Risk Adjustment Training

(1)

Risk Adjustment Training

HCC, CDPS, and Hybrid models

2014 National Conference

Education provided by:

Brian Boyce, BSHS, CPC, CPC-I

Proprietor & Managing Consultant, ionHealthcare, LLC

(2)

No part of this presentation may be reproduced

or transmitted in any form or by any means

(graphically, electronically, or mechanically,

including photocopying, recording, or taping)

without the expressed written permission of

AAPC or ionHealthcare, LLC.

2

Foundations of RA Models

What is Risk Adjustment?

(3)

Introduction

• Risk Adjustment is a methodology of adjusting estimated or

perceived risks as they relate to diagnosis codes of patients

• Understanding each current illness or diagnosis a patient has helps

to estimate needed funding for future years and in some models,

applies to payments for treating those illnesses

• There are different forms of risk adjustment models, to include:

4

HCC

CDPS

Hybrid

Introduction

•

Within risk adjustment models, there are usually two branches of risk

reviewed:

1. Diagnosis-based risk adjustment examples:

•

Chronic illness and Disability Payment Systems (CDPS) – Medicaid

•

Hierarchical Co-Existing Conditions (HCC-C) – Medicare

•

Diagnosis Related Groups (DRG) – Inpatient

•

Adjusted Clinical Groups (ACG) – Outpatient

2. Prescription-based risk adjustment examples:

•

MedicaidRx (UCSD)

•

RxGroups (DxCG)

•

Hierarchical Co-Existing Conditions (HCC-D)

(4)

Why It Matters

• For Medicare Advantage Plans

①

Risk Adjustment (RA) identifies patients who may need

disease

management interventions

and

②

RA establishes the

financial allotment

from CMS

toward the annual care

of each patient; with more dollars allocated for those with higher risk

scores

• For Medicaid and Commercial Plans

①

Risk Adjustment (RA) identifies patients who may need

disease

management interventions

and

②

RA establishes the “overall state of the population” by aggregating

diagnoses; which assists in

financial forecasting for future medical need

6

General RA Guidelines

• These programs operate on similar rules and

guidelines to include:

– Specific diagnoses

must be documented in a

face-to-face visit

by the

treating licensed provider

(

showing

credentials:

MD, DO, PA, NP, OT, CRNA, MSW, and similar master’s level

providers)

and the documentation must be

signed by the

treating provider

to be accepted

– Diagnoses must be clearly stated on the DOS (Date Of

Service) as a

current problem

– Diagnoses must be

documented each year

, ongoing as

each year is evaluated without historical context

influence

(5)

Acceptable Provider Specialties

8

CODE SPECIALTY CODE SPECIALTY CODE SPECIALTY

01 General Practice 25 Physical Medicine & Rehabilitation 67 Occupational Therapist 02 General Surgery 26 Psychiatry 68 Clinical Psychologist 03 Allergy/Immunology 27 Geriatric Psychiatry 72 Pain Management 04 Otolaryngology 28 Colorectal Surgery 76 Peripheral Vascular Disease 05 Anesthesiology 29 Pulmonary Disease 77 Vascular Disease 06 Cardiology 33 Thoracic Surgery 78 Cardiac Surgery 07 Dermatology 34 Urology 79 Addiction Medicine 08 Family Practice 35 Chiropractic 80 LCSW

09 Interventional Pain Management (IPM) 36 Nuclear Medicine 81 Critical Care (Intensivists) 10 Gastroenterology 37 Pediatric Medicine 82 Hematology 11 Internal Medicine 38 Geriatric Medicine 83 Hematology/Oncology 12 Osteopathic Manipulative Therapy 39 Nephrology 84 Preventative Medicine 13 Neurology 40 Hand Surgery 85 Maxillofacial Surgery 14 Neurosurgery 41 Optometry (optometrists) 86 Neuropsychiatry 15 Speech Language Pathologist 42 Certified Nurse Midwife 89 Certified Clinical Nurse Specialist 16 Obstetrics/Gynecology 43 CRNA 90 Medical Oncology 17 Hospice and Palliative Care 44 Infectious Disease 91 Surgical Oncology 18 Ophthalmology 46 Endocrinology 92 Radiation Oncology 19 Oral Surgery (Dentists only) 48 Podiatry 93 Emergency Medicine 20 Orthopedic Surgery 50 Nurse Practitioner 94 Interventional Radiology 21 Cardiac Electrophysiology 62 Psychologist 97 Physician Assistant 22 Pathology 64 Audiologist 98 Gynecologist/Oncologist 23 Sports Medicine 65 Physical Therapist 99 Unknown Physician Specialty 24 Plastic & Reconstructive Surgery 66 Rheumatology C0 Sleep Medicine

Diagnosis Code Value

• In risk adjustment models diagnosis codes carry a risk

adjustment value (RAF or “risk adjustment factor” in the HCC

model)

• This is similar to the concept of RVU (Relative Value Units)

assigned to CPT® codes

• The more severe or complex a diagnosis, the higher its value

• If two or more diagnoses are documented from the same

category, the diagnosis that is more severe or complex will

“trump” any others

(6)

Financial Matters

No Conditions Coded

(Demographics Only)

Some Conditions Coded

(Claims Data Only)

All Conditions Coded

(Chart Review by Certified Coder)

76 year old female

.468

76 year old female

.468

76 year old female

.468

Medicaid Eligible

.177

Medicaid Eligible

.177

Medicaid Eligible

.177

DM Not Coded

DM (no manifestations)

.118

DM with Vascular

Manifestations

.368

Vascular Disease

not coded

Vascular Disease

without complication

.299

Vascular Disease

with complication

.41

CHF not coded

CHF coded

.368

No interaction

+ Disease Interaction

bonus RAF (DM + CHF)

