1. Medicare + Choice Coding and Documentation for Encounters
Presented by:
Industry Collaboration Effort (ICE)
Encounter Data Team
Today’s session will cover these topics:
Background on ICE
Encounter data collection efforts currently underway
Risk Adjustment
ICD-9 Coding
HCPCS/CPT Coding
Documentation tips
Modifiers and their uses
Explain current and future reimbursement methodologies
Since this is a Train-the-Trainer session, we are going to help you identify the appropriate audience within your organization to train on the need for good coding

2. Purpose
To provide participants with the appropriate information and support needed to improve the quality and quantity of physician encounter data needed by your contracted health plans
Quality and Quantity equal the appropriate level of reimbursement

3. Objectives
At the completion of this session participants will be able to:
Understand their role in the data collection process
List the various uses of the data they provide
Identify common coding errors
Understand CMS’ plans for calculating reimbursement
Know who to contact if you have any questions
Ensure “Train the Trainer” sessions occur at the provider level.
The objectives of this session will enable those attending the session to train providers which include physicians, physician office staff, hospitals, and other ancillary providers.
At the end of the session you will be able to understand the providers role in the data collection process, learn how the data is used, understand the importance of coding to the highest level of specificity, and understand how CMS calculates a payment using risk adjustment factors.
The expectation is that individuals attending this training session will take this information and use to train the staff in their organization.

4. Introductions ICE - who are we? History of ICE Goals
Balanced Budget Act of 1997
Goals
Standardize processes and procedures where possible
Create administrative efficiency
Consistent regulatory compliance
Education
In October 1998, Health Net hosted the first ICE meeting
The original team was devoted to the collection of encounter data. The group’s collaboration has extended to provider groups, industry associations and now CMS regional office in SF and the CMS central office in Baltimore.
Since then ICE has expanded to many new teams dedicated to operationalizing all aspects CMS regulations including BBA. More information is available at the ICE web site.

5. ICE Mission Statement
Mission Statement/Scope of the ICE Encounter Data Team:
To collaboratively improve the collection and transmission of encounter data to CMS as required per the Balanced Budget Act of 1997, by identifying and resolving common issues; by collectively working on provider communication and education; by standardizing tools, processes, timeliness standards, and report formats; by collaboratively regarding clearinghouse expectations and negotiations; by collectively communicating with CMS for resolution of common issues.

6. ICE Goals Goals of the ICE Encounter Data Team:
Successful efforts will result in increased volume of data submissions from providers, thus increased Medicare payments; submission or transmission cost savings for hospitals due to standardization of health plan expectations; cost saving for hospitals and health plans via collective negotiations with clearing houses; improved customer relations between providers and health plans due to reduced expenses and increased revenues to hospitals, medical groups and health plans.

7. Want more info about ICE?
Go to ICE web site
locate discussion forums
become an ICE member
online calendar of activities
vast library of documents covering many topics
There is a great deal of information available on the site.
You can register to receive s regarding any area of interest.

8. Data Collection Physician data Hospital data CMS1500 UB92
Importance of clinical information
Clinical information identifies the health status of your members
Garbage in garbage out
Hospital data
UB92
I/P & O/P
Clinical data is generally reliable
Data is gathered from a CMS 1500 (formerly HCFA1500) or a UB92. Mirroring claim form logic to Medicare Fee For Service is a good practice.

9. Type of Data Collected Physician Data - result of face to face visit
Hospital Inpatient Data
Hospital Outpatient Data
______________________________
Inpatient Excludes:
SNF Inpatient, Hospice, ICF
Outpatient Excludes:
Lab, DME, Ambulance, ASCs, Prosthetics & Orthotics
Physician visits include MDs, DOs, DPMs, ODs, and physician extenders such as PAs, NPs, CNSs and Independently Practicing Physical Therapists, Occupational Therapists, Audiologists, Clinical Psychologists, etc.
For clarification of the services listed as Excluded Clinical laboratory and Technical portions of x-rays are excluded.

