SCIENCE OF DOCUMENTATION AND CODING

Transcription

1 SCIENCE OF DOCUMENTATION AND CODING MEDICARE RISK ADJUSTMENT HCC 1 INTRODUCTION Medicare Risk Adjustment/HCC Documenting and choosing the correct diagnosis code 2 1

2 VOCABULARY ICD-9-CM International Classification of Diseases 9 th Revision (Diagnosis Codes) HCC Hierarchical Condition Categories CMS Centers for Medicare and Medicaid Services Blue codes = HCC 3 MEDICARE RISK ADJUSTMENT Prior to 2003 payments made to the health plan were based solely on demographics Change in payment methodology mandated by the Balance Budget Act of 1997 MRA was implemented in 2003 Between 2003 and 2007 phase in project and since 2007 payment is based 100% based on a set of acute and chronic diagnosis codes (HCC s) Risk Adjustment pays more accurately for the predicted health cost expenditures by adjusting payments based on health status as well as demographics Accurate chart documentation and diagnosis reporting determines reimbursement! 4 2

3 MRA PAYMENTS Payment is made to Medicare Advantage Health Plans (not individual providers) Per HCC category (not per diagnosis code) The payments mentioned in the presentation are based on the patient being enrolled with the health plan for 12 continuous months No matter how many times in the year the diagnosis codes is reported it is just one payment 5 MEDICARE RISK ADJUSTMENT Approximately 70 Hierarchical Condition Categories (HCC S) Approximately 3600 Diagnosis codes within these categories Mostly chronic but some acute codes Provider must see the patient once a year at a minimum and document how they are treating, managing or assessing the chronic problems 6 3

4 S O A P NOTE Subjective: Documents the CC, HPI and ROS, PFSH (History) Objective: Documents the vitals, physical examination and results of diagnostic tests (Examination) Assessment: Documents physician s determination of the patient s condition based on information in the S&O (MDM) Plan: Documents plan of care (MDM) 7 CHOOSING A DIAGNOSIS CODE A joint effort between the health care provider and the coder is essential to achieve complete and accurate documentation, code assignment, and reporting of diagnoses and procedures. Annual code changes are implemented by the government and are effective Oct 1 of every year and valid through Sept 30 of the following year. 8 4

5 THINK OUT OF THE BOX! 9 CHRONIC KIDNEY DISEASE (CKD) Code 585, chronic kidney disease, has four digits. The fourth digit indicates the stage CKD 1 & 2 need additional evidence of kidney damage such as urine abnormality, ultrasound or biopsy CKD Stage I (GFR >90 + evidence of kidney damage) CKD Stage II (mild) (GFR evidence of kidney damage) CKD Stage III (moderate)(gfr 30-59) CKD Stage IV (severe)(gfr 15-29) CKD Stage V (End Stage but not on Dialysis) (GFR < 15) ESRD (on Dialysis) CKD unspecified 10 5

6 ESRD BUDDY CODE When a patient is on dialysis it requires two codes ESRD $2870 V45.11 Renal Dialysis Status $10,522 ESRD on Hemodialysis due to Diabetes Diabetes w/ renal manifestations CKD stage VI (ESRD) V45.11 Renal Dialysis Status 11 CKD and HTN Multiple Coding Technique Chronic Kidney Disease and Hypertension IT IS an assumed cause-and-effect relationship between CKD and Hypertension 585.X and (not 401.9) Even though the description for is Hypertensive Chronic Kidney Disease.you must also code the Chronic Kidney Disease 585.X Hypertensive CKD Stage and CKD Stage HTN CKD Stage 6 (ESRD on Dialysis) and V HTN