.182

Patient Total RAF

.645

Patient Total RAF

1.062

Patient Total RAF

1.973

PMPM Payment for Care

$

452

$

743

$

1,381

Yearly Reserve for Care

$

5,418

Yearly Reserve for Care

$

8,921

Yearly Reserve for Care

$

16,573

Hierarchical Categories

• Families or hierarchical groups/categories are used in risk adjustment

• More severe or complicated illnesses (by ICD code) in the family or

hierarchy will trump all others in the category or family

• Sometimes codes which are trumped by others from a medical

management perspective (Part C) may still carry value from a

prescription drug perspective (Part D)

• This leads to a strong need for coders to always code diagnoses to their

highest specificity so that all current diagnoses are accounted for each

encounter

• ICD guidelines instruct coders to code for a principal diagnosis, but also

all other comorbidities during each encounter

(7)

Hierarchical Categories in the HCC Model

12

2014 Hierarchical Categories in the HCC Model

Infection

Blood

Cerebrovascular

Disease

Complications

Neoplasm

Substance Abuse

Vascular

Transplant

Diabetes

Psychiatric

Lung

Openings

Metabolic

Spinal

Eye

Amputation

Liver

Neurological

Kidney

Disease Interactions

Gastrointestinal

Arrest

Skin

Disability Status

Musculoskeletal

Heart

Injury

Hierarchical Categories in the CDPS Model

13

2014 CDPS Major Categories

Psychiatric

Skin

Metabolic

Skeletal

Renal

Pregnancy

Central Nervous System

Substance Abuse

Eye

Pulmonary

Cancer

Cerebrovascular

Gastrointestinal

Developmental Disability

AIDS/Infectious Disease

(8)

Trump Examples (HCC)

If this HCC

is found…

**2014 Disease Group Label**

…Then Drop these

HCC’s:

8

Metastatic Cancer and Acute Leukemia

9,10,11,12

9

Lung and Other Severe Cancers

10,11,12

10

Lymphoma and Other Cancers

11,12

11

Colorectal, Bladder, and Other Cancers

12

14

If this HCC

is found…

**2014 Disease Group Label**

…Then Drop these

HCC’s:

17

Diabetes with Acute Complications

18,19

18

Diabetes with Chronic Complications

19

Trump Examples (CDPS)

•

Cardiovascular Category (4 levels)

1.

CARVH includes 3 Stage 1 groups and 7 diagnoses

2.

CARM includes 13 Stage 1 groups and 53 diagnoses

3.

CARL includes 26 Stage 1 groups and 314 diagnoses

4.

CAREL includes 2 Stage 1 groups and 35 diagnoses

•

Where the suffix of the Cardiovascular Category (CAR) establishes its place in

the hierarchy. For example:

–

VH (Very High) (weight 2.037): heart transplants, valves, etc.

–

M (Medium) (weight 0.805): heart attacks, etc.

–

L (Low) (weight 0.368): heart disease, etc.

–

EL (Extra Low): hypertension etc.

(9)

The HCC Model is Ever-Changing

• The original DCG/HCC model in 2000 identified 804 costly diagnosis

groups, mapped to 189 HCC codes

• Created a reporting model for reimbursement based on ICD codes within

families of conditions. (Hierarchal Categories)

• There are 2,944 ICD codes carrying Part C HCC value (over 3,000 in 2004)

• There are 1,475 ICD codes carrying Part D HCC value (over 3,000 in 2004)

• 978 ICD codes carry both Part C and Part D HCC value (~ 1500 in 2004)

• Major Changes are due for 2014

– Many Part C’s dropped to Part D only

– Blended model in 2014 (mixing values from 2013 model and 2014 model)

– Many new interactions

If this HCC is found… 2013 Disease Group Label …Then Drop these HCC’s:

5 Opportunistic Infections 112

7 Metastatic Cancer and Acute Leukemia 8, 9, 10 8 Lung, Upper Digestive Tract, and Other Severe Cancers 9, 10 9 Lymphatic, Head and Neck, Brain and Other Major Cancers 10 15 Diabetes with Renal Manifestations or Peripheral Circulatory Manifestation 16, 17, 18, 19 16 Diabetes with Neurologic or Other Specified Manifestation 17, 18, 19 17 Diabetes with Acute Complication 18, 19 18 Diabetes with Ophthalmologic or Unspecified Manifestations 19

25 End Stage Liver Disease 26, 27

26 Cirrhosis of Liver 27

51 Drug/Alcohol Psychosis 52

54 Schizophrenia 55

67 Quadriplegia/Other Extensive Paralysis 68, 69, 100, 101, 157

68 Paraplegia 69, 100, 101, 157

69 Spinal Cord Disorders/Injuries 157

77 Respirator Dependence/Tracheotomy Status 78, 79

78 Respiratory Arrest 79

81 Acute Myocardial Infarction 82, 83

82 Unstable Angina and Other Acute Ischemic Heart Disease 83

95 Cerebral Hemorrhage 96

100 Hemiplegia/Hemiparesis 101

104 Vascular Disease with Complications 105, 149

107 Cystic Fibrosis 108

111 Aspiration and Specified Bacterial Pneumonias 112

130 Dialysis Status 131, 132

131 Renal Failure 132

148 Decubitus Ulcer of Skin 149

(10)

If this HCC is found… **2014 Disease Group Label** …Then Drop these HCC’s: 8 Metastatic Cancer and Acute Leukemia 9,10,11,12

9 Lung and Other Sever Cancers 10,11,12 10 Lymphoma and Other Cancers 11,12 11 Colorectal, Bladder, and Other Cancers 12 17 Diabetes with Acute Complications 18,19 18 Diabetes with Chronic Complications 19 27 End-Stage Liver Disease 28,29,80 28 Cirrhosis of Liver 29 46 Severe Hematological Disorders 48 54 Drug/Alcohol Psychosis 55

57 Schizophrenia 58

70 Quadriplegia 71,72,103,104,169 71 Paraplegia 72,104,169 72 Spinal Cord Disorders/Injuries 169 82 Respirator Dependence/Tracheostomy Status 83,84 83 Respiratory Arrest 84 86 Acute Myocardial Infarction 87,88 87 Unstable Angina and Other Acute Ischemic Heart Disease 88 99 Cerebral Hemorrhage 100 103 Hemiplegia/Hemiparesis 104 106 Atherosclerosis of the Extremities with Ulceration or Gangrene 107,108,161,189 107 Vascular Disease with Complications 108 110 Cystic Fibrosis 111,112 111 Chronic Obstructive Pulmonary Disease 112 114 Aspiration and Specified Bacterial Pneumonias 115 134 Dialysis Status 135,136,137 135 Acute Renal Failure 136,137 136 Chronic Kidney Disease (Stage 5) 137 157 Pressure Ulcer of Skin with Necrosis Through to Muscle, Tendon, or Bone 158,161 158 Pressure Ulcer of Skin with Full Thickness Skin Loss 161 166 Severe Head Injury 80,167

How Does HCC Compare to CDPS?