10. Uses of Encounter Data Reimbursement from CMS Shared risk reporting
HEDIS
Performance measurements
Utilization
There are many other uses for encounter submission across all lines of business
Quality performance

11. Financial Impact PIP-DCG vs. CMS-HCC
PIP-DCG model = Principal Inpatient Diagnostic Cost Group
beneficiaries are assigned to a disease group based on future cost to diagnosis
a single most costly diagnosis is recognized from an inpatient stay greater than one day
CMS-HCC model = Hierarchical Condition Category
incorporates multiple diagnosis codes from ambulatory data (outpatient & physician)

12. Financial Impact PIP-DCG Vs CMS-HCC
Female, 76 years old, Medicaid eligible, COPD, CHF, vascular disease with complications
$14,396.34
$8,269.72
$13,610.32
$10,632.48
CMS-HCC
Model
(2004, proper coding; 70/30)
(no encounter submitted)
PIP-DCG
(current, CHF;
90/10)
This is just an example, we will go into detail later in the presentation. The example shows the importance of coding.
Under the old PIP-DCG model, only the highest diagnosis was paid, but with the new CMS-HCC model it is additive which can pay on multiple diagnosis categories.
This payment model relies on appropriate reporting of chronic conditions. In the example on the screen, the PCP will usually assess the patient’s COPD, CHF, vascular disease at the visit. These should each be coded on the CMS-1500.
Another example of multiple coding is in the treatment of a quadriplegic with decubitis ulcers. If the quadriplegia impacts the development/treatment of the decubitis then the decubitis and quadriplegia should be coded.

13. ICD-9-CM Coding
In excess of 3,100 diagnosis codes will be used to determine the risk adjustment portion of plan payment
The diagnosis codes are organized into 66 disease groups which form the basis for payment under CMS-HCC.

14. ICD-9-CM Coding
The ICD-9-CM coding system translates written medical terminology into numeric and alpha-numeric codes
The ICD-9-CM codes listed on your claim or encounter are intended to accurately reflect the patient’s condition as it relates to services rendered and documented during the encounter
While we're going to talk in general terms about ICD-9 coding, you should keep in mind that coding guidelines are dependent on the place of service. In coding inpatient claims, you can code "rule out" diagnoses as if they actually exist. In Outpatient hospital and physician coding, a rule out diagnosis is not coded. Instead, the symptoms are coded when a diagnosis has not been established. You should always refer to the official ICD-9 coding guidelines when in doubt.
Remember that your encounters may be audited--by the health plan, or by CMS. Documentation is as important in encounters as in fee for service claims.
If it’s not documented it didn’t happen!!

15. Best Practices in ICD-9-CM Coding
The code selected should always be at the highest level of specificity
The ICD-9-CM book is organized into three digit categories
250 Diabetes Mellitus
401 Essential Hypertension
480 Viral Pneumonia
MOST diagnosis codes require a fourth/fifth digit to provide sufficient specificity
A three digit code cannot be assigned if a category has fourth/fifth digits even if your billing or encoder system accepts it
The three digit categories are sometimes called families
Very few three digit codes are valid. For 2003, there are 96 codes which are complete at 3 digits.

16. Best Practices in ICD-9-CM Coding (cont.)
The fourth digit subcategory provides more specificity regarding:
Codes with a fourth digit of “9” are considered unspecified
If another digit more accurately describes the condition, do not use “9”
- Etiology
Cause
- Site
Specific area of the body
- Manifestation
Characteristic signs, symptoms or processes of an illness
Etiology or cause…site or specific body area, manifestation or characteristic signs, symptoms…etc.
Simply “filling” the code with “0” or “9” is a poor coding practice which can cost you revenue under risk adjustment, as you’ll see later in the presentation..

