Coding for Risk Adjustment

Coding for Risk Adjustment
New England MGMA Regional Conference Friday May 4, 2018 Cynthia Trapp, MS,CHFP, CMPE, CPCO, CPC, CPC-I, AAPC-Fellow, CCS-P, CHC

Agenda Defining Risk Adjustment History of CMS Risk Adjustment
Risk Adjustment Models HCC Concepts Provider Types Sources for Documentation How does HCC work? RAF Scores, Coding & Impact HCC Categories Coding Condition Examples Common Coding and Documentation Errors Coding/DocumentationTips

Defining Risk Adjustment
Risk adjustment is the method used to adjust bidding and payment kto health plans based on demographos (age and sex) as well as actual health status of a plan’s enrollees. Medicare risk adjustment is prospective, meaning diagnoses from the previous year and demographic information are used to predict future costs, and adjust payment. The purpose of Risk Adjustment allows CMS to pay plans for the risk of the beneficiaries they enroll. By risk adjusting plan payments, CMS is able to make appropriate and accurate payments for enrollees with differences in expected costs. Increased accuracy benefits patients, providers, health plans, and the nation as a whole.

What is Risk Adjustment?
Risk adjustment is a method of determining and balancing the cost associated with caring for patients with varying severities of illness. Risk Adjustment is current trend in payment methodology for leveling the payment and cost of caring for a patient between the payer and provider. Sicker the patient The higher the cost / The higher the payment Healthier the patient The lower the cost / The lower the payment This methodology aids in forecasting and predicting costs associated with caring for patients. It also allows for more payment for those institutions that treat patients with higher severity of illness. Plans and providers share in the Risk of caring for the patient through these methodologies. Risk adjustment is recognized as a critical componenet of competitive health insurance markets. State and other countries use this methodology to share in costs associated with healthcare. Netherlands, Switzerland, Germany, Ireland, Australia, South Africa. Massachusetts.

Elements used in Risk Adjustment
Insurance Status Medicare, Medicaid, etc… Age Gender Disability Status Socioeconomic Status Severity of Illness Using Diagnosis codes Place of service Serious conditions such as ESRD

History of CMS Risk Adjustment
Risk adjustment methodology for Medicare Advantage was first required in 1997 by the Balanced Budget ACT (BBA). When CMS first implemented risk adjustment , hospital inpatient diagnoses were collected to determine payment to Mediare Advantage organizations. In 2000, with the Benefits Improvement and Protection ACT of 2000 (BIPA), Congress mandated that ambulatory data also be collected. This change occurred gradually, and was fully implemented in 2007 with the completeion of 100% risk adjustment payments for the majority of MA organiztins. Some demonstration plans, however, were not fully phased in until The Medicare Prescription Drug, Improvement, and Modernization ACT (MMA) established the prescritption drug benefit (Part D) to go into effect under risk adjustment methodology in 2006.

History of CMS - HCC Model
Prior to 2000 – Adjusted Avg per Capita Cost (AAPCC) – Principal Inpatient Diagnostic Cost Group (PIP – DCG) – CMS- Hierarchical Condition Categories (HCC) – Version 12 CMS - HCC 2012 – Version 21 CMS – HCC 2014 – Version 22 CMS - HCC

History of CMS - HCC Model
Allows Medicare to revise its model as needed based on recent data on diagnoses and expenditures 2004 Model was improvement of individual variation of expenditures over PIP-DCG Model by 10% 2009 Model adjusted changes in diseases, treatment methods, coding, and changes in the Medicare program 2012 Model allowed for 12.5% improvement over the PIP-DCG model

Risk Adjustment Models

Predictive Modeling Used to anticipate future diagnoses of patients in Risk Adjustment To predict future health needs of patients or populations Performed with an analytical review of known data Suspect logic = looking for diagnosis that should be there but are not reported (e.g. past or current prescriptions) Chart reviews are typically done by either internal payer resources (coders) or by outside vendors. Reviewers are generally coders with a strong knowledge of ICD Coding guidelines as well as risk adjustment Official ICD Coding guidelines as well as the Coding Clinic® are sources used for risk adjustment

Types of Risk Adjustment Reviews
Prospective – Predictive Examples – CMS/HCC Model, Medicare Advantage, Medicare Part D, Netherlands’ risk model. Uses historical diagnosis codes to predict future expenses Data from 2016 predict costs in 2017 Focus is on impact of ongoing chronic conditions on costs First year, not feasible as no previous data existed Health plans, CMS, and other groups establish risk adjustment programs to help understand and account for varying costs associated with caring for patients, and to improve the quality of care, improve accuracy in reporting.