There are various systems using Risk Adjustment beyond HCC for Medicare

HMO plans. Some of these include:

Diagnosis based programs:

•Chronic Illness and Disability Payment Systems (CDPS) - Medicaid

•Hierarchical Co-Existing Conditions (HCC-C) - Medicare

•Diagnosis Related Groups (DRG) – Inpatient

•Adjusted Clinical Groups (ACG) – Outpatient

Prescription based programs:

•MedicaidRx (UCSD)

•RxGroups (DxCG)

•Hierarchial Co-Exisiting Conditions (HCC-D)

(11)

History of CDPS Model

• Started in 1996 to tailor current risk adjustment models to better apply to

Medicaid programs. Development started using claims from disabled

beneficiaries information from the Disability Payment System (DPS) from

Colorado, Michigan, Missouri, New York, and Ohio by Rick Kronick and

associates

• Update in 2000 to include disabled and TANF (Temporary Assistance for

Needy Families) beneficiaries from California, Georgia, and Tennessee.

This upgraded program was then renamed the Chronic Illness and

Disability Payment System (CDPS)

• In 2001, Todd Gilmer and associates developed the Medicaid Rx (MRX)

using CDPS information. Based on combining from the Chronic Disease

Score (CDS) developed by Von Korff and associates and the RxRisk model

by Fishman and associates

History of CDPS Model

• In 2008, CDPS and MRX models were updated using Medicaid data

from 44 states in 2001 and 2002. Another model was developed

employing both diagnostic and pharmacy data called CDPS + Rx

• Data was supplied by CMS from Medicaid Analytic eXtract (MAX)

data system. MAX data consists of patient-level data files with

information on Medicaid eligibility, utilization of services, and

payments for services

• More on CDPS:

University of California, San Diego website:

(12)

How Does CDPS & MRX Work?

• Mapping of diagnoses and/or pharmaceutical use to a group (vector)

of disease categories

• CDPS maps

16,461 ICD codes

to

58 CDPS categories

which lead

up to

20 major categories

related to major body systems (such as

cardiovascular) or type of disease (such as diabetes)

• MRX maps to

56,236 NDC codes

from patient utilization to

45

Medicaid Rx categories

This leads to “

Stage 1 Groups

” (build CDPS)

• Groups ICD codes, typically at 3-digit level (for ICD-9)

• Sometimes grouped at 4

th

or 5

th

digit when that extra digit describes

a more serious condition or version of a diagnosis

Predictive Modeling

Diagnosis

with no

complications

DME; Rx; CPT;

Labs; HCPCS;

etc.

Diagnosis

with some

complication?

(13)

Quality Improvement

• CMS defines the star ratings in the following manner:

5 Stars = Excellent Performance

4 Stars = Above Average Performance

3 Stars = Average Performance

2 Stars = Below Average Performance

1 Star = Poor Performance

• Variable weights are given to each measure with those

related to outcomes being weighted highest, followed by

patient experience measures in the middle, and process

measures being lowest

Quality Improvement

Medicare Part C Domains for 2014: Quality of Care

Domain 1

Staying Healthy – Screenings, Test, & Vaccines

Domain 2

Managing Chronic Conditions

Domain 3

Ratings of Plan Responsiveness & Care

Domain 4

Member Complaints, Problems Getting Services, & Choosing to Leave the Plan

Domain 5

Health Plan Customer Service

Medicare Part D Domains for 2014: Quality of Care

Domain 1

Staying Healthy – Screenings, Test, & Vaccines

Domain 2

Managing Chronic Conditions

Domain 3

Ratings of Plan Responsiveness & Care

(14)

Significance to Providers

• Providers have long attempted to establish the

seriousness and severity of the patients they treat

through the use of E&M CPT® codes

• Higher level E&M codes identify serious encounters,

utilizing more medical decision making, and are

reimbursed at a higher rate

• In Risk Adjustment scenarios, these CPT® codes have

no significance

• Instead,

specific diagnosis codes communicate

the

seriousness of

medical decision making

Significance to Providers

• Using

specific ICD Diagnosis Codes

will help convey

the true seriousness of the conditions being addressed

in each visit

• Documenting these carefully involves two main focal

points:

①

Identifying the Diagnosis as a current or ongoing problem

as opposed to a PMH (Past Medical History) or previous

condition

②

Choosing the most specific Diagnosis Code while also

being sure documentation supports it fully

(15)

Diagnosis Documentation

& Coding

Coding for Risk Adjustment

Documentation

• Documentation is the only key to collect appropriate

diagnosis codes for encounters

• When appropriate, coders should query the treating provider

if possible, however many coders working in risk adjustment

cannot query the providers, thus they must only code to the

best of their ability based on documentation given

• ICD guidelines state to code for all existing comorbidities for

each encounter that are a part of MDM (Medical Decision

Making)

(16)

Documentation

• Providers and Coders are equally guilty of choosing generic,

non-specific codes because they are memorized and easier

than stopping to look up a more specific diagnosis code

supported by the documentation

• Documenting complications and comorbidities is also

important for risk adjustment purposes

• Many providers still do not realize that the coding guidelines

largely prohibit medical coders from assuming any cause and

effect relationships and if these are not clearly documented in

the medical record, they are lost in translation

30

Documentation

• For example:

