/2008 2/21/2008 DOB: 1/6/1949 NORETTA HENSON /5/ /1/2007 N prvider signature n prgress nte TONEY JESSEE DOB: 9/6/ /4/ /25/2007 KENNETH JONES DOB: 11/18/1932 6/9/2008 6/9/2008 4/21/2008 4/21/2008 Page 5 f 21

6 HCC Cdes by Prvider fr Virginia 3/6/2008 3/6/ /6/ /6/2007 9/17/2007 9/17/2007 8/20/2007 8/20/2007 6/27/ /17/2007 "Mre inf required, request t be sent" 3/8/2007 2/20/2007 BILLY MORSE DOB: 8/6/1942 3/11/2008 RONNIE WOOTEN DOB: 10/25/ /5/2008 Page 6 f 21

7 HCC Cdes by Prvider fr Virginia Prvider Name: DAVID GULDSETH Prvider ID: MARCINE FOX DOB: 6/26/1934 7/17/2008 ROGER MULLINS DOB: 4/10/1941 7/7/2008 1/8/2008 Abbreviatins that are nt standard /28/2007 Prvider dcumented unacceptable symbls assciated with a valid diagnsis cde in the prgress nte 10/23/2007 9/25/2007 Prvider dcumented unacceptable symbls assciated with a valid diagnsis cde in the prgress nte /30/2007 Prvider dcumented unacceptable symbls assciated with a valid diagnsis cde in the prgress nte 7/9/2007 4/16/2007 Prgress nte is illegible r partially illegible /6/ /6/ /6/2007 2/6/2007 1/19/2007 CARL NOWAK DOB: 8/30/ /20/ /21/ /18/2007 Prvider dcumented unacceptable symbls assciated with a valid diagnsis cde in the prgress nte /14/ /2/ /5/2007 Abbreviatins that are nt standard Page 7 f 21

8 HCC Cdes by Prvider fr Virginia JACK PLUMMER DOB: 8/10/1934 9/10/2008 8/27/2008 5/28/2008 2/26/2008 7/30/2007 7/11/2007 7/11/2007 4/11/2007 4/11/2007 CAROLE RHEA DOB: 10/26/ /8/2008 Prvider did nt dcument diagnsis cde t the highest degree f specificity /3/2007 Abbreviatins that are nt standard /8/ /25/2007 Prgress nte is illegible r partially illegible JERRY SMITH DOB: 8/28/ /3/2008 8/11/2008 7/8/2008 3/6/2008 1/7/ /28/ /16/ /7/2007 8/8/2007 Page 8 f 21

9 HCC Cdes by Prvider fr Virginia 3/20/2007 SANDRA SMITH DOB: 2/12/1946 7/29/2008 4/14/2008 AUDRA STOPHEL DOB: 10/26/1935 6/4/2007 Prvider dcumented unacceptable symbls assciated with a valid diagnsis cde in the prgress nte DOB: 8/8/1927 CLIFFORD STOPHEL /3/ /1/ /1/ /8/2008 Prgress nte is illegible r partially illegible 10/15/2007 8/13/ /13/2007 5/23/2007 3/1/2007 Page 9 f 21