Coding for Risk Adjustment: Risk Adjustment Conditions and Coding Guidance Module: 3 Presented by: Revenue Program Management Highmark NOTE: This information is intended to assist with documentation only, in an effort to meet Centers for Medicare and Medicaid Services (CMS) documentation guidelines. Reference official ICD-10-CM coding guidelines and manuals or electronic medical coding software for accurate ICD-10-CM codes and specificity. This document is not intended to provide legal advice. This information is subject to change without notice. Updated November 2016. Highmark is a registered mark of Highmark Inc. 2016 Highmark Inc., All Rights Reserved
Contents A Guide to Risk Adjustment Conditions and Coding guidance.3 Addressing Superbill and EMR limitations and barriers..4 Commonly Missed Health Statuses...8 Documentation Do s and Don ts.10 Resources....16 2
Risk Adjustment Conditions and Coding guidance ICD-10 codes that map to HCC categories are those conditions that affect health status, Quality of Life (QOL), are typically chronic conditions, and were selected by CMS as HCC Certain acute conditions such as myocardial infarctions, fractures, and kidney injuries are also part of the HCC model. Acute conditions typically resolve without residual impact, it is important that the current status be reported accurately Chronic conditions should be evaluated at an office visit, at minimum one time per year, with evaluation, treatment, and plan All chronic conditions should be accurately submitted on a claim as the final step for risk adjustment The CMS HCC model includes health status conditions that impact patient QOL and Medicare Advantage plans fiscally Dialysis, long term insulin use, and asymptomatic HIV statuses BMI calculations with interpreted weight status and amputations should be documented 3
Superbill and EMR limitations Super-Bill Errors/Oversights Suggestion EMR Errors/Oversights Suggestion Diagnosis code not on the form, so the provider selects something similar OR Diagnosis code is on the form, but the provider hand writes a diagnosis code that is non-specific Always document exactly what injury/illness/disease the patient has and consult the current ICD manual for correct code assignment Search functions are difficult to navigate and users: Are unable to locate codes Cannot establish causal relationships Are not using system flags (Procedure Code Edits, Quality, etc.) Maintain dialogue with the EMR system sales/technical team Establish a dialogue with like users within the industry Develop and support education opportunities for coding staff Biller/Coder has no training and only consults the Alphabetic index (Volume 2) of the ICD manual Always verify the code assignment in the Numeric index (Volume 1) to ensure correct code assignment EMR verbiage is not always provider friendly (example: Suprapubic catheter = Cystostomy) As long as the written record contains all information used in Medical Decision Making, the coder can determine what ICD to assign The lapse between the time the Superbill is released for payment and when the doctor actually reviews and signs the medical record often causes dual processing Tighter internal controls around dictation and signoff Having to work between multiple systems; there is no central corridor for the varying components that complete chart documentation Build strong relationships with EMR vendors Develop and support education opportunities for coding staff and staff/vendors responsible for medical record retrieval and/or copying 4
Commonly missed Health Status conditions Health Status, Diagnoses and Complications Often Missed: Condition/Situati on/issue ICD-10(s) Documentation Guidance Aortic Calcification and PVD I70.0, I73.9 Complete a once-yearly assessment of cardiovascular conditions (can be included in treatment plans). Write out Peripheral Arterial Disease or Peripheral Vascular Disease and specify type of vascular disease Cardiac Arrhythmias (Atypical vs. Typical) Asymptomatic HIV infection status Transplant Status I49.9 Z21 Z94.x Tachy-Brady Syndrome, Paroxymal/Persistent/Chronic Atrial Fibrillation/Flutter are more severe and chronic forms of arrhythmias and must be stated as such, if they are present. Include in documentation any factors of the disease, coinfections, and/or medication adherence? Status of organ transplant; Liver Z94.4, Heart Z94.1, Lung Z94.2 5
Commonly missed Health Status conditions Health Status, Diagnoses and Complications Often Missed: Condition/Situation /Issue Chronic Obstructive Pulmonary Disease (COPD) vs. Chronic Bronchitis, Emphysema and Asthma ICD-10(s) J44.9, J43.9 Documentation Guidance Differentiate between diagnoses; coding guidelines instruct NOT to use COPD if more definitive conditions exist. Include documentation to support stable or exacerbations, does activity cause symptoms, and compliance with medication/medication changes. Dialysis Status Z99.2 Address hemodialysis or peritoneal dialysis i.e. how often, how the patient is tolerating the dialysis. Is the patient compliant? Protein-Calorie Malnutrition (Mild, Moderate) Pathological Fracture vs. Traumatic Fracture E46 Specificity in orthopedic conditions accounts for the most significant expansion in ICD10 Address chronic conditions such as (nutritional dwarfism or other protein-calorie malnutrition) and the reason why this is occurring. Assess nutritional intake and diet along with their ability to purchase food/obtain food/tolerate food. Is Kwashiorkor or Marasmus present? Is the fracture Intraoperative, Pathologic, or Traumatic? Also note displaced vs. non-displaced; is this initial encounter or sequela; laterality. 6
Commonly missed Health Status conditions Health Status, Diagnoses and Complications Often Missed: Condition/Situation/ Issue ICD-10(s) Documentation Guidance Alcohol/Drug Dependence F10.20 and F19.20 Drug dependence involves all the symptoms of drug abuse, BUT also involves the element of physical dependence. The dependence results in increased clinical evaluations and monitoring. Supplemental Oxygen Dependence & Hypoxemia Z99.81 & R09.02 How often is the patient using the oxygen, are results available from recent pulse oximetry testing? Respirator Dependence Z99.11 Is there an underlying diagnosis and what is the status of the underlying condition? Test oxygen saturation AND document with current settings Insulin Dependence (long-term current use) Z79.4 What is the patients most recent blood sugar/hba1c, how often do they test their blood sugar, and are they managing/compliant with injections? 7