1. A diabetic patient who comes in for a sore throat and is

diagnosed with strep throat:

• Many offices will only use the strep diagnosis code, yet diabetes is still a

current diagnosis, and one that surely was considered during treatment

options as a part of the Medical Decision Making

2. A hypertensive patient with CHF comes in to the office for follow

up:

• Many providers do not know that if the CHF and hypertension are

related, they must state this, otherwise coders are left to only code them

as separate diagnoses. CHF alone and HTN alone may “risk adjust” in

models, but “Hypertensive Heart Disease” is more serious

(17)

Documentation

• Diagnosis specificity is of paramount importance and in many

diagnoses, use of the word “chronic” can change the chosen

diagnosis code (and its subsequent risk value)

• Examples include (but are not limited to):

– Chronic Renal Insufficiency vs. Renal insufficiency

– Chronic Hepatitis B vs. Hepatitis B

– Chronic Bronchitis vs. Bronchitis

– Chronic cor pulmonale vs. cor pulmonale

32

Documentation

• Avoid homegrown abbreviations and document all cause and

effect relationships

• Include all current diagnoses as part of the current medical

decision making and carry them to the final assessment of the

encounter

• Each note needs a date, signature, & credential (MD, DO, NP, PA,

etc.)

• Document history of heart attack, any amputations, hypoxia,

status codes, ostomy, etc., when factual

• Only document diagnoses as “history of” or “PMH” when they no

longer exist or are a current condition

(18)

Documenting Diabetes

• Many providers have memorized the ICD-9-CM code of 250.00 for

diabetes, yet this is often NOT the correct code for many patients

• Diabetes codes in both ICD-9 and ICD-10 have specific codes to

identify diabetes-related manifestations

• In both: The

4

th

digit tells manifestation

and

5

th

digit tells if controlled

or uncontrolled

• Only diabetics with no manifestations should utilize the generic

diabetes ICD code

Diabetes in ICD-9-CM

ICD-9 Code

Manifestation by 4

th

digit; Stated as: “Due to, with, etc.”

250.

0

x

DM,

no mention of complication

250.

1

x

DM,

with Ketoacidosis

250.

2

x

DM,

with hyperosmolarity

250.

3

x

DM,

with coma/insulin coma

250.

4

x

DM,

with renal manifestations

250.

5

x

DM,

with ophthalmic manifestations

250.

6

x

DM,

with neurological manifestations

250.

7

x

DM,

with peripheral circulatory disorders

250.

8

x

DM,

with other specified manifestations

250.

9

x

DM,

with unspecified complications

Cause & Effect relationships must be documented by the provider when DM is the reason for any

manifestation. (Only exception is gangrene in DM may be assumed related.)

(19)

Diabetes in ICD-10-CM

Type 1

Type 2

Other Specified (*No Unspecified code)

E1

0

.

1x

-

[Check 5

th

] with

ketoacidosis

E11.

0

x

-

[Check 5

th

] with

hyperosmolarity

E13.

0

x-

-

[Check 5

th

] w/

hyperosmolarity

E13.

1x-

-

[Check 5

th

] w/

ketoacidosis

E1

0

.

2x

-

[Check 5

th

]

w/kidney complications

E11.

2x

-

[Check 5

th

]

E13.

2

-

[Check 5

th

]

E1

0

.

3x

-

[Check 5-6

th

]

w/ ophthalmic comp.

E11.

3x

-

[Check 5-6

th

]

w/ ophthalmic comp.

E13.

3

-

[Check 5-6

th

]

w/ ophthalmic comp.

E1

0

.

4x

-

[Check 5

th

]

w/ neuro. complications

E11.

4x

-

[Check 5

th

]

E13.

4

-

[Check 5

th

]

E1

0

.

5x

-

[Check 5

th

]

w/ circulatory comp.

E11.

5x

-

[Check 5

th

]

E13.

5

-

[Check 5

th

]

E1

0

.

6x

-

[Check 5-6

th

] w/

other spec. comp.

E11.

6x

-

[Check 5-6

th

] w/

other spec. comp.

E13.

6

-

[Check 5-6

th

] w/ other specified complications

E1

0

.

8

w/ unspecified

complications

E11.

8

w/ unspecified

complications

E13.

8

w/ unspecified complications

E1

0

.

9

without complications

E11.

9

without complications

E13.

9

without complications

Documenting & Coding Diabetes

• Under-documenting DM communicates a less serious DM

case, which

affects value of care

• Any manifestations must be documented as a cause and

effect relationship, for example:

①

Assessment: 1.

DM

2.

Polyneuropathy



Can only code:

250.00

and 356.9 (ICD-9-CM)



E11.9

and G62.9 (ICD-10-CM)

[Lower Value DM]

②

Assessment: 1

. DM

with

Polyneuropathy



Can code:

250.60

and 357.2

(20)

Documenting & Coding HTN

• Under-documenting HTN communicates a less serious

HTN case, which

affects value of care

• Any manifestations must be documented as a cause and

effect relationship (CKD is an exception)

Hypertension Type

ICD-9-CM

ICD-10-CM

HTN (primary, benign, essential,

malignant)

401.

x

I1

0

“with” Heart Disease

402

.xx

I11.

x

“with” CKD

403.

xx

I12.

x

“with” heart & kidney disease

404.

xx

I13.

x

Hypertension, secondary

405.

xx

I15.

x

Documenting & Coding Cancers

• Per guidelines, cancers are coded by their location and may

only be coded as active when current treatment is being

directed to the cancer

, or if the cancer is active and treatment

was refused

• Radiation, Chemotherapy, and Hormonal

treatments used

specifically for a given cancer qualify as current treatment

• Without current treatment, the patient only has a personal

history of cancer (V code) and these typically do not risk adjust

• Helpful to know if cancer is

primary, metastatic, and what

(21)