Concurrent Example – HHS-CC model for Health Insurance Marketplace Focus is on prediction of costs associated with current year acute health conditions Chronic conditions are often exacerbated by acute conditions – this model focuses on acute events Also captures high costs such as organ transplants, metastatic cancer, low birthweight babies, etc… Data from 2016 will predict costs for 2016. Health plans, CMS, and other groups establish risk adjustment programs to help understand and account for varying costs associated with caring for patients, and to improve the quality of care, improve accuracy in reporting.

Retrospective Uses historical diagnosis codes as measure of health status to predict expected expense for from a retrospective perspective Retrospective are typically prior year dates of service whereas concurrent can be current year combined with the prior year. Health plans, CMS, and other groups establish risk adjustment programs to help understand and account for varying costs associated with caring for patients, and to improve the quality of care, improve accuracy in reporting.

Models of Risk Adjustment
CMS – Hierarchical Condition Category, Part C (HCC-C) – used by Medicare CMS – Hierarchical Condition Category, Part D (HCC-D) Health and Human Services Hierarchical Condition Categories (HHS) – used by Commercial, Individual, and Small Groups Chronic Illness and Disability Payment Systems (CDPS) – Used by Medicaid MedicaidRx (UCSD) RxGroups (DxCG) Diagnosis Related Groups (DRG) – Inpatient Adjusted Clinical Groups (ACG) – Outpatient

HCC-C Model – Medicare – Part C
Hierarchical Condition Category, Part C Most common and recognized model Method for Medicare to adjust medical expense in Medicare Advantage (MA) contracts based on risk Filters diagnosis codes into (DxG’s) Diagnosis Groups and Condition Categories (CC’s) or hierarchies. Categories are then assigned an HCC numeric code which in turn is assigned an RAF (Risk Adjustment Factor) value

HCC Concepts

Principles of HCC Risk Adjustment
Diagnostic categories should be clinically meaningful. Diagnostic categories should predict medical expenditures. Diagnostic categories should have adequate sample size to estimate expenditures accurately. HCC’s should be used to characterize the person’s illness level within each disease process, while effects of unrelated disease processes accumulate. Diagnostic classification should encourage specific coding.

Principles of HCC Risk Adjustment
Diagnostic classification should not reward coding proliferation. Providers should not be penalized for recording additional diagnoses (monotonicity) Classification system should be internally consistent (transitive). The diagnostic classification should assign all ICD-9-CM or ICD-10-CM codes Discretionary diagnostic categories should be excluded from payment models.

Basic HCC Concepts Diagnosis Codes (ICD-10 CM) Diagnosis Groups (DXGs)
Condition Categories (CCs) Hierarchical Condition Categories (HCCs) CMS - Hierarchical Condition Categories (CMS-HCCs)

Basic HCC Concepts Diagnosis for Risk adjustment must be:
Documented in the medical record Based on face-to-face encounter Coded according to Official ICD-9/ICD-10 Coding Guidelines Acceptable provider type Coded to the highest level of specificity Not coded from the medication list unless linked to supportive documentation in the note Based only on definitive diagnosis. “Probable”, “suspected”, “questionable”, “rule out”, “working diagnosis” not allowed

Requirements Signature requirements Legible and signed Timely
Credentialed

Provider Types Acceptable Providers Unacceptable Providers MD, DO
Nurse Practitioner (NP) Physician Assistant (PA) CRNA, LCSW OT, PT CNM Licensed Practical Nurse (LPN) Licensed Vocational Nurse (LVN) Medical Assistant (MA or CMA) Nursing Assistant (NA or CAN) Registered Nurse (RN) Radiologist Nutritionist