17. Best Practices in ICD-9-CM Coding (cont.)
Fifth-digit coding provides additional specificity
You must code to the fifth-digit if the code has one
Consider using a master problem list to track diagnoses over time
Consider using random audits by certified coders to ensure coding accuracy
Because ICD-9 changes yearly (in October), be sure that the version you are using is valid for the dates of service. Be sure to update your super-bills, internal encounter forms, chargemasters and "cheat-sheets" to reflect these changes
Many ICD-9 code books have symbols which indicate when you must use a 4th or 5th digit
Two MAJOR changes to long-standing ICD-9 codes for 2003:
1) 428 series, (heart failure) has been expanded greatly, and includes 15 new codes. Diastolic, systolic and combined diastolic/systolic failure all have new codes. All include acute, chronic and acute or chronic
2) A new section includes multiple forms of terrorism to accurately reflect injury/mortality due to terrorism (See E979 series)

18. Master Problem List Sample Documentation:
Problem 1: Resting angina coming on in morning, associated with dyspnea, no palpitations
Problem 2: Pressure today is 125/76. She feels less tired on new medication. Will refill
Problem 3: Allergies really bothering her. Eyes watering & itching. Nasal mucosa irritated. Will prescribe antihistamine.
One possible method of tracking diagnosis information over time.

19. Diabetes Coding
Diabetes is a disease that is often miscoded, due to inadequate documentation.
The three digit category for diabetes is 250
Five digits are required for all diabetes codes
The first three digits indicate the patient has diabetes
The second “0” indicates there are no complications or other manifestations
Since diabetes is such a common diagnosis among the elderly, we’ll take some additional time looking at the coding structure.
The first three digits assign the diagnosis to a family or category
The fourth digit, in this case a “0” indicates that there are no complications.

20. Diabetes Coding (cont.)
If the physician specifically lists in the medical record any complications or manifestations of the diabetes that show the progression of the disease and/or response to treatment the additional documentation allows the biller/coder to select the proper fourth digit
Remember, the fourth digit only addresses complications and disease manifestations.
We'll get to the fifth digit shortly

21. Diabetes Coding (cont.)
Complications
There are two acute complications of diabetes mellitus
Diabetic ketoacidosis
250.1x
250.3x
Hyperosmolar nonketotic coma
250.2x
Other diabetic comas, such as hypoglycemic comas, are assigned to code 251.0

22. Diabetes Coding (cont.)
Manifestations
Renal manifestations:
250.4x
Ophthalmic manifestations:
250.5x
Neurological manifestations:
250.6x
Peripheral Circulatory disorders:
250.7x
Other Specified manifestations:
250.8x
Diabetes w/unspecified
complications:
250.9x
The fourth digit in diabetes coding is critical to coding accuracy. If your patient is being evaluated for multiple complications of diabetes, you should code all of the complications (peripheral vascular disease, renal disease, ophthalmic disease, etc..) as well as the code for the manifestation itself. For example...if the patient has diabetic retinopathy, you should code both and or
Because the paper CMS 1500 form has only 4 diagnosis fields, multiple coding is more difficult for paper claims/encounters. You will need to code the most important documented diagnoses --OR submit electronically!!!!!!!

23. Types of Diabetes
It is critical to identify the type of diabetes in the medical record.
If the physician states the level of control the patient is maintaining, this will allow the biller/coder to select the proper fifth digit.
By type of diabetes, the ICD-9 means insulin dependant (i.e. what was called "juvenile" diabetes, not merely insulin treated diabetes) The terms Juvenile type, Insulin Dependant Diabetes Mellitus or IDDM, or Type I diabetes are all synonymous
Make sure that the documentation matches the superbill.

24. Types of Diabetes (cont.)
Type 1 (IDDM) Controlled
250.x1
Type 1 (IDDM) Uncontrolled
250.x3
Type II (NIDDM) Controlled
250.x0
Type II (NIDDM) Uncontrolled
250.x2
Since many Type II diabetics use insulin, you cannot use insulin use to determine which type. If the type is not stated you should check with the physician (query)
In general terms, the distinction is that Type I (also called juvenile onset) diabetics don't make any insulin, and Type II diabetics (so called adult onset) make inadequate or unusable insulin
The coder can't infer whether a patient's diabetes is controlled or uncontrolled. It must be stated in the record
Diabetes is NOT considered out of control unless the physician identifies it as such in the diagnostic statement and/or body of the record.

