2What is CMS’s Hierarchical Condition Categories? Medicare Risk Adjustment payment model introduced by the Centers for Medicare and Medicaid (CMS) in 2004.The goal is to pay Medicare Advantage (MA) and Prescription Drug Plans (PDPs) accurately and fairly by adjusting payment for Enrollees based on their demographics and their health status.This Risk Adjustment payment model measures the disease burden that includes 70 HCC categories, which are correlated to diagnosis codes.Accurate diagnosis code documentation (ICD-9 CM) and reporting now determines reimbursement.3,600 ICD-9 codes map to 1 of 70 HCCs (mostly chronic but some are acute)
3Examples of Chronic Conditions The following HCCs reflect a few common chronic conditions found in Medicare population, that Medicare Advantage Plans look for to be documented in a patient’s chart:Diabetes without complications – HCC 19Chronic Obstructive Pulmonary Disease – HCC 108Congestive Heart Failure – HCC 80Breast Cancer – HCC 10Ischemic Heart Disease – HCC 92Angina – HCC 83Diagnoses from the previous year are used to establish capitation payments to the MA plan. HCCs must be captured every 12 months for CMS to reimburse. Health Status is re-determined every yearIf the HCC codes are captured outside the12 months (e.g. 12 months and 4 days), it will generate a 6-month revenue gap for that MA plan.
4Data Collection It all boils down to the data collection process! Physicians who do not exercise good documentation at each patient encounter will receive insufficient funding.Good documentation begins at the time of the patient’s face-to-face encounter with the physician.Document all clinical findings in the medical record (chart), and the medical record is used to support ICD-9-CM and HCC coding.
5The Process Care is Delivered to the Member (face-to-face encounter) Care and Diagnoses are Documented in the Chart / Progress NotesICD-9 CM codes are submitted on Claims based on the face-to-face encounter clinical findingsPlan & Providers can Deliver better careAnd reimbursement is receivedClaims data diagnosis codes are converted to HCC codesCMS Calculates MA Risk AdjustmentHCC codes data is submitted to CMS
6Document, Document, Document Is your documentation sufficient to fund the care for your sicker patients?The quality of diagnosis coding and supporting documentation must improve in order to maintain the same reimbursement payments.It All Begins with You!Goal = Properly Reflect the Member’s Health StatusFully assess ALL Chronic Conditions ….…at least annuallyThoroughly Document in the Chart (Progress Notes) ALL conditions evaluated for each visitCode to the Highest Level of Specificity (fully utilize the ICD-9 Diagnosis Coding System)
7Choosing Diagnosis Codes 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.
8Diabetes Mellitus All important 4th digit 250.00 no complication ketoacidosishyperosmolaritycomarenal manifestationsophthalmological manifestationneurological manifestationsperipheral circulatory disordersother specified manifestations
9Diabetes Manifestations Use multiple coding techniques for compound diagnosesDM with a manifestation (complication) requires that you document and code the manifestation as well.Peripheral Neuropathy due to DMDM with Neurological manifestations357.2 Peripheral Neuropathy in DMPVD due to DMDM with peripheral circulatory disordersPVD in diseases classified elsewhere