Inpatient Data allowed…
Covered Facilities Non-covered Facilities Short-term hospitals Religious non-medical healthcare institutions Long-term hospitals Rehabilitation hospitals Children’s hospitals Psychiatric hospitals Medical Assistance Facilities/Critical Access Hospitals Skilled Nursing Facilities Hospital Inpatient Swing bed components Intermediate Care Facilities Respite Care Hospice

Outpatient Data allowed…
Covered Facilities Non-covered Facilities Short-term hospitals Community Health Centers Federally Qualified Health Centers Religious non-medical healthcare institutions Long-term hospitals Rehabilitation hospitals Children’s hospitals Psychiatric hospitals Medical Assistance Facilities/Critical Access Hospitals Rural Health Clinic Free-standing Ambulatory Surgical Centers Home Health Care Free-standing Renal Dialysis Facilities Non-Covered Services Laboratory Services Ambulance Durable Medical Equipment Prosthetics/Orthotics Supplies Radiology Services

Acceptable Specialties (*AAPC)
Page 168 * page 168

Sources for Documentation
Acceptable Sources Progress Notes Office Notes Post Op Reports H&P ER Note Discharge Summary Consultation Report Cardiac Cath Report Anesthesia Notes

Sources for Documentation
Unacceptable Sources Signature Log Pathology Report Lab Report EKG, ECHO,Holter Report Radiology Reports Nursing Notes Problem List Medication List Demographic sheet

Common HCC Categories Chronic Kidney Disease Diabetes Mellitus
Hypertension Peripheral Arterial Disease (PAD) Major Depressive Disorders Stroke and Late effects of prior Stroke Chronic Conditions History of Heart Attack

Common HCC Categories Renal Dialysis Status Tracheostomy Status
Respirator Dependence Lower Limb Amputee Organ Transplant Status Asymptomatic HIV Status Protein Calorie Malnutrition Alcohol Dependence & Drug Dependence

2017 HCC Categories HCC-C Model

How does CMS-HCC work? Each patient is assigned a Risk Adjustment Factor (RAF) score RAF scores are based on: Patient’s age and sex Medicaid or disability status Total of all chronic conditions and disease interactions RAF identifies the patient’s health status Lower RAF indicates healthier patient Higher RAF indicates sicker patient Average FFS patient has a score of 1.00

How does CMS-HCC work? Cont… RAF scores are “additive”:
All qualifying diagnoses are included in the RAF score Risk factors are added to achieve “total” RAF score RAF scores are “predictive” Codes reported this year determine payments for next year Health status is re-determined each year, therefore codes must be submitted every year to be counted

2018 ICD-10 HCC and RxHCC Model Mid-year sample
*

2017 ICD-10 HCC Mid-Year Weights
*

2016 HCC Categories/Weights

Determining the RAF Score
Many different models and formulas Determine model being used Determine formula based on model used See CMS website at: Check Trump list

Trump List Medicare ensures that conditions in which diagnoses that are inherent within another are not duplicated or double calculated, hence the concept of “trumpting”. Therefore, diagnoses within “families” or “hierarchies” are “trumpted” by those that are the more severe, so in other words are not added in the total RAF score. Therefore RAF scores do not include those values that are “trumpted”. Coders do not eliminate codes due to Trump list Coders code all appropriate codes according to appropriate ICD Coding guidelines

Example of Trump List Always check current Trump lists HCC Description
Trumped 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 HCC Description Trumped HCC’s 17 Diabetes with Acute Complications 18,19 18 Diabetes with Chronic Complications 19 Always check current Trump lists

Suspect Logic Known conditions Progression of illness
DME needs – ex oxygen but no respiratory condition Use of prescriptions Labs CPTs, HCPCS, Socioeconomic status Disability = hospice ESRD, amputation

Risk Coding Steps Verify: Face-to-face encounter Approved provider
Provider signature/authentication Printed name and credential Date of service Documentation supports Diagnosis part of medical decision making

What supports coding for HCC?
Following ICD-10 Official Coding Guidelines Meds from Med list linked to condition in the note. Ex. 5 mg Prednisone PO daily for asthma. Notes that reflect test results in the note Ex. Chest x-ray confirms pneumonia Active current conditions Condition was Monitored, Evaluated, Assessed, or Treated. Think MEAT!

