icd-10 and risk adjustment.pdf

Confidential and proprietary – for internal use only Premera is an Independent Licensee of the Blue Cross Blue Shield Association

Tonya Owens Coding Quality Educator

HCC coding, documentation and audit preparation

ICD-10 and Risk Adjustment


Meet the presenter

Tonya Owens is a Coding Quality Educator at Premera BlueCross. She received her CPC, CEMC, CPMA, and CRC certificates from the American Academy of Professional Coders, with over 10 years’ experience in the healthcare field coding and auditing multi-specialty professional services, outpatient surgeries, labs, and pro-fee.

Tonya enjoys assisting providers in identifying risks, opportunities, and clinical documentation improvement. Experiences also include an extensive knowledge in AR revenue cycle and HCC coding and risk adjustment auditing.


Webinar objectives

• By the end of the session, you will: Understand Risk Adjustment (RA) Know general RA guidelines Understand the significance of RA to you and your practice Know how to document thoroughly Be able to code completely and accurately using ICD-10-CM


Risk adjustment and general guidelines


Testing … 1, 2, 3 …

How familiar are you with

risk adjustment?


Defining risk adjustment

Risk adjustment is a methodology of adjusting

estimated or perceived risks as they relate to diagnosis

codes of patients.


Calculating risk scores

HCC HCC Label 11 Colorectal, Breast (Age < 50), Kidney, and Other

Cancers 12 Breast (Age 50+) and Prostate Cancer,

Benign/Uncertain Brain Tumors, and Other Cancers and Tumors

13 Thyroid Cancer, Melanoma, Neurofibromatosis, and Other Cancers and Tumors

18 Pancreas Transplant Status/Complications

19 Diabetes with Acute Complications

20 Diabetes with Chronic Complications 21

Diabetes without complications 23 Protein – Calorie Malnutrition

ICD10 ICD10 Label HCC E0821 Diabetes mellitus due to

underlying condition with diabetic nephropathy

20

E0822 Diabetes mellitus due to underlying condition with diabetic chronic kidney disease

20

E0829 Diabetes mellitus due to underlying condition with other diabetic kidney complication

20

E08311 Diabetes mellitus due to underlying condition with unspecified diabetic retinopathy with macular edema

20

E08319 Diabetes mellitus due to underlying condition with unspecified diabetic retinopathy without macular edema

20

E08321 Diabetes mellitus due to underlying condition with mild non-proliferative diabetic retinopathy with macular edema

20

Hierarchical Condition Category (HCC) classification system


HCC hierarchy trump list Some HCCs hold more “value” than others…

If this HCC is found…

2015 Disease Group Label … Then drop these HCCs:

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

54 Drug/Alcohol Psychosis 55

57 Schizophrenia 58

70 Quadriplegia 71,72,103,104,169


General risk adjustment (RA) guidelines

Face to Face visits • Collect and update

health status • Approved provider

type

Management • Clearly state

diagnoses • Sign/authenticate

record

Annual Review • Refreshed health

status • Report conditions

on claims

OUTCOMES: • Improved patient health • Better audit/ regulatory compliance • Enhanced reputation among patients and payers


What does this mean for providers?

3 tie

r app

roac

h Identify new problems

early and avoid potential drug/disease interactions

Reinforce self-care and prevention strategies

Coordinate care collaboratively


Diagnosis codes

Diagnosis with no

complication

DME, Rx, CPT, Labs,

etc.

Diagnosis with some

complication?

Using specific ICD diagnosis codes will help convey the true complexity of the conditions being addressed in each visit!


Medical Records Review (MRR)

Retrospective:

• Medicare Risk Adjustment Data Validation Audits (RADV)

• Commercial Risk Adjustment – Initial Validation Audits (IVA)

• Medical Record Reviews (MRR) to validate that documentation matches codes reported on claims

Prospective:

• Receptive to feedback about the opportunities to improve coding and documentation

• Receive training (coders and/or clinicians) on requirements of complete coding and documentation

Does your documentation match what was sent on the claim?