10ESRD - Coding 585.6 ESRD $2870 V45.11 Renal Dialysis Status $10,522 When a patient is on dialysis it requires two codes585.6 ESRD $2870V45.11 Renal Dialysis Status $10,522ESRD on hemodialysis due to DiabetesDiabetes w/renal manifestations $3962585.6 CKD stage VI (ESRD)V45.11 Renal dialysis status $10,522** CKD hierarchs Nephropathy
11Documenting the diabetic connection Unclear whether “with” will be acceptable with CMS so preferable way to make connection“Due to”“Secondary”“Diabetic”Examples:Peripheral Neuropathy due to DMCKD Stage III secondary to DMDiabetic UlcerDiabetic Retinopathy
12Documenting the diabetic connection Coders are not allowed to assume a cause-and-effect relationshipIf you document like this:Assessment1. Diabetes Type II $12632. Peripheral Neuropathy $25503. CKD Stage III $2870These will be coded separately and the highest Diabetes HCC code will be missedIf you document like this, then the highest HCC in the diabetes will be captured:1. Diabetic peripheral neuropathy & $25502. CKD III due to Diabetes $3962 & $2870
13Ulcers-Non Pressure Vs. Pressure Two types of ulcersNon-pressure of chronic $3502Pressure or Decubitus $8993Pressure ulcer is a higher HCC than a non-pressure so it’s important to code it correctlyStage I pressure ulcer of sacrum707.03707.21Diabetic ulcer on the calfDM with other specified manisfestationsUlcer of the calf**Wounds are not HCC’s
14Metastatic CancerMets is the highest HCC $17,753 – only if the site it has metastasized to is documentedH/O Breast Ca with Mets to lung V10.3 & 197.0Prostate Ca on Lupron with bone Mets 185 &H/O Colon Ca with Mets to the liver V10.05 & 197.7If you document like this the highest HCC opportunity will be missedMetastatic Breast Ca $1622 (if Breast ca is under treatment) & 199.1Metastatic Colon Ca $1622 (if Colon ca is under treatment) & 199.1Lung Ca with Mets $8213 (if Lung ca is under treatment) & 199.1H/O Lung Ca with Mets $1622 V10.11 & 199.1
15Alcohol and Drug Dependence Alcohol dependence, Chronic alcoholism or Alcoholism in remission &Drug dependence or Drug dependence in remission(opiate, anxiolytic, sedative, hypnotic, hallucinogen, or amphetamine) &Patient has arrived at a stage of physical dependency and would experience physical signs of withdrawal with sudden cessation**Alcohol abuse and drug abuse are not HCCs! 305.xx
16Major Depression/Malnutrition Major depression 296.xxPHQ9 score > 105 of 9 DSMIV criteriaMedicationFollowing with a mental health provider**if only “Depression” 311 is documented…it is not an HCC code!Protein Calorie Malnutrition 263.xCommonly used indicatorsAlbumin <3.410% unintentional weight loss in 3-6 mos5% unintentional weight loss in 3-6 mosBMI <18.5, especially with a co-morbidityPoor nutrition or loss of appetiteWasting appearance or muscle wasting
17Common Omissions Year over Year Artificial openingsGastrostomy V44.1Colostomy V44.3Tracheotomy V44.0Ileostomy V44.2AmputationsBKA V49.75AKA V49.76Foot V49.73Toe V49.71 Great Toe or V49.72 Other ToesAAA – Abdominal aortic aneurysm (w/o mention of rupture not repair)Aortic Atherosclerosis 440.0
18Malfunctions / Complications Mechanical complication of device, implant or graft 996.xxVascular, Nervous, Genitourinary, Internal orthopedicInfection/Inflammatory reaction due to internal device, implant or graft 996.xxCardiacVascularNervous SystemIndwelling catheterInternal joint prosthesis, ortho or prosthetic deviceOther complications of device, implant or graft – occlusion, embolism, fibrosis, hemorrhage, pain, stenosis, thrombus 996.xxVascular device, implant or graftNervous system device, implant or graftGenitourinary device, implant or graftInternal joint prosthesis