Example of Note… 64 Year old disabled female patient with Type II diabetes and Diabetic Chronic Kidney Disease. Patient has congestive heart failure and Stage IV Chronic Kidney Disease (GFR 64 ml/min Filtration). Patient is obese, with a BMI of 56.0, is on insulin and is paraplegic. Patient is on Medicaid.

HCC Example… Coding is often very generic and unspecified… HCC DX
Description RAF Score Annual Payment -- 64 Yr Old Female 0.312 $ 3,763 Medicaid/Disabled Eligible 0.085 $ HCC19 E11.9 Diabetes w/no complications 0.121 $ 1,162 Total RAF Score 0.598 $ 5,741 *Using 2016 weights *Assumes Medicare payment of $9,600/annual

HCC Example… Adding in the specified diabetes code along with the CKD stage… HCC DX Description RAF Score Annual Payment -- 64 Yr Old Female 0.392 $ 3,763 Medicaid/Disabled Eligible 0.085 $ HCC 18 E11.22 Type 2 Diabetes Mellitus w/Diabetic CKD 0.378 $ 3,629 HCC 137 N18.4 Chronic Kidney Disease Stage 4 (severe) 0.230 $ 2,208 Total RAF 1.085 $ 10,416 *Using 2016 weights *Assumes Medicare payment of $9,600/annual

HCC Example… Adding the CHF and long term use of insulin… HCC DX
Description RAF Score Annual Payment -- 64 Yr Old Female 0.392 $ 3,763 Medicaid/Disabled Eligible 0.085 $ HCC 18 E11.22 Type 2 Diabetes Mellitus w/Diabetic CKD 0.378 $ 3,629 HCC 137 N18.4 Chronic Kidney Disease Stage 4 (severe) 0.230 $ 2,208 HCC 19 Z79.4 Long term use of (current) insulin 0.121 $ 1,162 HCC 85 I50.22 Congestive Heart Failure 0.377 $ 3,619 Total RAF 1.583 $15,197 *Using 2016 weights *Assumes Medicare payment of $9,600/annual

HCC Example… HCC DX Description RAF Score Annual Payment --
64 Yr Old Female 0.392 $ 3,763 Medicaid/Disabled Eligible 0.085 $ HCC 18 E11.22 Type 2 Diabetes Mellitus w/Diabetic CKD 0.378 $ 3,629 HCC 137 N18.4 Chronic Kidney Disease Stage 4 (severe) 0.230 $ 2,208 HCC 19 Z79.4 Long term use of (current) insulin 0.121 $ 1,162 HCC 85 I50.22 Congestive Heart Failure 0.377 $ 3,619 HCC 22 E66.01 Morbid Obesity 0.374 $ 3,590 Z68.43 BMI HCC 71 G82.20 Paraplegia, Unspecified 1.078 $10,349 Total RAF 3.409 $32,726 *Using 2016 weights *Assumes Medicare payment of $9,600/annual

Inadequate Coding Better Coding Properly Coded
64 Yr Old Female 0.392 Medicaid/Disabled Eligible 0.085 Diabetes w/no complications 0.121 Type 2 Diabetes Mellitus w/Diabetic CKD 0.378 Chronic Kidney Disease Stage 4 (severe) (Not Coded) 0.000 0.230 Long term use of (current) insulin Congestive Heart Failure (Not Coded) Congestive Heart Failure 0.377 Morbid Obesity 0.374 BMI Paraplegia, Unspecified 1.078 Total RAF 0.598 1.583 3.409 Annual Payment $5,741 $15,197 $32,726 *2016 Weights, *Assumes Medicare payment of $9,600/annual

Example #2 H/0 Breast Cancer, status-post mastectomy
Right Breast Cancer, S/P bilateral mastectomy, still taking Tomoxifen Inadequate Documentation/Coding Proper Documentation/Coding 51 Yr Old Female 0.263 Medicaid/Disabled Eligible 0.085 Personal history of Malignant Neoplasm of breast Z85.3 0.000 Malignant neoplasm of unspecified site of right female breast C509.11 0.0158 Acquired absence of unspecified breast and nipple Z90.10 Long term current use of selective estrogen receptor modulators (SERMS) Z79.811 Acquired absence of bilateral breast and nipple Z90.13 Total RAF 0.348 0.3638 Annual Payment $3,341 $3,492 *2016 Weights, * Assumes Medicare payment of $9,600/annual

