Consists of a provider specifically trained in Risk Adjustment documentation and coding

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2 QRA Coaching Consists of a provider specifically trained in Risk Adjustment documentation and coding Mining medical records for Risk Adjustment diagnoses Available for one on one coaching on risk adjustment, coding, quality, etc Program is designed to help you achieve better coding, documentation, and quality for your patients and your business Coordination will take place with your office staff, managers, PBMs, and market medical directors More details to come WellMed Medical Management - Do not copy or distribute without written permission. 2

3 Financial Disclosure Dr. Robin Eickhoff has no relevant financial interests to disclose.

4 Objectives By the end of this presentation, you will be able to apply best practices to improve risk adjustment processing system (RAPS) documentation in your clinic.

Introduction During this presentation, we ll look at the following:

documentation will and won t support a diagnosis The impact of

Medicaid Services (CMS) Risk Adjustment Data Validation (RADV) audit

5 Introduction During this presentation, we ll look at the following: The language barriers between coding and clinical language When documentation will and won t support a diagnosis The impact of documentation that does not validate on a Centers for Medicare and Medicaid Services (CMS) Risk Adjustment Data Validation (RADV) audit WellMed Medical Management - Do not copy or distribute without written permission. 5

6 Coding Language vs. Clinical Language Avoid history of statements Unspecified vs. Other Specified in coding language WellMed Medical Management - Do not copy or distribute without written permission. 6

7 History of In clinical language, Patient presents with History of DM, HTN, Hyperlipidemia means patient has these diagnoses HOWEVER In coding language, this means the diagnoses: Are in the history and no longer active. Would be coded as a Z code: Personal History of and not billable codes. This is particularly a problem if history of is used in the Assessment section. WellMed Medical Management - Do not copy or distribute without written permission. 7

8 Unspecified vs. Other Specified Unspecified There is not enough detail in the documentation to use a more specific diagnosis/code. Lazy man s code Other Specified The specific diagnosis is known, however there is no specific ICD-10 code to match it. You must also identify what the OTHER is in the documentation. WellMed Medical Management - Do not copy or distribute without written permission. 8

9 Unspecified Sometimes there is no other choice: e.g. PVD is unspecified, but usually a more specific code exists. Using a less specific diagnosis can result in decreased reimbursement: Major Depressive Disorder, single episode (with no severity specified), does NOT risk adjust! Ex: Major Depressive Disorder, single episode, mild (or moderate, severe, in remission) all risk adjust. WellMed Medical Management - Do not copy or distribute without written permission. 9

10 Unspecified Example: Major Depression Documentation WellMed Medical Management - Do not copy or distribute without written permission. 10

11 Unspecified 8. Single major depressive episode on zyprexa at 2.5 mg a day, patient takes ½ tab po qdaily WALK THE uses diazepam at night time and occasionally during day, understands risks of using zyprexa and diazepam F32.9: Major depressive disorder, single episode, unspecified 15.Single major depressive PLANK!! episode declines medical rx at present. She again declines medical treatment. F32.9 Major depressive disorder, single episode, unspecified WellMed Medical Management - Do not copy or distribute without written permission. 11

12 Unspecified 8. Single major depressive episode on zyprexa at 2.5 mg a day, patient takes ½ AVAST, tab po qdaily MATEY! PASS uses diazepam at night time and occasionally during day, mild understands risks of using zyprexa and diazepam F32.9: Major depressive disorder, single episode, unspecified THE RUM! 15.Single major depressive episode declines medical rx at present. She again declines medical treatment. mild F32.9 Major depressive disorder, single episode, unspecified WellMed Medical Management - Do not copy or distribute without written permission. 12

13 Other Specified You MUST document what OTHER is!! If there is no specific documentation identifying other, the documentation will not validate for a CMS audit. WellMed Medical Management - Do not copy or distribute without written permission. 13

14 Example Other specified Current Medications Taking Diazepam 5 MG Tablet 1 tablet as needed Twice daily Micardis HCT MG Tablet 1 tablet Once per day Levothyroxine Sodium 75 MCG Tablet 1 tablet Once per day Atorvastatin Calcium 20 MG Tablet 1 tablet Once per day Alendronate Sodium 70 MG Tablet 1 tablet Q weekly for Osteoporosis Aspir-8181 MG Tablet Delayed Release 1 tablet Once per day Vitamin D UNIT Capsule 1 capsule Once per day Vitamin B-6 MG Tablet 1 tablet Once per day Flonase 50 MCG/ACT Suspension 1 spray in each nostril Once per day Not Taking/PRN Zantac 150 Maximum Strength 150 MG Tablet 1 tablet q day prn reflux sxs Reason for Appointment 1. 6 month f/u 2. Pt unaccompanied at today s visit 3. Pt brought in a list of current medications but not the bottles History of Present Illness General: The patient is an 80-year-old female with history of hypertensions, major depression, sinus bradycardia, coronary artery disease, pulmonary hypertension, and CK D3. The patient presents to clinic for routine follow-up and reports she s been doing very well. The patient informs me she continues to perform all of her activities of daily living and walks for exercise. She states she likes to stay active and she tries to follow a low-fat low-cholesterol diet. The patient denies depression SI/HI, shortness of breath, external chest pain, palpitations, black/red stools, fever/chills, malaise or acute change in vision/speech/memory/extremity function. The patient does admit to experiencing nocturnal leg and foot pain and is requesting medication for her neuropathy. WellMed Medical Management - Do not copy or distribute without written permission. 14