7 CHF and HTN Multiple Coding Technique CHF AND HYPERTENSION IT IS NOT an assumed cause-and-effect relationship between CHF and Hypertension and If the patient has both conditions and you consider the heart failure due to the hypertension then documentation needs to state: Hypertensive CHF and Hypertensive Heart Failure and Hypertension with CHF and Heart Failure due to Hypertension and *Hypertensive Heart Failure with CKD , 428.0, DIABETES MELLITUS Code 250, Diabetes Mellitus, has five digits which describe w or w/o complication and Type I or II not stated as uncontrolled or uncontrolled Example Diabetes Mellitus Type II w/o complication not stated as uncontrolled or Diabetes Mellitus Type I w/o complication not stated as uncontrolled New code for Secondary Diabetes effective October 2008 Secondary Diabetes (Diabetes due to, in, secondary, or with drug-induced or chemical induced infection) According to coding guidelines, the use of insulin in a diabetic patient has no bearing on which type the patient has Type I is Juvenile onset Type II is Adult onset 14 7

8 DIABETES MELLITUS Explanation of fifth digit adult onset (type II), not stated as uncontrolled adult onset (type II), uncontrolled Must state in the documentation, uncontrolled or out of control in order to code a 2. Poorly controlled or suboptimal control or high glucose reading is not considered uncontrolled so it would be juvenile onset (type I), not stated as uncontrolled juvenile onset (type I), uncontrolled 15 DIABETES MELLITUS Explanation of fourth digit: no complication ketoacidosis hyperosmolarity coma renal manifestations ophthalmological manifestation neurological manifestation peripheral circulatory disorders other specified manifestations 16 8

9 DIABETES WITH MANIFESTATION BUDDY CODE Use multiple coding techniques buddy code for compound diagnoses Diabetes with a manifestation (complication) requires that you document and code the manifestations as well Peripheral Neuropathy due to DM Diabetes with neurological manifestations Peripheral Neuropathy in DM PVD due to DM Diabetes with peripheral circulatory disorders PVD in other diseases 17 DIABETES WITH MANIFESTATION 18 9

10 DIABETES WITH MANIFESTATION 19 DIABETES WITH MANIFESTATION If your patient has diabetes and one of the many complications, make sure and document the diabetes with the complications throughout your SOAP note and in your assessment using one of the following three acceptable ways Due to Diabetes or DM Secondary to Diabetes or DM Diabetic Appropriate examples Peripheral Neuropathy due to Diabetes CKD stage 3 secondary to Diabetes Microalbuminuria due to DM PVD secondary to DM Diabetic Ulcer Diabetic Retinopathy 20 10

11 DIABETES MULTIPLE CODING TECHNIQUE Coders are not allowed to assume a cause-and-effect relationship If you document like this: Assessment 1. DM $ Peripheral Neuropathy CKD Stage These will be coded separately and the highest HCC code will be missed. If you document like this, then highest HCC will be captured: 1. Diabetic Peripheral Neuropathy and CKD Stage 3 due to Diabetes $3962 and ULCERS VS WOUNDS Ulcers vs Wounds Ulcers are HCC s 707.XX Wounds are not HCC s 870.X 897.X Providers frequently use the terms ulcer and wound synonymously in describing certain lesions on the skin. The term wound should be used to document traumatic conditions such as an avulsion, cut, laceration or a surgical wound The term ulcer should be used to document an area of breakdown in the skin. (i.e. Diabetic Ulcerations, Venous Stasis Ulcers) It is possible for a condition that started out as a traumatic injury to progress into a ulceration. (Diabetic patients w/ PVD) 22 11

12 ULCERS Two types of ulcers, a non-pressure or chronic ulcer 707.1X $3502 decubitus or pressure ulcer 707.0X $8993 Pressure ulcer (Decubitus) is a higher HCC than a non Pressure ulcer so important to document correctly Pressure ulcers generally can be staged I thru IV Two codes are required (buddy code), one for the ulcer and one for the stage Example: Stage 1 Pressure Ulcer Sacrum and If you document Diabetic Ulcer on the calf Diabetes with other specified manifestations Ulcer of the calf 23 COMMONLY MISCODED DIAGNOSES CVA Acute condition that can only be documented and coded during the initial episode of care Once the patient is discharged from the hospital, documentation should reflect a past history of CVA such as H/O CVA, Old CVA, S/P CVA V12.54 UNLESS THEY HAVE A LATE EFFECT! Late effects of CVA if any should be documented and coded as such: CVA w/hemiplegia/hemiparesis CVA w/dysphagia The following documentation is not acceptable to indicate Hemiparesis as a result of a CVA CVA with weakness CVA with R or L sided weakness 24 12