Code all status condition codes

Condition Examples

Artificial Opening Status
Artificial opening status has an effect on risk adjustment in that DME supplies are costly as well as put the patient at risk for other conditions such as infection. An artificial opening was one in which an opening was made to the outside of the body and likely replaces or bypasses a normal body function. Examples of artificial openings include tracheostomy, gastrostomy, colostomy, ileostomy, tracheostomy, etc Artificial openings for purposes of risk adjustment are permanent openings. Proper documentation is critical for the coder to know how to code appropriately NG tubes, Ports, catheters, and chest tubes are not considered artificial openings. Most artificial openings have two code choices. Status of the code indicates that the opening is current or that the opening is being cared for. Stoma or ostomy are indications that the patient may have an artificial opening.

Artificial Opening Artificial Opening Codes Description ICD-10 Code
HCC Category HCC Value HCC $ Value Tracheostomy, status of Z93.0 82 1.055 $10,128 Gastrostomy, status of Z93.1 188 0.571 $5,481 Ileostomy, status of Z93.2 Colostomy, status of Z93.3 Cystostomy, status of Z93.50 Other artificial openings of GI tract (Jejunostomy, Duodenostomy, etc.) Z93.4 Nephrostomy, Ureterostomy, Urethrostomy, Z93.6

Ileostomy with other conditions
Often associated with other diseases such as: Crohn’s disease, Ulcerative Colitis. Colorectal Cancer Ileostomy with other conditions Description ICD-10 Code HCC Category HCC Value HCC $ Value Crohn’s Disease, small intestine K50.00 35 0.294 $2,822 Crohn’s Disease, small intestine, with intestinal obstruction K50.012 33 0.246 $2,361 Ulcerative Colitis, without complications K159.0 Ulcerative Colitis, with intestinal obstruction K518.12 Malignant neoplasm of colon with rectum C19 11 .301 $2,899 Malignant neoplasm of colon, unspecified C18.9 Malignant neoplasm of small intestine (RxHCC=19) C17.9 9 .97 $9,312

BMI and Obesity BMI is a measure weight as it relates to height
BMI value may be captured by any clinician and does not need to be stated by the treating physician to be coded. BMI does add value for risk adjustment Obesity must be stated by the treating provider in order to code and bill however, only Morbid Obesity is Risk adjusted BMI may be coded without an obesity statement from the provider but obesity may not Coders may not code BMI from their own calculations. BMI value must be documented by a clinician. BMI should not be coded in the primary position It is important for risk adjustment to capture the morbid or severe obesity diagnosis vs. simply obesity from the provider if that is the diagnosis for the patient ICD Official Guidelines: Section 1, B, 14

BMI and Obesity ICD Official Guidelines: Section 1, B, Documentation for BMI, Depth of Non-pressure ulcers, Pressure Ulcer Stages, Coma Scale, and NIH Stroke Scale For the Body Mass Index (BMI), depth of non-pressure chronic ulcers, pressure ulcer stage, coma scale, and NIH stroke scale (NIHSS) codes, code assignment may be based on medical record documentation from clinicians who are not the patient’s provider (i.e., physician or other qualified healthcare practitioner legally accountable for establishing the patient’s diagnosis), since this information is typically documented by other clinicians involved in the care of the patient (e.g., a dietitian often documents the BMI, a nurse often documents the pressure ulcer stages, and an emergency medical technician often documents the coma scale). However, the associated diagnosis (such as overweight, obesity, acute stroke, or pressure ulcer) must be documented by the patient’s provider. If there is conflicting medical record documentation, either from the same clinician or different clinicians, the patient’s attending provider should be queried for clarification. The BMI, coma scale, and NIHSS codes should only be reported as secondary diagnoses. * Section 1.B.14.

BMI BMI BMI in adults is defined as age 21 years and over.
Description ICD-10 Code HCC Category HCC Value HCC $ Value BMI under 40.0, adult Z68.1 –Z68.39 No HCC No Value $0.00 BMI , adult Z68.41 22 0.273 $2,620 BMI , adult Z68.42 BMI , adult Z68.43 BMI , adult Z68.44 BMI 70.0-or greater, adult Z68.45 BMI in adults is defined as age 21 years and over. Pediatric BMI is 2 to 20 years and is determined based on percent of growth chart.