Documenting & Coding Depression

• Patients who are on anti-depressant therapy are considered to

have “major depression” clinically

• Providers rarely document it this way, often only noting

“depression”

• Coders can only code what is documented and “depression”

alone defaults to “situational depression” such as bereavement

or job loss or other temporary depression

• Depression assessment tools are often used to validate or

support moderate to severe or “major depression” but when

patients are receiving therapy these scores may not reflect the

diagnosis and this should be noted

Provider Signatures

• Providers must always sign or authenticate their records

• CMS has clarified that this may be a full signature or initials or

other mark, however is the signature or mark is illegible, then there

must be some other way to determine the providers name, such

as a printed name on the encounter, such as on letterhead

• When more than one provider is listed on letterhead, the treating

provider should be marked in some fashion

• Documentation which lacks proper signature or credential of the

treating provider may still be coded, as this can be obtained later

(22)

Choosing Diagnoses From

Various Portions of the Encounter

Where Current Diagnoses May Be

Documented

Current Diagnoses

• While most will readily agree that the assessment and plan

portions of any encounter will have solid documentation on current

diagnoses, these areas may be missing diagnoses, or combined

data that may be found elsewhere

• In most all other forms of coding, ICD codes are selected by

choosing those diagnoses which were “addressed” or fit the

primary diagnosis, or even the local coverage determination for a

procedure

• When coding for risk adjustment purposes, it is appropriate to

code for all current diagnoses in each encounter

(23)

Current Diagnoses

• Some organizations may choose a conservative approach and

prefer that there be some form of treatment or acknowledgment of

the diagnosis in the encounter, however there are many diagnoses

in risk adjustment models which may never be treated or

acknowledged because they just exist:

– Old MI (having had an heart attack) carries value

– Amputations carry value

– Drug Addiction codes carry value

– “Family and personal history of” codes carry value in the CDPS

model

– Etc.

44

Code for All Diagnoses

• Risk adjustment models allow for collection of diagnoses from

face-to-face visits from outpatient and inpatient encounters

• Diagnoses should not be collected from radiological or other

diagnostic test orders or reports or laboratory requests or

results with the exception of pathology, which is considered a

consult

• When diagnoses are noted within the face-to-face encounter,

such as a summary of findings or results noted, then those

diagnoses may be collected

(24)

Code for All Diagnoses

• Some coders may confuse E&M guidelines for diagnosis

reporting as it pertains to the selection of the E&M level of

service codes

• When choosing a level of service for E&M, diagnosis codes

should only be counted toward the level of service when they

are documented how they were evaluated or addressed

• This is entirely related to selection of level of service for E&M

purposes, and does not change the fact that ICD coding

guidelines instruct coders to include all comorbidities for each

encounter

46

ICD-9 Coding Guidelines

ICD-9-CM:

Section IV. Diagnostic Coding and Reporting Guidelines for Outpatient Services

H. ICD-9-CM code for the diagnosis, condition, problem, or other reason for encounter/visit

List first the ICD-9-CM code for the diagnosis, condition, problem, or other reason for

encounter/visit shown in the medical record to be chiefly responsible for the services provided. List

additional codes that describe any coexisting conditions. In some cases the first-listed diagnosis

may be a symptom when a diagnosis has not been established (confirmed) by the physician.

(ICD-9-CM, 2013)

K. Code all documented conditions that coexist

Code all documented conditions that coexist at the time of the encounter/visit and require or

affect patient care treatment or management. Do not code conditions that were previously

treated and no longer exist. However, history codes (V10-V19) may be used a secondary codes if

the historical condition or family history has an impact on current care or influences treatment.

(ICD-9-CM, 2013)

(25)

ICD-10 Coding Guidelines

ICD-10-CM:

G. ICD-10-CM code for the diagnosis, condition, problem, or other reason for encounter/visit

List first the ICD-10-CM code for the diagnosis, condition, problem, or other reason for

encounter/visit shown in the medical record to be chiefly responsible for the services provided. List

additional codes that describe any coexisting conditions. In some cases the first-listed diagnosis

may be a symptom when a diagnosis has not been established (confirmed) by the physician.

(ICD-10-CM, 2013 Draft)

J. Code all documented conditions that coexist

Code all documented conditions that coexist at the time of the encounter/ visit and require or

affect patient care treatment or management. Do not code conditions that were previously

treated and no longer exist. However, history codes (categories Z80-Z87) may be used as

secondary codes if the historical condition or family history has an impact on current care or

influences treatment. (ICD-10-CM, 2013 Draft)

48

CMS Guidelines

• Medicare has also recommended that coders follow official

coding guidelines, as well as Coding Clinic® determinations

• The Coding Clinic® is a division of the AHA (American

Hospital Association) and they make all final determinations

on the appropriate utilization of diagnosis codes

• The Coding Clinic® has several rules that pertain to Risk

Adjustment that will be covered later

• The CMS Risk Adjustment Participant Guide also supports

coding for all current diagnoses

(26)

CMS Participant Guide Excerpts

6.4.1 Co-Existing and Related Conditions

:

The instructions for risk adjustment

implementation refer to the official coding guidelines for ICD-9-CM, published at

www.cdc.gov/nchs/icd9.htm and in the Coding Clinic. Physicians should code all

documented conditions that co-exist at the time of the encounter/visit, and require or

affect patient care treatment or management. Do not code conditions that were previously

treated and no longer exist. However, history codes (V10-V19 not in HCC model) may be

used as secondary codes if the historical condition or family history has an impact on

current care or influences treatment.

•

Co-existing conditions include chronic, ongoing conditions such as diabetes (250.XX,

HCCs 15-19), congestive heart failure (428.0, HCC 80), atrial fibrillation (427.31, HCC

92), chronic obstructive and pulmonary disease (496, HCC 108). These diseases are

generally managed by ongoing medication and have the potential for acute exacerbations

if not treated properly, particularly if the patient is experiencing other acute conditions. It is

likely that these diagnoses would be part of a general overview of the patient’s health

when treating co-existing conditions for all but the most minor of medical encounters.