Documenting For Risk Adjustment


Can’t use in Outpatient Records: May use in Outpatient Records:

Suggestive of/Symptoms of/Likely Early/Underlying

Consistent with/Compatible with Evidence of

Suspicious of/Pending Element of

Presumed/Sign(s) of/Suspect Significant

Cholesterol Thyroid Increased/elevated/decreased

Assessment: J44.9 – Stable, continue meds E11.9 – Stable, order labs return to office in 3 months

Assessment: 1. COPD (J44.9)– Stable, continue

current meds 2. Diabetes II (E11.9)– Stable, order

labs and return to office in 3 months

Improving documentation: Wording for diagnosis capture


Documentation: chart notes, ICD-10, specificity

• Patient name, DOS, acceptable signature

• Verify medication list is updated

Complete Chart notes

• Show support for a condition – MEAT

• Coders can’t make assumptions – state conditions

Support for ICD Codes • Laterality, stage,

anatomical site • Is it acute, chronic,

a complication?

Document Specificity


Documentation: unclear example 1

CC: “Annual comprehensive visit”

HPI: Patient is 38yr old female here for annual physical. She has a history of CHF, diabetes and neuropathy.

O: HT:5.6 WT:130 BMI: XX Physical exam shows no signs of distress…

Assessment: Annual exam, diabetes & neuropathy, CHF

Plan: Continue current medications; follow up in 3 months.


Documentation: clear example

CC: “Annual comprehensive visit”

HPI: Patient is 38yr old female here for annual physical. She has CHF and Type II diabetes with neuropathy.

O: HT:5.6 WT:130 BMI: XX Physical exam shows no signs of distress…

Assessment: Annual exam, diabetic neuropathy, CHF Plan: Continue current medications; follow up in 3 months.


Documentation: unclear example 2

Betty Borderline, a 36-year-old female, referred to psychiatrist by gynecologist for potential treatment of major depression. Reports difficulty sleeping and concentrating; she has been feeling sad for more than 2 years, often feels hopeless. The patient is on a trial of Prozac; recommend she begin seeing a psychologist as adjunctive therapy.


Documentation: clear example 2 (part 1)

Betty Borderline - Medical history includes: • hyperlipidemia • allergic rhinitis • psoriasis • doesn’t smoke • occasional alcoholic drinks • no history of illicit drugs • family history is significant for type 2 diabetes mellitus and coronary

artery disease • currently on loratadine, fluticasone nasal spray for allergic rhinitis,

uses fluocinonide cream for psoriasis flare ups; atorvastatin for elevated cholesterol

Reports difficulty sleeping and concentrating; she has been feeling sad for more than 2 years, often feels hopeless. The patient is on a trial of Prozac; recommend she begin seeing a psychologist as adjunctive therapy.


Documentation: clear example 2 (part 2)

Based on assessment and past medical history, diagnoses are: • Axis I: Major Depressive Disorder, recurrent, moderate • Axis II: None • Axis III: Hyperlipidemia, Allergic Rhinitis, Psoriasis • Axis: IV: None • Axis: V: 60 Treatment Plan/ Recommendations include: • Major Depressive Disorder: Cognitive Therapy and

Relaxation Techniques; Rx for Seroquel XR 150 mg PO QD; continue other medications as prescribed.

• Return 2 weeks or earlier if needed.


Valid Provider Signatures


What makes a signature valid?

Improper Authentication Proper Authentication Provider: Jane Doe, MD Status: Signed but not read

Provider: Jane Doe, MD Status: Auth (verified) Verified by: Jane Doe, MD on 5/5/2015 at 19:16

Electronically Signed by: John Smith

Electronically Signed by: John Smith, MD on 11/5/2015 at 9:05 am

Providers must always sign or authenticate their records


Coding for Risk Adjustment


Coding guidelines: ICD-10-CM

ICD-10-CM: Section IV. Diagnostic Coding & Reporting Guidelines for Outpatient Services 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)


Coding guidelines: ICD-10-CM

ICD-10-CM: Section IV. Diagnostic Coding & Reporting Guidelines for Outpatient Services 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)

List first the ICD-10-CM code for the diagnosis

Code all documented conditions that coexist at

the time of the encounter

List additional codes that describe any coexisting

conditions


TAMPER or MEAT ?

Did the clinician “TAMPER” with the condition? • Treat, Assess, Medicate/Monitor, Plan,

Evaluate, Referral Is there enough “MEAT” to support this condition? • Monitor, Evaluate, Assess, Treat


Coding from chief complaint: 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.

What would you code?



HPI: 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.