Obesity and Malnutrition
Description ICD-10 Code HCC Category HCC Value HCC $ Value Protein-calorie malnutrition E40- E64.0 21 0.545 $5,232 Over weight E66.3 No HCC No Value $0.00 Morbid, (severe) obesity due to excess calories E66.01 22 0.273 $2,620 Morbid, (severe) obesity with alveolar hypoventilation E66.2 Obesity may only coded when documented by a clinician. Proper wording is crucial for correct code assignment

Angina Heart-related pain / Cchronic or sudden and unexpected
I20 Angina pectoris Use additional code to identify: Exposure to environmental tobacco smoke (Z77.22) History of tobacco dependence (Z89.891) Occupational exposure to environmental tobacco smoke (Z57.31) Tobacco dependence (F17.-) Tobacco use (Z72.0) Excludes 1 notes I20.0 – I20.9 I20.9 Angina pectoris, unspecified

Angina Angina pectoris Description ICD-10 Code HCC Category HCC Value
Angina pectoris, unspecified or NOS I20.9 88 0.14 $960 Unstable Angina I20.0 Angina w/Atherosclerotic Heart Disease I25.110 87 0.218 $2,093 Angina w/CABG or Transplanted Heart I25.700 Post-Infarction Angina I23.7

Cardiac conductive disorders
Types of Cardiac conditions can include: Supraventricular Tachycardia AV Block Sick Sinus Syndrome Atrial Ventricular Fibrillation Atrial Ventricular Flutter Cardiac conduction disorders can be due to arterial clogging, CAD, cardiomyopathy Conduction disorders can develop over time and/or can be caused by medication or can be congenital Patients may have multiple cardiac conductive disorders Risk scores are higher for the most severe conditions

Cardiac conductive disorders are coded only when documented as current conditions Previous conduction disorders that have been surgically fixed or treated with an implant (e.g. pacemaker) are coded as “history of” unless the implant malfunctions Be very careful understand “history of” properly. Watch for the use of “history of” in the documentation because the patient may indeed have the current condition. (Some providers will use the term “history of” when the condition is current.)

Cardiac Conductive Disorders
Supraventricular (SVT) Tachycardia Description ICD-10 Code HCC Category HCC Value HCC $ Value Paroxysmal supraventricular tachycardia I47.1 96 0.268 $2,573 Paroxysmal ventricular tachycardia I47.2 Paroxysmal tachycardia, unspecified I47.9

Atrial Fibrillation/Flutter Description ICD-10 Code HCC Category HCC Value HCC $ Value Paroxysmal Atrial Fibrillation I48.0 96 0.268 $2,573 Persistent Atrial Fibrillation I48.1 Chronic Atrial Fibrillation I48.2 Unspecified Atrial Fibrillation I48.91 Typical Atrial Flutter I48.3 Atypical Atrial Flutter I48.4 Unspecified Atrial Flutter I48.92

Ventricular Fibrillation/Flutter Description ICD-10 Code HCC Category HCC Value HCC $ Value Ventricular Fibrillation I49.01 84 0.302 $2,899 Persistent Atrial Fibrillation I49.02

AV Block Description ICD-10 Code HCC Category HCC Value HCC $ Value AV Block, first degree I44.0 No HCC No Value $0.00 AV Block, second degree (Mobitz type II) I44.1 AV Block, complete I44.2 96 0.268 $2,573

Cardiomyopathy Three Types Dilated Hypertrophic Restrictive

Cardiomyopathy Three Types Associated with cause of heart failure
Dilated Hypertrophic Restrictive Associated with cause of heart failure Cardiomyopathy Description ICD-10 Code HCC Category HCC Value HCC $ Value Cardiomyopathy, unspecified I42.9 85 0.323 $3,101 Obstructive Hypertrophic Cardiomyopathy I42.1 Cardiomyopathy due to drug and external agent I42.7 Alcoholic Cardiomyopathy I42.6 Ischemic Cardiomyopathy, I25.5 No HCC No Value $0.00

CVA and TIA CVA (Cerebrovascular Accident) is an emergent loss of brain function due to lack of continual blood circulation to the brain. TIA (Transient Ischemic attack) is a temporary loss of blood flow to the brain without infarction or cell death.

