Risk Adjustment Coding/Documentation Checklist The following list should be used to ensure that all member and diagnosis-related information is reported, and all the member s chronic conditions are documented thoroughly, accurately, consistently and to the highest level of specificity. o Patient Identification each page of the record contains the patient s name and date of service. o Supporting Documentation the entire medical record must be reviewed to determine all current diagnosis codes. Reminder: The Official ICD-9/ICD-10 Guidelines for Coding and Reporting* must be followed. Documentation contained in the history, review of systems (ROS), physical exam or medical decision-making can be used to support diagnosis code(s). All diagnosis codes must be documented during the face-to-face visit. Physician documentation reflects the level of disease severity. Code is assigned to the highest level of specificity documented. Documentation must indicate an assessment and a treatment plan for each diagnosis: Assessment Stable Improved Tolerating Medication(s) Deteriorating Plan Monitor Discontinue Medication(s) Continue Current Medication(s) Refer o M.E.A.T. to report condition(s), the documentation must support that the physician: Monitored Evaluated Assessed/Addressed Treated o Provider Signature/Authentication/Date each encounter contains: Provider signature (dated 30 days or less from date of service) and credentials to authenticate the documentation is accurate. Provider printed name and credentials. If the credential is missing, it can be supported by a document containing the physician s letterhead or notation in that specific encounter that designates their credentials. Acceptable electronic signature statements: Authenticated by Validated by Attested by Completed by Signed by o Annual Visits verify appointments for patients with chronic conditions are scheduled at least once per year. o Healthy Outcomes identify patients who would benefit from inclusion in Horizon Blue Cross Blue Shield of New Jersey s Chronic Care Program. o Claim Submission electronic medical record or a clearinghouse can report multiple diagnosis codes per visit. Horizon BCBSNJ is able to accept up to 25 diagnosis codes. *In keeping with the U.S. Department of Health and Human Services mandate, Horizon BCBSNJ will reject claims submitted with ICD-9 codes and date(s) of service (or inpatient dates of discharge) on or after October 1, 2015. 1
Documentation Improvement Opportunities The following are common areas for improvement in documentation. The most effective course of action to evaluate documentation practices and code assignment is to identify areas for improvement through chart and coding audits. A proactive approach will ensure patient conditions are documented to the level of disease severity and coded to the highest level of specificity documented. Use these opportunities to: Educate both physician and coding staff. Create documentation best practices. Reinforce ICD-9/ICD-10 reporting guidelines*. o Diabetes with Manifestations Due to, secondary to or diabetic must be documented to code the cause-and-effect relationship. Coder cannot assume there is a cause-and-effect relationship. The physician must document the relationship to code. If documentation indicates the patient uses insulin routinely, code V58.67 (Z79.4). Peripheral Vascular Disease (PVD) due to uncontrolled type 2 diabetes 250.72 Diabetes with peripheral circulatory disorders, type 2 or unspecified type, uncontrolled 443.81 Peripheral angiopathy in diseases classified elsewhere E11.51 Type 2 diabetes mellitus with diabetic peripheral angiopathy without gangrene o Hypertension with Congestive Heart Failure Due to, secondary to or hypertensive must be documented to code the causal relationship. Documentation must state the causal relationship between hypertension (HTN) and heart disease (CHF). Coder cannot assume there is a causal relationship. The physician must document the relationship to code. Benign hypertensive CHF with left ventricular failure 402.11 Benign hypertensive heart disease with heart failure 428.1 Left heart failure I11.0 Hypertensive heart disease with heart failure I50.1 Left ventricular failure *In keeping with the U.S. Department of Health and Human Services mandate, Horizon BCBSNJ will reject claims submitted with ICD-9 codes and date(s) of service (or inpatient dates of discharge) on or after October 1, 2015. 2
o Cancer When a primary malignancy has been previously excised or eradicated from its site, and there is no current treatment directed to that site and no evidence of any existing primary malignancy, assign code from category V10, personal history of malignant neoplasm. Documentation of extension, invasion or metastasis to another site is coded as a secondary malignant neoplasm to that site. The secondary site would be the primary diagnosis with the V10 code used as a secondary code. Treatment to site is considered chemotherapy, radiation, adjunct therapy or patient elects not to have any treatment. History of breast cancer with metastasis to right lung 197.0 Secondary malignant neoplasm of lung V10.3 Personal history of malignant neoplasm of breast C78.01 Secondary malignant neoplasm of right lung Z85.3 Personal history of malignant neoplasm of breast o Chronic Kidney Disease (CKD) Physicians or other health care professionals must document a diagnosis of CKD and stage. A diagnosis and stage cannot be assigned based on lab values. Document Stage 1 to 6 (if documentation states mild, moderate or severe, a code may be assigned for Stages 2 to 4 as appropriate). Stage 6 is known as End Stage Renal Disease (ESRD). Document dialysis status as appropriate. ESRD on hemodialysis due to type 2 diabetes 250.40 Diabetes with renal manifestations 585.6 CKD Stage 6 ESRD V45.11 Renal dialysis status E11.22 Type 2 diabetes mellitus with diabetic CKD N18.6 ESRD Z99.2 Dialysis status/dependence on renal dialysis Stage Description 1 CKD Stage 1 585.1 N18.1 2 CKD Stage 2 (mild) 585.2 N18.2 3 CKD Stage 3 (moderate) 585.3 N18.3 4 CKD Stage 4 (severe) 585.4 N18.4 5 CKD Stage 5 585.5 If requires chronic dialysis, code 585.6 N18.5 If requires chronic dialysis, code N18.6 6 ESRD 585.6 N18.6 Unspecified CKD Unspecified 585.9 N18.9 3