13 MYOCARDIAL INFARCTION Myocardial infarction MI - Acute condition that can only be documented and coded as acute during initial episode of care or with a stated duration of 8 weeks or less If patient had an MI and it is over 8 weeks old then document and code Old MI, S/P MI or H/O MI COMMONLY MISCODED DIAGNOSES Arteriosclerosis of the Aorta Stricture and reduced elasticity of artery; due to plaque deposits Pathologic Fracture of the Vertebrae Fracture due to bone structure weakening by pathological processes (e.g., osteoporosis, neoplasm's) This is not the same as a Compression Fracture of the Vertebrae, unless it is specified as Non-Traumatic 26 13

14 PACEMAKER WITH SSS OR COMPLETE AV BLOCK If the patient has had a pacemaker implant then you do not code the sick sinus syndrome or complete AV block It can and should be documented as S/P pacemaker for SSS Pacemaker for complete AV block You would code V45.01 Pacemaker Status only 27 COMMONLY MISCODED EVENTS Cancer When a primary malignancy has been previously excised or eradicated from its site and there is no further treatment directed to that site and there is no evidence of any existing primary malignancy, a code from category V10 Personal History of malignant neoplasm, should be used to indicate the former site of the malignancy. Any mention of extension, invasion, or metastasis to another site is coded as a secondary malignant neoplasm to that site

15 COMMONLY MISCODED DIAGNOSES Treatment to the site is considered: Chemotherapy, Radiation or Adjunct therapy (Considered current cancer if patient elects to not have treatment) Breast CA on Tamoxifan, Arimidex, Femara etc. would be considered adjunct therapy and coded and documented as current Documentation needs to say Breast Ca on Tamoxifan if not then H/O Breast Cancer V10.3 Prostate Ca on Lupron, Casodex or Zoladex, would be coded and documented as current 185 Documentation needs to state Prostate Ca on Lupron if not then H/O Prostate Cancer V METASTATIC CANCER Mets is the highest HCC if you document the site of the metastases! $17,753 Breast Cancer on Arimidex with Mets to liver and Prostate Cancer on Lupron with bone Mets 185 and H/O Colon Cancer with Mets to the liver V10.05 and If you document like this highest HCC will be missed Metastatic Breast Cancer $ and Metastatic Colon Cancer (if colon cancer is under current treatment) and Lung Cancer with Mets (if lung cancer is under current treatment) and H/O Lung Cancer with Mets $1622 V10.11 and

16 ALCOHOL AND DRUG DEPENDENCE Alcohol Dependence (Addiction) or Chronic Alcoholism or Alcoholism in remission or This chronic condition is identified by the patient who is unable to cease alcohol use even with detriments to health, social interactions and job performance. These patients generally experience physical signs of withdrawal with any sudden cessation of drinking. Drug Dependence (Addiction) or Drug Dependence in remission or This chronic mental and physical condition is related to the pattern of the patient s drug or drug combination intake and is characterized by behavioral and physiological reactions. These reactions are the obsession to take the drug, the need to have the feeling of its psychic effects or the attempt to avoid the discomfort of abstinence. Any sudden cessation typically triggers physical signs of withdrawal. (opiate, anxiolytic, sedative, hypnotic, hallucinogen or amphetamine) 31 ALCOHOL AND DRUG ABUSE Alcohol Abuse 305.0X Patients who have been identified as having alcohol abuse represent those who have developed a problem with drinking, including those that drink alcohol in excess but have not arrived at a stage of physical dependency. Drug Abuse 305.XX Drug abuse includes cases where the individual, for whom no other diagnosis is possible, has come under medical care because of the maladaptive effect of a drug on which the patient is not dependent. In nondependent abuse of drugs, the individual generally has taken the drug on personal initiative to the detriment of health or social functioning. Patients who have been identified as drug abusers have developed a problem with drugs including those that take an excess of drugs but have not arrived at a stage of physical dependency