CVA and TIA Both can be caused by thrombosis (clot), hemorrhage, or embolism Risk factors for both include: Age, long-term high blood pressure, diabetes, uncontrolled high cholesterol, smoking, a-fib History of stroke, or TIA (transient ischemic attack)

CVA and TIA Coding for CVA is only allowed as current in the episode for which it is treated and/or occurring. Once treated, code “history of” Late effects of CVA may be coded as appropriate however documentation must state cause and effect relationship to the residual condition Late effects of CVA and TIA include: Aphasia – inability to speak Dysphasia – difficulty speaking Dysphagia – difficulty swallowing Ataxia – lack of muscle coordination Hemiparesis/Hemiplegia – weakness on one side of the body According to the “Coding Clinic” – the word hemiparesis must be documented for hemiparesis due to CVA in order to code it.

CVA and TIA CVA and TIA Description ICD-10 Code HCC Category HCC Value
Non-traumatic hemorrhages I60.00-I62.9 99 0.263 $2,525 Cerebral Infarction due to…. (RxHCC = 206) I63.00-I63.9 100 Vascular Disease with complications I67.0 107 0.4 $3,840 Monoplegia, Other Paralytic Syndromes I I69.969 104 0.395 $3,792 Hemiplegia/Hemiparesis I I69.969 103 0.538 $5,165

CVA and TIA According to ICD-10 coding guidelines, coders are instructed to code the following additional conditions with CVA and when present Alcohol abuse and dependence (F10.-) Exposure to environmental tobacco smoke (Z77.22) History of tobacco use (Z87.891) Hypertension (I10-I15) Occupational exposure to environmental tobacco smoke (Z57.31) Tobacco dependence (F17.-) Tobacco use (Z72.0)

CVA and TIA CVA and TIA Description ICD-10 Code HCC Category HCC Value
Alcohol abuse and dependence F10.- 55 0.383 $3,677 Exposure to environmental tobacco smoke Z77.22 No HCC No Value $0.00 History of tobacco use Z87.891 Hypertension I10-I15 Occupational exposure to environmental tobacco smoke Z57.31 Tobacco dependence F17.- Tobacco use Z72.0

Chronic Kidney Disease (CKD)
CKD is a decrease in the function of the kidneys and their ability to filter waste from the body Patients with high blood pressure, diabetes or have relatives with CKD are at a higher risk for CKD. CKD can cause cardiovascular diseases, anemia, and pericarditis.

Coders may not code CKD or stage from lab values. Treating provider must document the diagnosis. If documentation states between two stages, coders should code the lower stage. If documentation says mild, moderate, or severe, coders should use the corresponding stages II-IV

Description ICD-10 Code HCC Category HCC Value HCC $ Value CKD, stage 1 N18.1 No HCC No Value $0.00 CKD, stage 2 (mild) N18.2 CKD, stage 3 (moderate) N18.3 CKD, stage 4 (severe) N18.4 137 0.237 $2,275 CKD, stage 5 N18.5 136 ESRD (End Stage Renal Disease) Requires chronic dialysis N18.6 CKD, unspecified N18.9 CMS/HCC – PACE/ESRD in V model uses V22. No HCC or No Value for CKD Stages 1-3

Dialysis Dialysis is a procedure which helps to maintain the functions of the kidney when the kidney cannot maintain its own function. Once a patient is on dialysis, they generally remain on dialysis awaiting a kidney transplant. Two types of dialysis: Hemodialysis – patient connects to a dialyzer through a surgically created AV fistula Peritoneal dialysis – patient is connected to an external bag which pulls the waste Dialysis Description ICD-10 Code HCC Category HCC Value HCC $ Value Dialysis Status/dependence on renal dialysis (Or AV fistula/shunt) Z99.2 134 0.422 $405.12 Admission/encounter for dialysis Z49.-