15 Example Other specified Assessments 1. Need for pneumococcal vaccine Z233 (Primary) 2. Polyneuropathy in other diseases classified elsewhere General medical examination Z Hypothyroidism, unspecified E Vitamin D deficiency, unspecified E Pure hypercholesterolemia E Bradycardia, unspecified R Anemia in chronic kidney disease D Atherosclerosis of aorta I Essential (primary) hypertension I Gastro-esophageal reflux disease without esophagitis K Atherosclerotic heart disease of native coronary artery without angina pectoris I Major depressive disorder, recurrent, in partial remission F Other secondary pulmonary hypertension I Chronic kidney disease, stage 3 (moderate) N Diverticulosis of large intestine without perforation or abscess without bleeding K Age-related osteoporosis without current pathological fracture M Allergic rhinitis, unspecified J Polyneuropathy in diseases classified elsewhere G63 20.Other abnormal glucose R Aortic ectasia, unspecified site I WellMed Medical Management - Do not copy or distribute without written permission. 15

16 Example Other specified 4. Hypothyroidism, unspecified Notes: The patient is currently on levothyroxine 50 g 1 tablet daily. Her WALK THE thyroid levels are within normal limits. We ll continue to monitor patients thyroid levels. 5. Vitamin D deficiency, unspecified Notes: patient remains on vitamin D unit capsules 1 by mouth daily, vitamin D level is on target and she was instructed to continue with the supplement. 19. Polyneuropathy in diseases classified elsewhere Notes: The PLANK!! patient complains of nighttime leg pain with give patient trial of Neurontin 100 mg 1 by mouth daily at bedtime. Reviewed medication profile and precautions. Reviewed fall precautions the patient. Patient will monitor symptoms and return to clinic in 3-4 weeks if symptoms persist. 20. Other abnormal glucose Notes: The patient s recent hemoglobin A1c was 5-9. Discussed dietary modifications c low card diet and benefits of daily exercise. We ll continue to monitor patient s hemoglobin A1c and make med changes as needed. WellMed Medical Management - Do not copy or distribute without written permission. 16

17 Example Other specified Assessments 1. Epigastric AVAST, pain (Primary) MATEY! PASS 2. Diabetes with neurological manifestations, type II or unspecified type, not stated as uncontrolled Diabetes with other specified manifestations, type II or unspecified type, not stated as uncontrolled Other and unspecified hyperlipidemia Polyneuropathy in diabetes THE RUM! 6. General medical examination V Diabetes with other specified manifestations, type II or unspecified type, not stated as uncontrolled Notes: See DM with neuro. 4. Other and unspecified hyperlipidemia Notes: 2/12/1012 trig 162 HDL 38. Secondary to DM. We discussed the importance of regular exercise and dietary modifications to control lipids. Recheck lipids as noted, monitor hepatic function with LFTs.

18 Cancer Documentation Arrr! Largest area of frustration with documentation for both providers and coders Assume the person doing the audit does NOT have clinical background Most coders do NOT have clinical background, not required for certificate WellMed hires RNs that are also coders, but this is unique When CMS does audits, they are looking documentation stating specifically the cancer is active. Not enough to just choose the Malignant Neoplasm of code. WellMed Medical Management - Do not copy or distribute without written permission. 18

19 Cancer Documentation Arrr! Documenting ACTIVE treatment (chemo, adjunctive therapy, radiation) will confirm the diagnosis. Documenting abnormal lab values (CEA, CA27-29, PSA) will NOT confirm the diagnosis. You must tie the labs and diagnosis together. Medications Lists can be used to confirm a diagnosis, but with new medications, a coder may not recognize what that medicine is being used to treat, so document it! WellMed Medical Management - Do not copy or distribute without written permission. 19