C.) Diabetes, COPD, HX of DVT and PVD Primary Code: Diabetes: E11.9 Secondary code: COPD – J44.9

Territory Code: Personal HX of DVT Z86.718 Fourth Code: Personal HX of other diseases of the circulatory

system – Z86.79



HPI: Mr. Smith is a 68-year-old male with a history of prostate cancer and rheumatoid arthritis. He is here today for a follow-up on his hormonal treatment of androgen deprivation therapy and to evaluate the effectiveness of his current dosage on Humira.

What would you code?



HPI: Mr. Smith is a 68-year-old male with a history of prostate cancer and rheumatoid arthritis. He is here today for a follow-up on his hormonal treatment of androgen deprivation therapy and to evaluate the effectiveness of his current dosage on Humira

D.) Prostate cancer and RA Primary code: Prostate Cancer: C61

Secondary code: Rheumatoid Arthritis – M06.9


Check-in: complete the codes

HISTORY OF PRESENT ILLNESS: • Stable CHF on current regimen • Diabetes type II with polyneuropathy • A1c improved with increased doses of NPH insulin • Nerve pain has improved on current medication • Chronic renal insufficiency is stable • Complaints: SOB and increased wheezing and coughing; no symptoms of CAD.

He had follow-up with Dr. X and she also thought he was doing quite well. PFSH: Quit smoking in 1998 MEDICATIONS: (Reviewed and reconciled with patient today 08/06/20xx) ASSESSMENTS: COPD Congestive heart failure Diabetes type II with polyneuropathy PLAN: Continue all current medications; follow-up in 3 months


Check-in: how did you do?

J44.1 Coronary Obstructive Pulmonary Disease w/acute exacerbation

I50.9 Congestive heart failure, unspecified

E11.42 Type 2 diabetes mellitus with diabetic polyneuropathy

K21.9 Gastro-esophageal reflux disease without esophagitis

I12.9 Hypertensive chronic kidney disease with stage 1 through stage 4 chronic

kidney disease, or unspecified chronic kidney disease

N18.3 Chronic Kidney Disease, stage 3 (moderate)

I25.10 Atherosclerotic heart disease of native coronary artery w/out angina

pectoris

Z79.4 Long term (current) use of Insulin


Check-in: a second Look

HISTORY OF PRESENT ILLNESS: • Stable CHF on current regimen • Diabetes type II with polyneuropathy • A1c improved with increased doses of NPH insulin • Nerve pain has improved on current medication • Chronic renal insufficiency is stable • Complaints: SOB and increased wheezing and coughing; no symptoms of CAD.

He had follow-up with Dr. X and she also thought he was doing quite well. PFSH: Quit smoking in 1998 MEDICATIONS: (Reviewed and reconciled with patient today 08/06/20xx) ASSESSMENTS: COPD Congestive heart failure Diabetes type II with polyneuropathy PLAN: Continue all current medications; follow-up in 3 months


How does coding to the highest specificity impact RAF?

No Conditions Coded (Demographics only)

Some Coded Conditions (Claims Data Only)

All Conditions Coded (Chart reviewed by Certified

Coder)

76 year old female 0.468 76 year old female 0.468 76 year old female 0.468

DM Not Coded DM (no manifestations) 0.118 DM w/Vascular manifestation 0.368

Vascular Disease not coded

Vascular Disease w/out complications 0.299

Vascular disease w/complication 0.41

CHF not Coded CHF not coded CHF Coded 0.368

No Interaction No interaction *Disease Interaction Bonus RAF (DM and CHF) 0.182

Patient total RAF: 0.468 Patient total RAF 0.885 Patient total RAF 1.018 PMPM Payment for care: $452

PMPM Payment for Care: $743 PMPM Payment for Care $1,381

HCC Financial Difference in Coding Specificity


1. Document thoroughly 2. Code to the highest specificity 3. Evaluate patients with chronic/complex

conditions annually 4. Code all conditions that are supported in

documentation 5. Ensure that codes make it to the claim 6. Review medication lists with patient as often as

possible 7. Utilize PMH and Active condition lists

appropriately 8. Don’t copy and paste 9. Review your documentation and verify it

supports the codes 10. Don’t forget to sign the note!


Questions?

035235 (11-2015)

icd-10 and risk adjustment.pdf

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