25. Multiple Coding Techniques
Used when more than one code number is needed to identify a given condition and provide a more complete picture of the diagnosis
The use of multiple codes allows all of the components of a complex diagnosis to be identified
The medical record must mention the presence of all the elements for each code number used
Multiple coding techniques is a concept that you might not have known had a name, although you probably use it all of the time.
It's used to describe two or more diagnoses that are linked together--by cause and effect or due to complications.
In an earlier slide, we talked about diabetes with retinopathy. The notes for (diabetes with ophthalmic complications) indicate that you should also use a code to identify the manifestation. In this case, that code would be (background diabetic retinopathy) or (proliferate retinopathy)

26. Multiple Coding Techniques
This example demonstrates coding to the fourth digit--we still haven’t chosen the fifth--but the ICD-9 code book has alerted us to the fact that we will need to code ANOTHER separate code in addition to the diabetes.
For the purposes of this example, we’ll assume that the patient has polyneuropathy.

27. Multiple Coding Techniques (cont.)
If you look at polyneuropathy in diabetes, there is a cross reference-telling you to code first the underlying disease
Code the primary condition first and then code the complication. (Outpatient/Physician).

28. Diabetes Case Study
A patient with Type I diabetes presents to the ophthalmologist for an evaluation of the progression of his diabetic cataracts. His blood sugar levels have been well controlled and he is following his diet and exercise plan according to his primary care physician’s instructions.
This case study will help to demonstrate the concept of multiple coding techniques, and some of the complexity of diabetes coding.
This is a Type I (insulin dependent) diabetes patient who also has diabetic cataracts. The patient's blood sugar is well controlled.
What is the appropriate 4th digit? 5 (Ophthalmic manifestations)
What is the appropriate 5th digit? 1 (controlled Type I diabetes)
Are other codes required? YES. The description of 250.5x says "use additional code to identify manifestation"

29. Diabetes Case Study

30. Diabetes Case Study (cont.)
Renal Manifestations:
4th digit =4
250.4x
Ophthalmic Manifestations:
4th digit =5
250.5x
Neurologic Manifestations:
4th digit =6
250.6x
Peripheral Circulatory Disorders:
4th digit =7
250.7x
Other Specified Manifestations:
4th digit =8
250.8x
Unspecified Manifestations:
4th digit =9
250.9x
250.5 is the correct 4th digit
1. What is the proper fourth digit code for this case?

31. Diabetes Case Study (cont.)
2. What is the proper fifth digit for this case?
3. Are there any additional codes required?
The proper fifth digit is 1 (remember, the note states that the patient's blood sugar is well controlled)
Yes, an additional code is required.

32. Diabetes Case Study (cont.)

33. Diabetes Documentation
Critical elements:
Type
Level of control
Manifestations and complications by category
Manifestations and complications specified by site

34. Impact of Specific Diabetes Coding on Risk Adjustment
Example: Diagnosis of Diabetes with chronic renal failure
In the first case:
Physician documents: Diabetes
Biller/coder codes:
Associated payment: $475/yr
This is a good example of how specific documentation can lead to more accurate coding AND better reimbursement.
If the diagnosis or assessment only says "diabetes" the coder can choose nothing more specific than

35. Impact of Specific Diabetes Coding on Risk Adjustment
In the second case:
Physician documents: Diabetes with chronic renal failure, insulin dependent
Biller/coder codes: (diabetes with renal manifestations, insulin dependent
Associated payment: $1,852/yr
Difference in payment due to insufficient documentation = $1,377/yr
“IDDM - ESRD” equals complete documentation required for payment. (Insulin Dependent Diabetes Mellitus - End Stage Renal Disease)

36. Heart Failure Coding
Heart failure coding has been expanded to 15 codes for 2003
Codes are now divided into:
Systolic heart failure (428.2x)
Diastolic heart failure (428.3x)
Combined systolic & diastolic heart failure (428.4x)

37. Heart Failure Coding
Each subcategory is further subdivided by 5th digit
5th digit 0 = unspecified
5th digit 1= acute
5th digit 2 = chronic
5th digit 3 = acute on chronic
Key is documenting
Coding for heart failure has expanded to the 5th digit.