19Examples of how much it matters? HCC Code Annual ReimbursementHCC Diabetes with no complications $ 485HCC x DM w/ ophthalmic manifestations $ 831HCC X –3X DM w/ acute complications $ 948HCC x DM w neurologic manifestations $1,338HCC x DM w/ renal or peripheral circulatory manifestations $1,852Note: Some categories have a hierarchy, such as Diabetes, in such categories, only the highest HCC would “count”
21Specificity Don’t report this If the pt really has (Does not risk adjust) (Does risk adjust)311 Depression xx Major DepressionAsthma Chronic Obstructive Asthma496 COPD/492.8 Emphysema490 Bronchitis Chronic BronchitisCAD Angina Unst AnginaCardiac Dysrhythmias Atrial Fibrillation577.0 Chronic Pancreatitis Chronic PancreatitisHepatitis C Chronic Hepatitis C805.8 Fx of Vertebrae Path FX of VertebraeCVA Late Effects CVA w/ Hemiplegia
22“Additional Coding Examples” Does NOT Risk Adjust:~401.0 Malignant Hypertension~ Coronary atherosclerosis~ Atherosclerosis unspecified~ Other specified cardiacdysrhythmia, otherDoes Risk Adjust:~ Hypertensive HeartDX-Malignant w/o heart failure~ Angina pectoris unspecified~ 440.3X Atherosclerosis of by-pass graft of extremities~ Atrial fibrillation
23Documentation TipsDon’t document “H/O” of any disease that currently exists.The statement “history of” in ICD-9 terms means that the patient no longer has this condition. However, “H/O” is ok when documenting some status conditions such as Amputation, Old MI or Cancer.Rule of thumb in coding isIf a patient is on a medication for a condition and if the medication were to be stopped, would the condition resume, and the answer is mostly likely or yes, then you still code the condition.ExamplesH/O CHF – pt is on lasix 428.0H/O Angina – pt has nitroquick 413.9H/O COPD – pt is on Advair 496This also applies to a pacemaker for SSS or Complete or 3rd degree heart attack..if the SSS or Heart Block is documented you can still code it or 426.0
24Treating, Managing or Assessing the Chronic Conditions In order for CMS to make the payment to the health plan the diagnoses submitted must be from a face-to-face visit and the visit must indicate how the chronic conditions are being treated, managed or assessedSample languageAssessment PlanStable MonitorImproved D/C medsTolerating meds Continue medsDeteriorating ReferExample: Hypertensive CKD III, stable well controlled, continue medsExample: COPD, stable on Advair
25Critical 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.A medical record entry mustBe legibleSupport all diagnoses codedBe complete and accurateHave a provider signature and credentialsIdentify the patient and date of serviceDocument the patient’s progress and results of treatmentJustify the treatment and level of careUse only standard abbreviations and keep them to a minimumPromote continuity of care among the healthcare providers
26Coding GuidelinesCoded according to the ICD-9-CM Guidelines for Coding and Reporting; assigned based on dates of service within the data collection period,Submitted to the MA organization from an appropriate risk adjustment provider type and an appropriate risk adjustment physician data source.The medical record documentation must support an assigned HCC.All chronic conditions must be assessed and reported no less than once a year… “If a patient is Diabetic, it must be in the chart every year”!All conditions must be documented in the medical record.Medical record must support codes reported on the claim or encounter form.Provider should document and code to the highest level of specificity.Each diagnosis must have an assessment and a plan.