50

CMS Participant Guide Excerpts

•

Co-existing conditions also include ongoing conditions such as multiple sclerosis (340, HCC 72),

hemiplegia (342.9X, HCC 100), rheumatoid arthritis (714.0, HCC 38) and Parkinson’s disease

(332.0, HCC 73). Although they may not impact every minor healthcare episode, it is likely that

patients having these conditions would have their general health status evaluated within a

data reporting period, and these diagnoses would be documented and reportable at that time.

•

MA organizations must submit each required diagnosis at least once during a risk adjustment

reporting period. Therefore, these co-existing conditions should be documented by one of the

allowable provider types at least once within the data reporting period. (CMS Participant

Guide, 2008)

•

The above excerpts give several examples on how to review diagnoses for Risk

Adjustment purposes

•

CMS also acknowledges the common issue of diagnoses marked as “history of”

(27)

CMS Participant Guide Excerpts

•

Use of “history of.” In ICD-9-CM, “history of” means the patient no longer has the

condition and the diagnosis often indexes to a V code not in the HCC models. A

physician can make errors in one of two ways with respect to these codes. One error is

to code a past condition as active. The opposite error is to code as “history of” a

condition when that condition is still active. Both of these errors can impact risk

adjustment. (CMS Participant Guide, 2008)

• Because the purpose is to code for all known diagnoses for each patient

in risk adjustment models, diagnoses from any portion of the record

should be valid, provided that they are accurately documented as

current diagnoses

• This includes current diagnoses from the CC (Chief Complaint) or HPI

(History of Present Illness); PMH (Past Medical History) when still

current; Current, Ongoing, or Active Problem Lists; ROS (Review of

Systems); Exam; and Assessment and Plan portions

52

Coding from Chief Complaint or HPI

• Entries from the CC/HPI portion of any record should be carefully

evaluated by the wording used by the treating provider

• All documented diagnoses should be coded and any that are only noted

as historical, should be left as PMH (Past Medical History) or

questionable (which is covered later in this chapter)

• In the next slide there are two examples of how wording can influence

the selection of current diagnoses from the CC or HPI portion of the

record

• Coders must carefully review how diagnoses are documented, a history

of statement can be interpreted as historical only and no longer existing,

or can also be interpreted as a current ongoing problem that has been

present for a long time for the patient

(28)

Coding from Chief Complaint or HPI

Example 1:

CC: Ms. Jones is a 70 year old female who comes in today for her

follow up of her diabetes and COPD. She has a history of DVT and peripheral

vascular disease. She has had no issues or complaints since her last visit to the

office.

•

RATIONALE:

The CC clearly states the patient is here for the diabetes and COPD, while the DVT

and PVD are merely mentioned as historical in nature and are not clear to be current conditions.

Additionally, these 2 conditions are not known to be permanent and life-long and therefore should

not be coded as current.

Example 2:

CC: Ms. Jones is a 70 year old female with a history of diabetes and

COPD and she is here today for a follow up on her blood sugar control and to

evaluate her inhaler effectiveness.

•

RATIONALE:

This CC lists both conditions as “historical” yet it also affirms that they are current

conditions being treated and therefore are appropriate to code as current.

54

Coding from PMH (Past Medical History)

• PMH (Past Medical History) is one of the biggest areas of contention

when reviewing medical records

• CMS (per the above excerpt) has even recognized that providers may

sometimes incorrectly list a current diagnosis as PMH or vice versa.

–

“One error is to code a past condition as active. The opposite error is to code

as “history of” a condition when that condition is still active” (CMS Participant

Guide, 2008).

• Per our coding guidelines, as well as CMS guidance, coder cannot code

for conditions that were previously treated and no longer exist.

• If a condition is not listed as current and only as historical, there must be

a way to identify those diagnoses that are still valid separate from those

which are truly historical.

(29)

Past Medical History (PMH)

56

CC/HPI:

Mr. Jones is here

today for follow up of his

diabetes, CHF,

and PVD.

PMH:

MI in 2002

CHF

PVD

A/P:

1.

Diabetes

CC/HPI:

Mr. Jones is here

today for his diabetes, he

has a known

CHF, and PVD.

PMH:

MI in 2002

CHF

PVD

A/P:

1.

Diabetes

Coding from PMH (Past Medical History)

• If a coder believes any diagnosis is current, but it is only listed as PMH

or historical, coders should ask themselves: “Did the provider

TAMPER

™

(Treatment, Assessment, Monitor/Medicate, Plan, Evaluate,

or Referral) with the diagnosis in that DOS (date of service)”?

(30)

Coding from PMH (Past Medical History)

• Most organizations collect diagnoses, even if they are “PMH only” so

that they might have something to send in case of a RADV audit

• CMS has said in RADV training that they accept diagnoses listed in

PMH listings when they are interpreted as still being current or ongoing

for the patient

• There are some diagnoses, however that should never be collected as

PMH only because they have their own history of codes:

58

Fractures

Cancers

CVA

MI

HIV

Amputations

Anything noted as resolved

Anything noted as repaired

Coding from Lists

(Current, Ongoing, Active, Chronic, etc.)

• Coders must use caution when given diagnosis lists

• While it is appropriate to code for all known current diagnoses, caution

should be exercised to avoid improperly coding any diagnosis in such a

list which could not be current, is not believed to be current, or appears

to be mistakenly brought forward from a past visit documentation

• In general, if diagnoses are listed as current, ongoing, active, chronic,

etc., they may be coded, especially if there is another specific separate

listing of PMH diagnoses

• Conditions that resolve and have no additional mention in the record

should not be coded unless TAMPER

™

guidance is met

(31)

Coding from Lists

(Current, Ongoing, Active, Chronic, etc.)