38. NEC vs. NOS
NEC - Not Elsewhere Classifiable - NEC is used when the ICD-9-CM system doesn’t have a code specific to the patient’s condition
NOS - Not Otherwise Specified - NOS is used when the coder lacks sufficient information to code to a higher level of specificity. This is the equivalent of “unspecified”
Before we move on to the procedural coding section, we should touch on the difference between NEC and NOS.
NEC means that there is no code for what the patient has. You've looked under every possible entry in the index of diseases, and this is as close as you can get.
NOS means the coder doesn't have enough information to code to the highest level of specificity. This is a documentation issue.
Take a look at charge capture document (charge master) to make sure you don’t have a lot of NOS and NEC.

39. HCPCS / CPT Coding

40. HCPCS - HealthCare Common Procedural Coding System
CPT Codes
(Level I)
Local Codes
(Level III)
National Codes
(Level II)
HCPCS is a 3 level coding system
Level 1 is the AMA's CPT
Level 2 are HCFA's National Alpha-numeric codes
Level 3 are Local Alpha-numeric codes. These are not necessary for M+C encounters
(your health plan may still ask for them)
Developed by the AMA
Developed by local
Medicare carriers
Developed by CMS

41. CPT Coding CPT stands for Current Procedural Terminology.
It was developed by the American Medical Association (AMA) in 1966.
It is a listing of five-digit, numeric codes for reporting medical services and procedures performed by physicians.
CPT is revised and published annually by the AMA to keep pace with changes in medical practice.
These are the level 1 HCPCS codes
The lag between new technology development and CPT is about 2-3 years.
For example-- the lag between the widespread use of laparascopic cholecystectomy and a new CPT code was almost 3 years.

42. CPT Organization
The procedures and services with their identifying codes are in numerical order within CPT with the exception of the Evaluation and Management services which are listed first.
Section
Code Range
Evaluation and Management
99201 to 99499
Anesthesiology
00100 to 01999
Surgery
10040 to 69979
Radiology
70010 to 79999
Pathology and Laboratory
80002 to 89399
Medicine
90701 to 99199
Category III Codes
0001T to 0044T

43. National Codes Are the Level II HCPCS codes.
Published annually by CMS.
Codes consist of five characters and are alpha-numeric.
Were created because CPT describes only physicians’ procedures and services and CMS needed another method to code supplies, injections, and other procedures and services it recognized were not found in CPT. These codes are typically billed when services are provided in the medical office or in the Outpatient hospital setting.
Example: J Bicillin 600,000 Units

44. Evaluation and Management Services
CMS does not require a specific set of Evaluation and Management Guidelines for Medicare + Choice provider.
The code chosen by the physician must accurately describe the services rendered.
In the Medicare fee-for-service program, physicians currently have the option of choosing the 1995 or the 1997 E & M guidelines.
When we did this training in 2001, we were told the 2000 E&M guidelines would most likely go into effect in June 2001, superceding all previous version.
As of today’s date, the 2000 version of the codes have not been implemented. Use of either version is acceptable for M+C choice claims or encounters.

45. Evaluation and Management Services
We strongly suggest that you follow Fee-for-Service CMS guidelines when selecting an E&M Code, and when coding encounters in general. CMS has notified Health Plans that physician encounter data will be subjected to Medical Records Review.
If you've never read the back of a CMS1500 form, you might want to do it now. All of the rules listed on the CMS1500 apply to Encounter data submission as well.

46. Tips for Documenting Procedures
Include narrative indications for surgery
If the procedure is related to an injury include information regarding place and mechanism of injury
If a repeat procedure is performed, provide the following information:
1. Physician who performed the first procedure
2. Date the first procedure was performed
3. Brief narrative stating the reason(s) the procedure is being repeated
For the second bullet the place of injury is referring to the geographical location.

47. Data Validation
CMS will conduct data validation to ensure there’s consistency between the claim and the medical records.
As medical information is updated it is important that consistency exists between the claim and the medical record to ensure a successful data validation by CMS.
Revenue may be at risk if it’s not documented

48. Modifiers

49. Modifiers
Consist of 2 digits that are appended to procedure codes. Provides additional information as to how the procedure was different from the typical service described in CPT.
The CPT system contains 33 modifiers.
HCPCS modifiers are 2 digit alpha or alpha numeric.
Modifiers simply modify a procedure. For example, the HCPCS modifiers T1-T9 and TA indicate that a certain procedure was performed on a specific toe.