17 MALNUTRITION Malnutrition 263.X Undercoded in the elderly Commonly used indicators: Albumin < % unintentional weight loss in 6-12 months 5% unintentional weight loss in 3-6 months BMI < 18.5, especially with co-morbidity Marked reduction in physical capacity Wasting appearance or muscle wasting Poor nutrition or loss of appetite or seriously curtailed food intake Cachexia DEEP VEIN THROMBOSIS Acute DVT (Initial episode of care) Chronic DVT (On an anti-coagulant) H/O DVT (No anti-coagulant) V12.51 Need to document Chronic DVT if pt is on anticoagulant therapy Same guidelines for Pulmonary Embolism 34 17

18 MAJOR DEPRESSION Major Depression 296.XX Criteria to diagnose Major Depression PHQ9 Score > 10 5 of 9 DSM IV Criteria SIGECAPS (sleep, interest, guilt, energy, concentration, appetite, psychomotor changes and suicidal ideation, plus a depressed mood) Other recognized depression screening tool Depression (Situational, Grief) 311 is not an HCC! 35 COMMON OMISSIONS Artificial Openings Gastrostomy V44.1 Colostomy V44.3 Tracheostomy V44.0 Ileostomy V44.2 Amputations BKA V49.75 AKA V49.76 Foot V49.73 Toe V49.71 or V49.72 AAA Abdominal Aortic Aneurysm (w/o repair) 36 18

19 DOCUMENTATION TIPS FOR ACCURATE CODING Don t document history of ANY disease that currently exists. The statement history of in ICD-9 terms means that the patient no longer has this condition. However, history of is ok when documenting some status conditions such as an Amputation. Incorrect H/O CHF (meds Lasix) H/O Angina (meds nitroquick) H/O COPD (meds Advair) Correct Compensated CHF stable on Lasix Angina stable on Nitro COPD controlled w/advair 37 CRITICAL SUCCESS FACTORS CODING GUIDELINES Completely assess the patient s health status and properly document all conditions Fully assess all chronic conditions every 6 months Accurately document in the medical record all conditions evaluated during each visit Codes marked on the encounter form or reported in EMR note must be fully supported in the chart note for the visit Document and code to the highest level of specificity 38 19

20 CRITICAL SUCCESS FACTORS CODING GUIDELINES A medical record entry must Be legible Support all diagnoses coded Be complete and accurate Have a provider signature and credentials Identify the patient and date of service Document the patient s progress and results of treatment Justify the treatment and level of care Use only standard abbreviations and keep them to a minimum Promote continuity of care among the healthcare providers 39 TMA TREAT, MANAGE OR ACCESS In order for CMS to make the payment, documentation must be from a face to face visit and you must indicate how you are treating, managing or assessing the chronic conditions Each diagnosis must have an assessment and a plan Sample Language Assessment Stable Improved Tolerating Meds Deteriorating Plan Monitor D/C med Continue current meds Refer Example: Hypertensive CKD 3, stable well controlled. Continue meds Example: COPD, stable on Advair 40 20

21 STRIVE FOR DUCT TAPE NOTES NOT SCOTCH TAPE NOTES 41 DOCUMENTING THE CORRECT DIAGNOSIS DON T REPORT THIS IF THE PATIENT REALLY HAS (Does Not Risk Adjust) (Does Risk Adjust) 311 Depression 296.XX Major Depression Asthma Chronic Obstructive Asthma 496 COPD / Emphysema 490 Bronchitis Chronic Bronchitis CAD Angina, Unstable Angina 412 Old MI Cardiac Dysrhythmia AFib / AFlutter Fracture of Vertebrae (Initial episode of care) Pathological FX of Vertebra Pancreatitis Chronic Pancreatitis Hepatitis C Chronic Hepatitis C 42 21

22 CRITICAL SUCCESS FACTORS CODING GUIDELINES Probable, suspected, questionable, R/O, versus, working diagnosis,?, likely etc cannot be coded! Code the condition to the highest degree of certainty for that encounter/visit, such as symptoms, signs, abnormal test results, or other reason for the visit. Resolved or Healed cannot be coded. 43 TOP 10 HCC GROUPS 1. COPD 496 COPD Asthma w/chronic COPD Chronic Bronchitis Emphysema 2. CHF CHF Primary Cardiomyopathy (Ischemic is not an HCC) Hypertensive Heart Disease w/heart Failure 3. VASCULAR DISEASE Peripheral Vascular Disease PVD in other diseases (diabetes) Acute DVT Chronic DVT Atherosclerosis of Aorta Abdominal Aortic Aneurysm 44 22