Example:

Chronic Problems:

A-Fib (on Coumadin)

Acute Pancreatitis (admitted 2002)

Old MI

CVA (2000)

CKD (Followed by Dr. Jones, nephrology)

Prostate CA

•

RATIONALE:

The above list may be titled as “chronic conditions, but not all of the conditions listed are

current. This is a common problem for coders. The A-Fib is clearly current as there is current medical

treatment, the acute pancreatitis appears to be historical only, the Old MI may be coded as factual, the CVA

is not only historical (one could code a history of code and any related residual conditions if noted, but an

active CVA code cannot be coded once a patient has been discharged for the CVA anyway, CKD is clearly still

under treatment, and Prostate CA lacks any current ongoing treatment that would be necessary to code a

cancer as current.

60

Coding from ROS (Review of Systems)

• Some coders have voiced concerns about coding diagnoses from the

ROS (Review of Systems) portion of the record and this hesitation can

be related back to the E&M coding guidelines

• While this portion of the medical record documentation’s intention is for

the purpose of documenting any talking points with the patient for

feedback on how they are doing by systems, many providers will still

document accurate diagnoses in this section of a record

• The main warning in this area is to avoid coding for any “patient-stated”

conditions

• Conditions or diagnoses that are only reported by the patient as

recounting to the current provider are not acceptable without provider

validation.

(32)

Coding from ROS (Review of Systems)

Example 1:

ROS: Respiratory: COPD, Hypoxia, on inhaler and home oxygen

Cardiovascular: no complaints of SOB, no palpitations, MI 1992

•

RATIONALE:

The above ROS annotates that the patient is on current treatment

for the COPD and there is a valid Old MI noted during the ROS as well that is valid.

Example 2:

ROS: Respiratory: patient states her PCP told her she has COPD

•

RATIONALE:

The above ROS merely annotates a patient stated condition that is

not confirmed by the current treating provider. It is ‘diagnosis hearsay’ and

should not be coded.

62

Coding from the Exam

• The exam portion of the medical record’s purpose is a

placeholder to document the actual physical exam portion of

the encounter between the patient and the treating provider

• Many providers may still also list valid diagnoses in this

section of the record and any diagnoses documented, as

current should be coded appropriately

• Often this may be the only area where amputations, an

ostomy, or other important factors may be noted

(33)

Coding from the Exam

Example 1:

Exam: Extremities: Good Lt. pedal pulses; Rt. Above Knee

Amputation (2006).

•

RATIONALE:

In the above exam, the provider merely uses the exam portion to annotate that there

is a above the knee amputation. The code for amputation status would be appropriate to code.

Example 2:

Exam: Appearance: Appears cachectic.

•

RATIONALE:

In the above exam, the provider is merely annotating an appearance and not making

a diagnosis of cachexia. “Appears” is the same as “likely” which is not a diagnosis.

64

Coding from the Assessment & Plan

• The assessment and plan portions of any record are the final portions of

documentation for each encounter

• These should generally always be coded, with one word of caution, in

that many providers will list items in the assessment, which have

resolved or are no longer current.

– Examples of potential improper diagnoses in assessment/plan:

• Stroke: Should only be coded as current up to discharge of care for stroke in inpatient

setting. Outpatient follow up visits should be coded as “history of stroke”

• Cancers: Many providers are unclear if cancers are still current and cancers may only be

coded as current if there is current ongoing chemo, radiation, or hormonal treatment

toward the cancer, or if the cancer id present and the patient has refused treatment or

“watchful waiting” has been chosen

(34)

Clinical Documentation Barriers

For Risk Adjustment Purposes

Provider Signatures

• Most organizations flag signature issues so that they can

improve provider documentation with feedback to providers

• The lack of a signature or credential does not make the

diagnosis untrue and should still be captured when

appropriate

• In a RADV (Risk Adjustment Data Validation) audit by CMS,

the printed name, credential, and signature may all be

validated during the audit via an attestation

• Diagnoses themselves however cannot be authenticated

during such an audit

(35)

Signature Issues

Unacceptable Signature/ Authentication

Acceptable Signature/ Authentication

“Signed but not read”

Handwritten signature or initials of treating

provider

“Dictated but not signed/ read”, etc.

Electronic signature/ authentication

(e.g. “authenticated by”, “completed by”,

“finalized by”, “validated by”, “attested by”,

“sealed by”, etc.

Signed by someone other than the treating

provider (nurse, transcriptionist, etc.) on

providers behalf

Signature stamps were phased out effective

12/31/2008. (Note that some EMR systems affix

a JPEG that may look like a signature stamp and

these are approved)

68

Using Signs and/or Symptoms instead of making a

Diagnosis

•

Coding guidelines instruct it may be appropriate to code for signs and or

symptoms, when the treating provider has not yet established a diagnosis

ICD-9-CM:

E. Codes that describe symptoms and signs

•

Codes that describe symptoms and signs, as opposed to diagnoses, are acceptable for reporting purposes

when a diagnosis has not been established (confirmed) by the provider. Chapter 16 of the ICD-9-CM,

Symptoms, Signs, and Ill-Defined Conditions (Codes 780.0 – 789.9) contain many, but not all codes for

symptoms. (ICD-9-CM, 2013)

ICD-10-CM:

D. Codes that describe symptoms and signs

•

Codes that describe symptoms and signs, as opposed to diagnoses, are acceptable for reporting purposes

when a diagnosis has not been established (confirmed) by the provider. Chapter 18 of the ICD-10-CM,

Symptoms, Signs, and Abnormal Clinical and Laboratory Findings Not Elsewhere Classified (Codes R00 –

R99) contain many, but not all codes for symptoms. (ICD-10-CM, 2013 Draft)

(36)

Uncertain Diagnosis - Outpatient

Cannot Use in Outpatient Records:

May Use in Outpatient Records:

Suggestive of

/

Symptoms of / Likely

Early / Underlying

Consistent With

/

Compatible With

Evidence of

Suspicious for

/

Pending

Element of

Probable

/

Suspect

/

Tendency

/

Possible

Component of

Presumed

/

Sign(s) of / Suspect

Significant

Pre-______

/ or

______ vs. ______

Compensated

Rule-Out

/

Perhaps

/

Questionable

Results show ___________

70

Uncertain Diagnosis - Inpatient

• Uncertain diagnoses are handled differently in the inpatient vs.