50. Modifiers May Be Used to Indicate:
A service or procedure has both a professional and technical component.
A service or procedure was performed by more than one physician.
A service or procedure has been increased or reduced.
A bilateral procedure was performed.
A service or procedure was provided more than once
A secondary procedure was also performed
Unusual events occurred
Some services have both a technical component and a professional component. The technical component is the performance of the test itself, the professional is the interpretation. If you are billing for the interpretation of a pulmonary function test, you might bill to indicate that only an interpretation was done.
If you did bilateral bunion surgery, you would use modifier 50 to indicate that it was done on both feet.
Unusual circumstances (modifier -22) is considered by most Medicare Carriers to be an overused modifier. This is because the Relative Value Units under the Medicare fee schedule were developed using AVERAGE work intensity -- that is, the allowance is supposed to compensate for the normal range of work intensity. Some cases are easy, some are difficult. Carriers expect that unless a case is considerably more difficult than normal modifier 22 will not be used.

51. Modifier - 25
Significant Separately Identifiable Evaluation and Management Service by the Same Physician on the Same Day of a Procedure
This modifier indicates that on a day a procedure or services identifier by a CPT code was performed, the patient’s condition required a significant, separately identifiable E/M service above and beyond the usual preoperative and postoperative care associated with the procedure that was performed. Assign the proper E/M code as appropriate for the services rendered.
If the patient came in only with a complaint about his knee, and the history and examination was limited to an assessment of the knee, NO Evaluation and Management code should be billed. The allowance for the joint aspiration includes the level of assessment needed to make the determination to aspirate the joint.
Again, this doesn't mean that everytime an office based procedure is done that no E&M can or should be billed. It's a matter of the medical necessity and appropriateness of billing both. If the services are unrelated, then billing an E&M code is appropriate. Just be sure the modifier is on the claim and the medical record supports its use.

52. Modifier -25
Example: A patient is seen in the office for evaluation of his COPD, coronary artery disease and diabetes. He is also complaining of swelling in his knee which developed after he fell while getting out of his car. The physician performs an expanded, problem-focused history and examination of his chronic illnesses along with his knee and performs a joint aspiration of the knee.
20610
496
719.06 1 2
Since there is a separately identifiable E&M service for the chronic illnesses, the office visit is coded with modifier -25 appended to show other services were rendered unrelated to the joint aspiration
If the patient came in only with a complaint about his knee, and the history and examination was limited to an assessment of the knee, NO Evaluation and Management code should be billed. The allowance for the joint aspiration includes the level of assessment needed to make the determination to aspirate the joint.
Again, this doesn't mean that every time an office based procedure is done that no E&M can or should be billed. It's a matter of the medical necessity and appropriateness of billing both. If the services are unrelated, then billing an E&M code is appropriate. Just be sure the modifier is on the claim and the medical record supports its use.

53. Anesthesia Modifiers
CMS requires that all anesthesia claims have modifiers:
Anesthesiologist Services:
AA - Anesthesia personally performed by the anesthesiologist
AB - Medical direction of own employees (<4 employees)
AC - Medical direction of other than own employees (<4 individuals)
AD - Medical Supervision by a physician: more than 4 concurrent anesthesia procedures
This list is not complete...see your HCPCS guide for additional modifiers
We are aware that these are not traditionally used in managed care, but are mandatory in Fee For Service Medicare.
Check with your health plan to see if they wish you to use the HCPCS modifiers
We expect CMS to monitor the use of these codes and compare the Managed Care use to FFS
The bottom line is that if there is a specific code for the service.. USE IT

54. Anesthesia Modifiers CRNA Services:
QX - CRNA service with medical direction by a physician
QY - Medical direction of one CRNA by an anesthesiologist
QZ - CRNA service without medical direction

55. Unlisted Procedures
Every section of the CPT book has an unlisted procedure code.
Used for procedures performed for which there is not a specific code listed in the CPT book.
Often used for new procedures resulting from medical advances and research. NOTE: Beginning with 2002 CPT, Category III codes are being developed. Check for a Category III code prior to using an unlisted code.
Are NOT assigned when a more descriptive code is available.
The category III codes begin with 00 and end with “T”

56. Miscellaneous Coding Information
Anesthesia included in surgical procedure - anesthesia rendered by the surgeon is NOT reported separately.
“Separate” procedures - procedure codes listed in the CPT as separate procedures are usually part of a more comprehensive service. If it is the only procedure done on a given date, then it may be billed separately.
Designation of sex procedures - codes which include gender in their description cannot be billed for the opposite gender.
Example: Catheter placement for injection of contrast material is not reported separately.
Catheter placement for patient to injection drugs at home is separately billable.