23 TOP 10 HCC GROUPS 4. CANCER All malignant neoplasm's including Melanoma but not skin cancer All secondary malignant neoplasm's Highest HCC if site is documented 5. SPECIFIED HEART ARRHYTHMIA Complete AV Block Atrial Fibrillation Sick Sinus Syndrome 6. DIABETES All Diabetes (250.XX) and most of the manifestations 7. ISCHEMIC OR UNSPECIFIED STROKE 436 CVA Unspecified Cerebral Artery Occlusion, w/infarction 45 TOP 10 HCC GROUPS 8. ANGINA/OLD MI Angina 412 OLD MI 9. RHEUMATOID ARTHRITIS & INFLAMMATORY CONNECTIVE TISSUE DISEASE Rheumatoid Arthritis Systemic Lupus Erythematosus 725 Polymyalgia Rheumatica Sacroiliitis 10. ISCHEMIC HEART DISEASE Unstable Angina Acute Myocardial Infarction 46 23

24 OTHER COMMON HCC DIAGNOSIS CODES 340 Multiple Sclerosis Parkinson's Seizure Disorder Proliferative Diabetic Retinopathy Paraplegia Quadriplegia 042 HIV Liver Cirrhosis without mention of alcohol Crohn s Disease Muscular Dystrophy 340 Multiple Sclerosis Cerebral Palsy Cystic Fibrosis Transplants Heart, Liver, Lung, Pancreas, Intestines, Bone Marrow, Stem Cell 47 Common Synonyms PVD (Peripheral Vascular Disease) = Peripheral Angiopathy = PAD (Peripheral Artery Disease) = Claudication = Polyneuropathy = Peripheral Neuropathy = Major Depression = Depressive Psychosis = Parkinson s = Paralysis Agitans = Unstable Angina = Intermittent Coronary Syndrome = Sick Sinus Syndrome (SSS) = Sinoatrial Node Dysfunction = Chronic Sinus Bradycardia =

25 ACUTE CODES Septicemia/Sepsis Intestinal Obstruction/Perforation Coma, Brain Compression Respiratory Arrest Cardio Respiratory Failure and Shock Cerebral Hemorrhage Aspiration, Bacterial and Pneumococcal Pneumonias Third Degree Burns Head Injuries Complications or Malfunctions of device, implant or graft Opportunistic Infections 49 CASE SCENARIO Mrs. Smith, an 85 year old white female who lives at home alone. Patient presents with symptoms consistent with UTI. Patient feels more tired and has less energy, poor appetite. She had a heart attack (MI) a year ago. Patient has mild degree of malnutrition, frail and has lost 30 lbs within 6 mos. A urinalysis was performed which shows white cells and leukocyte esterase and microalbuminuria. Serum creatinine 1.4 Patient is complaining of urinary discomfort, weakness, has dry and itching skin last 6 mos. PMH: Diabetic Nephropathy, R BKA status stable and UTI. Her serum creatinine 6 mos before that was 1.3, lab findings revealed CKD III. Plan : DM Glyburide 2.5mg po QD, UTI Cipro, Malnutrition Ensure supplements. Rtn in 3 mos. Refer to Nephrologist for CKD Assessment : DM & UTI

26 RAF (Risk Adjusted Factor) DIFFERENCE! DM UTI Demographic.454 TOTAL RAF.616 $4805 What the documentation says and how to appropriately document these diagnoses in the progress note? Added to the assessment: CKD III due to DM, R BKA status due to DM DM w/ renal manifestations CKD III Malnutrition DM w/ peripheral circulatory BKA V Old MI Demographic.454 TOTAL RAF $24, CONTACT INFORMATION Susan Wyatt, CPC, CPC-I, CPMA HCC Risk, Auditor and Education Manager CareMore Health Plan Susan.wyatt@caremore.com 52 26