outpatient settings

• Diagnoses that are still uncertain in an inpatient encounter, and

are still uncertain at the time of discharge may be reported,

however, if during the inpatient stay, tests and other evaluation

determine that the diagnosis is not accurate then it may not be

coded

• Thus, a probable or possible heart attack, if still uncertain at the

time of discharge, may be coded as a heart attack and a possible

heart attack that was ruled out by discharge cannot be coded as a

heart attack

(37)

“Consistent with…”

• Many providers, especially in pathology use the phrase “consistent with”

when describing a diagnosis or condition

• The provider may feel that they are diagnosing the condition to the best

of their ability based on known data and therefore use this phrase to

establish their relative certainty with a very small margin of error

• However, The Coding Clinic® has ruled that this terminology means the

same as “suspected” and that the provider is still unsure of the

diagnosis and therefore it is not acceptable wording to establish a

diagnosis

• “Consistent with” diagnoses may be coded in inpatient settings if the

diagnosis is still uncertain at the time of discharge

72

Use of Up and Down Arrows [↑ or ↓]

• Coding Clinic® issued a 2011 answer on the use of up and

down arrows for diagnosis coding purposes (e.g.

↑

cholesterol, ↓ thyroid

) and per the Coding Clinic®, “it is not

appropriate for the coder to report a diagnosis based upon up

and down arrows

• Diagnosing a patient’s condition is solely the responsibility of

the provider

• “Up and down arrows can have variable interpretations and

do not necessarily mean “abnormal”. They could simply be

indicating change (including improvement) over past results”.

(Coding Clinic®, 2011)

(38)

Overview

• Risk Adjustment is a method to collect all known current diagnoses

for each patient to improve disease management, forecast for

financial needs, and establish payment in some cases

• Coders should follow ICD coding guidelines to code for all

coexisting conditions while also following Coding Clinic®

determinations

• Some entities may only be focused on HCC relevant codes, while

others may be more global, such as CDPS

• Some entities may choose a conservative approach in the

collection of codes, while being mindful of costs

74

Risk Adjustment Coding

• Risk Adjustment coding takes a slightly different mindset from coding for

Fee-For-Service encounters

• There are often difficult decisions that can be encountered in risk

adjustment diagnosis collection, but if coders adhere to the TAMPER™

guideline, these can become easier

• There may be other entities with policies and procedures that may be

inconsistent with this teaching, however this presentation is congruent

with the concepts and purposes of risk adjustment data collection

• Look for more information on Risk Adjustment from AAPC and

ionHealthcare in the future

(39)

THANK YOU

Brian Boyce, BSHS, CPC, CPC-I

Proprietor and Managing Consultant

www.linkedin.com/in/boycebrian/

Brian@ionHealthcareLLC.com

Contact Us at: www.ionHealthcareLLC.com

76

Applying Concepts Quiz

1. Mr. Jones came in for follow up visit with his PCP. A full SOAP note was

documented and signed by the treating MD.

Assessment:

1.

DM with polyneuropathy

2.

Hypertension

3.

Heartburn

Can the coder document GERD in the above note?

a)

Yes

(40)

Applying Concepts Quiz

1. Answer:

b)

No

Rationale: The documentation of “heartburn” is only a symptom and does not

risk adjust. The diagnosis of GERD (gastro-esophageal reflux disease) must

be made specifically.

This example illustrates the importance of documenting actual diseases as

opposed to their symptoms if they are a current true diagnosis.

Applying Concepts Quiz

2.

Ms. Smith came in for follow up visit with her PCP. A full SOAP note was

Assessment:

1.

Diabetes (DM) Type II

2.

Peripheral Neuropathy

3.

Hypertension

What are the proper codes for the diabetes & neuropathy listed above?

a)

250.00, 357.2

b)

250.60, 356.9

c)

250.00, 356.9

d)

250.60, 357.2

(41)

Applying Concepts Quiz

2. Answer:

c)

250.00, 356.9

Rationale: In this example, There is no “cause & effect” demonstrated

between the diabetes and the peripheral neuropathy. If the provider has

documented the cause & effect relationship such as: “DM with peripheral

neuropathy”, “Peripheral neuropathy due to diabetes”, “Diabetic

peripheral (or poly) neuropathy”, etc., then the codes would be justified

for a 250.60 and a 357.2.

This example illustrates the importance of documenting all cause & effect

relationships, especially in diabetes.

Applying Concepts Quiz

3. Mr. Chung came in for follow up visit with his PCP. A full SOAP note was

CC/HPI:

Mr. Chung is here for follow up of his COPD, Diabetes, HTN. He has a

history of prostate cancer.

Medications:

Singulair, Albuterol inhaler, Actos, NPH insulin, sliding scale,

HCTZ, Atenolol.

Assessment:

1. COPD, 2. Diabetes, 3. Hypertension

Can the coder code for prostate cancer as an active diagnosis?

a)

Yes

(42)

Applying Concepts Quiz

3. Answer:

b)

No

Rationale: Prostate cancer is only listed as a “history of” in the CC/HPI of this

record. In this scenario, a “Personal history of prostate cancer” would be

appropriate but not an active prostate cancer code. Guidelines require

that in order for cancers to be coded as current/active, there must be

treatment directed to the cancer. If the patient had been on radiation,

chemo, or hormonal treatment for his prostate cancer, then it could be

coded as a current diagnosis.

This example is a reminder of cancer coding guidelines.

Applying Concepts Quiz

4. Ms. Hernandez came in for follow up visit with her PCP. A full SOAP note

was documented and signed by the treating MD.

CC/HPI:

Ms. Hernandez is here for follow up of her Diabetes, HTN, and

Depression with anxiety.

Medications:

Actos, NPH insulin, sliding scale, HCTZ, Atenolol, Prozac,

Clonazepam.

Assessment:

1. Depression, 2. Dia

Risk Adjustment Training