Commonly missed Health Status conditions Condition/Situation /Issue Quadriplegia and Paraplegia Parkinson s Disease Cerebrovascular Disease ICD-10(s) G82.20, G82.50- G20 I67.9 I69.xxx Documentation Guidance Address activities of daily living (ADLs), if skin is intact, and other complications. What cervical vertebral level is affected. Is it secondary Parkinsonism and if so, what are the underlying causes? Document increase/decrease in muscle rigidity, gait stability (bradykinesia), history of recent falls, and management of ADLs. Cerebrovascular disease does not risk adjust. Hemiplegia s/p CVA does risk adjust so specify any residual effects. CVA becomes history of when the member is discharged from the hospital after the acute episode. Residual/Late effects of CVA should be coded using ICD-10 from the time they present, until resolved. Amputations Acquired absence of Z89.xxx Status all amputations Also note any gait stability, if skin intact, managing ADLs, sensations/pain (Note: Toes are frequently missed/overlooked) 8
Commonly missed Health Status conditions Condition/Situation/ Issue ICD10(s) Documentation Guidance Morbid Obesity/BMI (if BMI is not <40) E66.01 BMI 40 or greater is Morbid Obesity; the BMI code is a secondary code to the weight diagnosis which must be documented in the office visit. Include any effect weight has on gait or ADLs, if a device to assist with gait stability is required, and what education or counseling for weight loss and exercise was provided Current artificial opening status - Stoma/Ostomies Depression vs. Major Depression Z93.x F32.9 vs. F32.x, F33.x Assess stomas, if the patient is managing with or without difficulty, and impact on ADL s. NOTE: Complications must be noted/coded separately; Suprapubic Catheter = Cystostomy Major depressive disorder is not the same as depression caused by a loss, such as the death of a loved one or a reaction to a medical condition. Please note the severity and type Mild, Moderate, Severe, then Recurrent, Single episode, or In Remission. Also code if psychotic symptoms present. i.e. Major Depression, Recurrent, Moderate F33.1 9
Documentation and Coding Do s and Don ts Common Documentation/ Coding Issues Do Not Do Signatures/Credentials Do not omit signatures or credentials Do not write illegibly Do not neglect to sign and include consultative reports Causal Relationships Do not list co-existing, manifestations of conditions as separate diseases Do not omit treatment complications or disease interactions Interpretation/ Acknowledgement of laboratory, radiology, diagnostic studies, etc. Do not initial or sign-off on laboratory, radiology, or other diagnostic studies without referencing/detailing them in the clinical note Signature, including credentials on all notes Maintain an office signature log that can be made available to outside parties upon request Use phrases such as with, due to, because of or related to to establish relationships between diagnoses Clearly acknowledge and interpret the findings of the studies in the medical record, including plan of action Be cognizant of verbiage used on radiology reports Example: Radiologist notes compression fracture question whether this should be pathological fracture 10
Documentation and Coding Do s and Don ts Common Documentation/ Coding Issues Over-reporting diagnoses coding/ documentation Do Not Do not report rule out conditions that are not present Do Use the ICD-10-CM code that is chiefly responsible for the item or service provided Use fourth and fifth digits where applicable Code a chronic condition as often as applicable to the patient s treatment Code and bill all documented conditions that coexist at the time of the visit that require or affect patient care or treatment. Incomplete/underreporting diagnoses coding/documentation Do not code conditions that no longer exist Use the ICD-10-CM code that is chiefly responsible for the item or service provided Use fourth and fifth digits where applicable Code a chronic condition as often as applicable to the patient s treatment Code and bill all documented conditions that coexist at the time of the visit that require or affect patient care or treatment. Specificity Do not use unspecified codes, unless absolutely necessary Code to specificity by following national coding guidelines and accurately describe a patient s condition through coding nomenclature 11
Documentation and Coding Do s and Don ts Common Documentation/ Coding Issues Do Not Do Wounds vs. Pressure Ulcers Do not simply state ulcer in medical record documentation, or use the terms wound or sore interchangeably to describe a pressure ulcer Use the term pressure ulcer, as appropriate Include the stage of the pressure ulcer, location, and laterality Use the term venous ulcer where appropriate Acute vs. Chronic Do not exclude the word chronic if it is not a new condition Report the word chronic, where appropriate with diagnoses such as: Chronic Bronchitis, Chronic Asthmatic Bronchitis, Chronic Hepatitis C, Chronic Pancreatitis, Chronic Sinus Bradycardia, Chronic Respiratory Failure History Of Do not document active, chronic, or current conditions as history of Document and support conditions which are no longer present by using phrases such as history of or resolved 12
Appendix CMS websites for Clinical Documentation Best Practices http://www.cms.gov/outreach-and-education/medicare-learning-network- MLN/MLNProducts/downloads/Signature_Requirements_Fact_Sheet_ICN905364.pdf http://www.cms.gov/outreach-and-education/medicare-learning-network- MLN/MLNProducts/downloads/Signature_Requirements_Fact_Sheet_ICN905364.pdf http://www.csscoperations.com/internet/cssc3.nsf/files/2013_ra101participantguide_5cr_08151 3.pdf/$File/2013_RA101ParticipantGuide_5CR_081513.pdf https://www.cms.gov/apps/acronyms/listall.asp?letter=p 13
Thank You! This concludes the Coding for Risk Adjustment: Risk Adjustment Conditions and Coding Guidance