o Chronic Obstructive Pulmonary Disease (COPD) COPD encompasses many conditions, such as emphysema, chronic bronchitis and obstructive asthma. Documentation must indicate the diagnosed condition and not simply COPD. Unspecified COPD should only be used if there are no related respiratory conditions; otherwise the diagnosed condition should be documented and coded as appropriate. Document acute on chronic events where there is an acute exacerbation or worsening symptoms such as shortness of breath or prolonged mucous production. COPD with obstructive asthma with acute exacerbation 493.22 Chronic obstructive asthma with acute exacerbation J45. Asthma (requires 4th and 5th digit) requires the asthma be described as: 4th Digit u Mild intermittent u Mild persistent u Moderate persistent u Unspecified And 5th Digit u Uncomplicated u Exacerbated u Status asthmaticus (a severe exacerbation not responding to treatment) also lists additional codes for related factors: Exposure to environmental tobacco use Occupational exposure to environmental Exposure to tobacco use in perinatal tobacco smoke period Tobacco dependency History of tobacco use Tobacco use o Cerebral Vascular Accident (CVA) Acute conditions can only be documented and coded during the initial episode of care. Once the patient is discharged from the hospital, documentation would be for history of CVA. Late effects must be specified as due to CVA otherwise it cannot be coded as a late effect. CVA on 5/1/15 Hemiparesis due to CVA on right side dominant V12.54 Personal history of transient ischemic attack (TIA) and cerebral infarction without residual deficits Z86.73 Personal history of transient ischemic attack (TIA) and cerebral infarction without residual deficits 4
Late effects (residual deficits) of CVA should be documented and coded as appropriate. Common late effects include: u Aphasia u Dysphasia u Dysphagia u Ataxia u Hemiparesis/hemiplegia 438.20 Late effects of CVA with hemiplegia/hemiparesis I69.961 Other paralytic syndrome following unspecified cerebrovascular disease affecting right dominant side requires code for side, dominant vs. non-dominant or bilateral. requires additional codes for related factors: Alcohol abuse/dependency Exposure to environmental tobacco use History of tobacco use Hypertension Occupational exposure to tobacco Tobacco dependency Tobacco use o Major Depressive Disorder (MDD) The documentation must include the characteristics of the mood disorder (such as mild, moderate, severe, major, mania, single, with or without psychotic features, recurrent, partial or full remission). The following criteria must be met in order to code MDD: All of the following must apply (use the 9-item patient health questionnaire to evaluate): u Symptoms do not meet requirements of a mixed episode (bipolar disorder) u Symptoms cause significant impairment in daily activities (social, work and any other areas of concern) u Depression is not related to a substance or bereavement unless continuous for more than two months with severe impairment, morbid preoccupation, psychotic symptoms or psychomotor retardation u Symptoms are present for two weeks or more and cause significant distress or impairment At least one of the following must apply (MDD Algorithm): u Depressed mood every day or nearly every day u Diminished interest in activities At least four of the following must apply: u Weight loss or gain (5 percent) or appetite increase or decrease nearly every day u Insomnia or hypersomnia nearly every day u Psychomotor agitation or impairment u Feelings of worthlessness or guilt every day u Fatigue or loss of energy nearly every day u Diminished ability to concentrate or think (self-reported or observed by others) u Delusional u Recurrent thoughts of death, suicide or suicide attempt 5
If you have documented a minimum of five symptoms total, your patient meets the requirements for MDD. If not, code as appropriate to other depressive/behavioral disorders. ICD-9 Diagnosis (4th digit): 296.2X MDD, single episode 296.3X MDD, recurrent ICD-9 Diagnosis (5th digit): 0 = Unspecified 1 = Mild 2 = Moderate 3 = Severe without psychotic behavior 4 = Severe with psychotic behavior 5 = In partial or unspecified remission 6 = In full remission 296.21 Major depressive disorder, single episode 296.34 Major depressive disorder, recurrent episode F32.0 Major depressive disorder, single episode, mild F33.3 Major depressive disorder, recurrent severe with psychotic symptoms o Status Codes that are Frequently not Documented and/or Coded Most of these conditions are permanent and must be documented annually: Artificial openings (e.g., colostomy, tracheostomy, gastrostomy, ileostomy, cystostomy) Amputation HIV Transplant Renal dialysis Oxygen therapy Insulin dependence History of heart attack Implants (joint replacements hips, knees; lens implants; cardiac pacemakers and defibrillators; spine hardware plates, rods and screws; coronary stents) Horizon Blue Cross Blue Shield of New Jersey is an independent licensee of the Blue Cross and Blue Shield Association. The Blue Cross and Blue Shield names and symbols are registered marks of the Blue Cross and Blue Shield Association. The Horizon name and symbols are registered marks of Horizon Blue Cross Blue Shield of New Jersey. 2015 Horizon Blue Cross Blue Shield of New Jersey. Three Penn Plaza East, Newark, New Jersey 07105. HorizonBlue.com CMC0007435 (0915) 6