57. Summary for Providers Coding/Billing Staff
If you are currently submitting Medicare fee-for-service claims, continue with that approach for Medicare + Choice claims and encounters.
If you are currently paying M+C encounters or claims on behalf of a health plan, all data elements on a CMS 1500 or UB92 must be recorded and transmitted to the health plan.
If you are new to filing a Medicare bill or encounter, we have given you training on best practices in coding to get you started.
Physicians should provide sufficient documentation to enable accurate diagnosis coding by billers/coders.
Use a documentation format that supports the level of evaluation and management service reported.
Provide an “Indications for Surgery” narrative on operative reports.
Provide information to the biller/coder when a modifier is necessary.

58. Tips for Your Office or Facility
Review your superbill to make certain that all codes are current.
If diagnosis codes are printed on your superbill, allow enough code choices for the physician to accurately and completely describe that patient’s condition, to the highest level of specificity.
Biller/coders: make sure your codes are valid on a yearly basis.
If you are having difficulty with a downstream provider’s format, please ask your health plan for assistance.
Each procedure line may have a unique diagnosis.

59. BBA DATA SUBMISSION DEADLINES AND CMS PAYMENT SCHEDULE
This slide provides a chart of key dates to remember regarding submission and CMS payment dates.
One of the important items is Period 6, for dates of service 7/1/02-6/30/03 the reimbursement from CMS changes from 10% risk adjusted to 30% risk adjusted. The impact of these adjustments are based on your contractual arrangements with your healthplans. Therefore, any specific details related to financial impact should be addressed with your healthplan.
It should also be noted that these dates are subject to change by CMS. However, this is what we have been communicated thus far.
Points of clarification:
CMS Sweep Date - is the last date a claim can be accepted at CWF to be considered for payment in the next year.
Retro Date Cut-off - is the last date a claim can be accepted at CWF for that period to be considered for payment. Data submitted after this date will not be considered for payment by CMS.
Beginning 7/1/02, healthplans are required to submit professional and outpatient encounter data to CMS. All data for DOS after 7/1/02 will be subject to new CMS RAPS processing and new risk adjustment. Period 5 data submitted for retro consideration (after 9/02) will be processed by new RAPS system but will be edited per existing edits and paid per existing risk adjustment methodology.
*NOTE: Although the dates for CMS Sweep and Retroactive Data Cut-off are not available the percentage of reimbursement for risk adjustment is known to be 75% for 2006 and 100% for 2007

60. PIPDCG Payment Example
76 year old female
Medicaid eligible
COPD
CHF
Vascular disease with complications
living in Los Angeles County, CA.
2003

61. PIPDCG Payment Example
Demographic Payment Calculation
Monthly rate book for LA County:
Part A: $ Part B: $323.21
Jane Doe, Medicaid factor:
Part A: Part B: 1.25
Part A: $ x 1.45 = $580.48
Part B: $ x 1.25 = $404.01
Monthly demographic capitation payment (Part A plus Part B)
$ $ = $ (100% demographic)
The rate book information used here is from The rate book information changes annually. We used the old rates books to be able to provide this example, because 2003 rates are not yet available.

62. PIPDCG Payment Example
Risk Adjustment Payment Calculation
Monthly rate book for LA County:
Part A: $ plus Part B: $ = $723.54
Rescaling factor =
Rescaling rate: $ x = $715.96
Rescaling factor is the demographic adjustment for geographical area.