20 Example Cancer Assessments 1. Malignant neoplasm of prostate C61 (Primary) WALK THE 2. Gastrostomy status Z Alzheimers disease, unspecified G Secondary hyperaldosteronism E Polyneuropathy in disease classified elsewhere G63 6. Hypertensive heart and chronic kidney disease with heart failure and stage 1 through stage 4 chronic kidney disease, or unspecified chronic kidney disease I Paroxysmal atrial fibrillation I Unspecified diastolic (congestive) heart failure I Atherosclerosis of aorta I Peripheral vascular disease, unspecified PLANK!! I Hyperlipemia E CKD (chronic kidney disease) stage 2, GFR ml/min N Actinic keratoses L Prediabetes R73.09 Treatment 1. Malignant neoplasm of prostate Notes: Has been on Lupron in the past and followed with urology, not interested in pursuing further treatments or f/u at this time. WellMed Medical Management - Do not copy or distribute without written permission. 20

21 Example Cancer Assessments 1. Malignant AVAST, neoplasm of prostate C61 (Primary) MATEY! PASS 2. Gastrostomy status Z Alzheimers disease, unspecified G Secondary hyperaldosteronism E Polyneuropathy in disease classified elsewhere G63 6. Hypertensive heart and chronic kidney disease with heart failure and stage 1 through stage 4 chronic kidney disease, or unspecified chronic kidney disease I Paroxysmal atrial fibrillation THE I48.0 RUM! 8. Unspecified diastolic (congestive) heart failure I Atherosclerosis of aorta I Peripheral vascular disease, unspecified I Hyperlipemia E CKD (chronic kidney disease) stage 2, GFR ml/min N Actinic keratoses L Prediabetes R73.09 Treatment 1. Malignant neoplasm of prostate Notes: Has been on Lupron in the past and followed with urology, not interested in pursuing further treatments or f/u at this time. We will continue to monitor this active cancer for progression. WellMed Medical Management - Do not copy or distribute without written permission. 21

Example Cancer Current Medications Taking Simvastatin 40 mg Tablet 1 tablet in the evening Once a day Benazepril HCI 20 MG Tablet 1 tablet Once a day Aspirin 81 MG Tablet 1 tablet Once a day Calcium

22 Example Cancer Current Medications Taking Simvastatin 40 mg Tablet 1 tablet in the evening Once a day Benazepril HCI 20 MG Tablet 1 tablet Once a day Aspirin 81 MG Tablet 1 tablet Once a day Calcium 600 MG Tablet 1 tablet with meals twice a day Vitamin D 5000 IU 1 tablet as needed Once a day Tamoxifen Citrate 20 MG Tablet 1 tablet Once a day Levothyroxine 25 MCG Tablet 1 tablet Once a day Vitamin D 5000 unit Capsule as directed Reason for Appointment 1. 5 month f/u 2. pt accompanied by husband 3. pt brought in a list of current medications but not the bottles verbally went over to the best of the patients ability History of Present Illness General: The pt is an 82 y/o F who presents for routine f/u on her Mult Med Problems. She continues to be followed by Oncology for her Breast Cancer. She has a hx of venous stasis ulcers and c/o new lesion on her Lt Leg which she states started about 5 wks ago. She denies SOB, CP, Palp, Wt loss, F/c, pain, N/v or acute change to her visions/speech/memory or extremity functions. WellMed Medical Management - Do not copy or distribute without written permission. 22

23 Example Cancer Assessments 1. Venous AVAST, stasis ulcer of left lower extremity MATEY! (Primary) PASS 2. Chronic kidney disease, Stage I Breast CA Pure hypercholesterolemia Benign essential hypertensions General medical examination V70.9 THE RUM! Treatment 3. Breast CA Notes: The patient continues to be followed by oncology for this and is currently taking tamoxifen 20 mg 1 tablet daily. WellMed Medical Management - Do not copy or distribute without written permission. 23

24 Cancer Documentation Ugh! If active surveillance is taking place (patient has ACTIVE cancer) you need say that specifically. Active surveillance is when patient has active cancer and you are just monitoring it. It is not active surveillance if the patient has undetectable or normal tumor markers and you are just watching for recurrence. Even if the oncologist documents active cancer! WellMed Medical Management - Do not copy or distribute without written permission. 24

25 Cancer Documentation Ugh! Resolve active cancer once patient is considered treated and in remission. Exception: Leukemia and multiple myeloma in remission are still considered active cancers. Don t forget to document metastatic cancer location. Example: Secondary Malignant Neoplasm of lymph nodes. WellMed Medical Management - Do not copy or distribute without written permission. 25

26 When Your Coder Reviews Your Notes Don t make them look like this WellMed Medical Management - Do not copy or distribute without written permission. 26

27 When Your Coder Reviews Your Notes Or this Or this Or this! WellMed Medical Management - Do not copy or distribute without written permission. 27

28 When Your Coder Reviews Your Notes Make them look like THIS!! WellMed Medical Management - Do not copy or distribute without written permission. 28

29 When Your Coder Reviews Your Notes and say WellMed Medical Management - Do not copy or distribute without written permission. 29

30 Summary You are now able to apply best practices to improve RAPS documentation in your clinic.

31 Questions?

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