27Coding GuidelinesWhich Medical Record(s) can be submitted for validation?Hospital InpatientHospital OutpatientOr Physician medical record when more than one option is available.What must Providers report?All diagnoses (not just primary diagnosis) that impact the patient’s evaluation, care, and treatment including:Main reason for visit,Co-existing acute conditions,Chronic conditions (such as A Fib, CHF, CKD, RA, DM, COPD/Asthma, Cardiomyopathy),Care rendered,Conclusion and diagnosis,
28Additional Coding Guidelines Incomplete Inpatient RecordsDischarge summaryValid IP record for coding if it has both the admit and discharge datesUse Inpatient Coding guidelines to codeAdmission history and physical not valid for IP record codingConsults during the inpatient stay may be coded as physician recordsER visit on the same date as admission date can be coded as an outpatient visitUse Inpatient Coding Guidelines to code
29Example of Good Documentation Chief ComplaintS: Voices no complaint except that she wishes she could visit her sister, who is hospitalized. States she is able to get around, including bathroom and cafeteria, without difficulty. Denies any pain or shortness of breath. No change in bowel or bladder habits.O: Patient alert, oriented to person, disoriented to place and time. No acute distress.Cardiac: RRR no rubs, gallops or murmurs notedLungs CTA bilat. No cough or wheezing noted.Abd soft non tender to palpitation with Colostomy intact, skin dry and intact surrounding pink-red stoma, liquid brown feces.Diminished sensation LE bilaterally, skin cool with rubor.Old incision for L great toe amputation dry and intact. Able to ambulate to toilet and cafeteria with walker.A: Diabetes with peripheral circulatory disorders, currently controlled; with peripheral vascular disease due to diabetes; and diabetes with neurologic manifestations of diabetic polyneuropathy.Finger stick blood sugar ranges in past 2 weeks. Diabetes controlled on current regimen a.c. & h.s. insulin; sliding scale insulin if needed. V55.3 Functioning colostomy, no change in plan of care.V49.71 Old amputated L great toe - stable.Mild senile dementia (see notes October 10, 2006)Osteoporosis with vertebral fractures (see notes September 13, 2006).P: Continue current diet & insulin regimen. Retain sliding scale order for prn with notification parameters. Continue current activity level.Authenticated by: Physician, MD
30Tips Reason for Visit: This is the chief complaint of the patient: Clear, Concise, Consistent, Complete, and LegibleSOAP Approach: Subjective, Objective, Assessment, PlanProblem List Approach: a numbered and dated index of patient’s problems kept in front of medical record, from identification through resolutionReason for Visit: This is the chief complaint of the patient:“weakness, headache, and liver cancer”Care Rendered: This is what was done to address the chief complaint.“examination and blood work”Conclusion and Diagnosis: This is the outcome of the findings based on the care rendered.“Anemia with coexisting conditions of Adult onset diabetes, neuropathy, COPD, and Asthma”
31Top Ten HCC Groups COPD $3112 CHF $3198 Vascular Disease $2465 Asthma w/ chronic COPD (Chronic Obstructive Asthma)Chronic BronchitisEmphysemaCHF $3198CHFPrimary Cardiomyopathy (Ischemic is not an HCC)Hypertensive Heart Disease w/ heart failureVascular Disease $2465Peripheral Vascular DiseasePVD in other diseases (diabetes)Acute DVT440.0 Atherosclerosis of AortaAbdominal Aortic AneurysmCancer $1622-$8213All malignant neoplasm’s including Melanoma but not skin cancerAll secondary malignant neoplasm’s – Highest HCC if site is documented $17,753
32Top Ten HCC Groups Ischemic Heart Disease $2215 Unstable AnginaSpecified Heart Arrhythmia $2285Complete AV blockAtrial FibrillationSick Sinus SyndromeDiabetes $1264-$3962All diabetes (250.xx) and most of the manifestationsIschemic or Unspecified Stroke $2067CVAUnspecified cerebral artery occlusion, w/ infarctionAngina/Old MI $1903413.9 Angina Pectoris412 Old MIRheumatoid Arthritis & Inflammatory Connective Tissue Disease $2699714.0 Rheumatoid Arthritis710.0 SLEPolymyalgia RheumaticaSacroiliitis
34Audits CMS audits medical records to validate documentation. Validation AuditsSuperbills are not considered sufficient documentation … they are a reporting format only.Documentation must show the diagnosis was assigned within the data collection period.Data discrepancies that are found as a result of audit may cause a risk adjusted payment to be changed.
35We welcome your feedback and appreciate your cooperation. Contact InformationPlease remember, “If it’s not documented, then…. It didn’t happen”Use proper ICD-9 CM coding and specificityPlease call or us at anytime for questions or for assistanceJessica Rivas (818) ext. 430Linda Deaktor (818) ext. 236Kimberley Litzsey (818) ext. 303We welcome your feedback and appreciate your cooperation.