63. PIPDCG Payment Example
Risk factors
Jane Doe, demographic base factor = 0.588
Medicaid = 0.440
CHF (PIPDCG 16) = 2.438
Total risk factor: = 3.466
Monthly risk adjusted capitation (100% risk adjusted payment)
$ x = $2,481.52

64. PIPDCG Payment Example
Blended Risk Adjustment Payment Calculation
90/10 Blend
Demographic : $ x 0.9 = $886.04
Risk: $2, x 0.10 = $248.15
Total Monthly Blended payment = $ $ = $1,134.19
Annually (if she lives and stays enrolled in an M+C plan) $13,610.32
The $13, annualized amount includes both Medicare part A and B.

65. CMS-HCC Payment Payment estimation =
Female, 76 years old, Medicaid eligible, COPD, CHF, vascular disease with complications, LA County, 2004
Payment estimation =
76 year old female (0.483)
Medicaid (0.183)
COPD (0.376)
CHF (0.417)
Vascular disease with complications (0.677)
CHF with COPD (0.241)
2.377 (relative risk factor)
Now let’s look at using the new CMS-HCC payment methodology.
Relative Risk Factor = relative to average expenditure for a Medicare beneficiary.

66. CMS-HCC Payment 2.3725 x $715.96 = $1,701.84 (100% risk)
$ = (100% demographic)
70% demographic ($689.14) % risk ($510.55) = total blended payment ($1,199.69)
Annual = $14,396.34
Risk adjustment is slated to be phased in over four years. The example above relates to 30% in 2004 (dates of service 7/1/02 through 6/30/03) so you can see we are already well into the first reporting cycle data collection.

67. Risk Adjustment Factor New vs. Old
Female, 76 years old, Medicaid eligible, COPD, CHF, vascular disease with complications
PIP-DCG (current model)
90% Demographic : $886.04
10% Risk : $
Total Monthly Blended payment = $1,134.19
Annualized=$13,610.32
HCC (new risk adj model)
70% demographic: $689.14
30% risk: $510.55
Total Monthly Blend payment = $1,199.69
Annualized= $14,396.34
Now that we have gone through the coding, compared the two models, here’s the slide again from earlier in the presentation showing the differences between the two models.

68. Coding Adjustments
As indicated in the previous examples, accurate coding impacts reimbursement.
Please follow-up with the Medicare Encounter Data Report contact in your plan (listed on Health plan contact list in the ICE Web-site) on how to adjust previously submitted claims or encounters.

69. Submitting Your Data

70. Tips for Your Office or Facility
Paper Submission
Direct to Health Plan
Vendor (i.e. Clearinghouse)
TPA, IPA, or Medical Group
Refer to Resource Guide to complete CMS 1500 and UB92
Electronic Submission
Vendor
Whether you submit paper or electronic claims, periodically check your payer tables or dictionaries to ensure you are submitting to the correct address.
Refer to the Resource Guide to determine how to complete a CMS1500 and UB 92 claim form.
If you have sub-capitated providers, verify the providers are submitting all encounters.
Each visit is considered an encounter. Ensure that each visit is recorded and sent to the Health Plan, TPA, IP or Medical Group as an encounter claim. This includes post operative surgery visits, maternity visits, and other case rate arrangements.
For questions -- Please refer to the
“Where to submit guide”

71. Final Check List Charge/Fee Tickets/Super Bill
Cheat Sheets - Specialists
Claims Systems
Training for Physicians
Charge Tickets/Fee Tickets/Superbill: Does your current Fee Ticket encourage inaccurate coding? Make appropriate changes to ensure accurate coding. If you must use your current supply of fee tickets, consider implementing an “interim” guide.
Cheat Sheet - Specialist: Would your specialists benefit by a “cheat sheet” designed specifically for their specialty? If yes, consider creating one and laminating it for those specialists.
Claim Systems: Is the system able to handle multiple diagnosis codes? What is the maximum? Are all diagnosis codes for each encounter entered into the system for submission? How many diagnosis code fields are transmitted to the health plans?
Education for Physicians: What is the most effective way to educate your physicians?

72. Resource Guide
The resource guide included in your handout today contains a number of web-sites where you can obtain more coding and billing guidance.
Access the web for a copy of the full presentation that will be available in April The Web address is:

73. QUESTIONS?