Arteriovenous (AV) Fistula
AV Fistula is a connection between two organs or vessels that normally do not connect May be congenital, acquired, or surgically created AV Fistula Description ICD-10 Code HCC Category HCC Value HCC $ Value AV Fistula, acquired (due to disease or trauma) I77.0 108 0.298 $2,861 AV Fistula, congenital Q24-Q28 -- 0.00 $0.00 AV Fistula, complication T82.9

Chronic Obstructive Pulmonary Disease (COPD)
CPOD is used to describe conditions such as Emphysema, chronic bronchitis, and obstructive asthma Symptoms and treatments are similar Often require oxygen due to low levels of oxygen in the blood Most cases are related to smoking

Advanced COPD can lead to other co morbidities such as pulmonary hypertension, cur pulmonale (right sided heart failure), cachexia, osteoporosis, heart disease, and depression

COPD is a chronic condition but patients can have an acute exacerbation of it Acute on Chronic is when symptoms of the chronic condition suddenly worsen Example: shortness of breath, mucous production, bacterial or viral infections, hypoxia, respiratory distress, or failure Coders must code appropriately for acute on chronic conditions

Chronic Bronchitis is an increase in the mucous and inflammation of the bronchioles which limits airflow. Bronchitis is coded based on acute, chronic or acute on chronic or with another COPD diagnosis, such as emphysema or obstructive asthma. Emphysema is an inflammation of the alveoli. It reduces the elasticity of the lung and causes the patient to have difficulty breathing Emphysema is also coded based on chronic with co morbidities

Description ICD-10 Code HCC Category HCC Value HCC $ Value Bronchitis, NOS J40 No HCC No Value $0.00 Simple chronic bronchitis J41.0 111 0.328 $3,149 Mucopurulent chronic bronchitis J41.1 Mixed simple and mucopurulent chronic bronchitis J41.8 Unspecified Chronic Bronchitis J42 Unilateral Pulmonary Emphysema J43.0 Panlobular Emphysema J43.1 Centrilobular Emphysema J43.2 Other Emphysema J43.8 Emphysema, unspecified J43.9 COPD with acute lower respiratory infection J44.0 COPD with acute exacerbation J44.1 COPD, unspecified J44.9

Asthma Asthma is a narrowing or tightening of the bronchioles which causes inflammation in the air passages. It can cause a patient to have wheezing, shortness of breath, cough, and a feeling of tightness in the chest

Asthma Asthma can be genetic or can be triggered by certain allergies, foods, animals, mold, or other environmental factors. Other conditions that often affect asthma patients include sinusitis, GERD, sleep apnea, anxiety, and depression

Asthma Documentation for Asthma should include terms such as mild intermittent, mild persistent, moderate persistent, or severe persistent to be coded properly. Documentation should also include terms to describe if the asthma is uncomplicated, exacerbated, or has acute severe exacerbation and if not responding to normal treatment Coding COPD with asthma on the same DOS uses the main COPD code (J44.9) and a second code from J45 to identify the type of Asthma

Asthma According to ICD-10 coding guidelines, coders are instructed to code the following additional conditions are coded with Asthma and when present Exposure to environmental tobacco smoke (Z77.22) Exposure to tobacco smoke in the perinatal period (P96.81) History of tobacco use (Z87.891) Occupational exposure to environmental tobacco smoke (Z57.31) Tobacco dependence (F17.-) Tobacco use (Z72.0)

Complications of care Complications of care Description ICD-10 Code
HCC Category HCC Value HCC $ Value Certain early complications of trauma, NEC T79.- 173 0.266 $2,554 Complications of procedures, NEC T81.- 134 0.422 $4,051 Complications of cardiac and vascular prosthetic devices, implants and grafts T82.- 176 0.597 $5,731 Complications of genitourinary prosthetic devises, implants, and grafts T83.- Complications of internal orthopedic prosthetic devices, implants, and grafts T84.- Complications of internal prosthetic devices, implants, and grafts T85.- Complications of transplanted organs and tissues T86.- 186 1.00 $9,600 Complications of peculiar to reattachment and amputation T87.- 7th digit for initial , subsequent, sequela encounters.

Congestive Heart Failure (CHF)
CHF is caused by other conditions that weaken the heart muscles and does not allow the heart to pump enough blood. CHF develops over time and causes blood to build up in the other organs causing: Pulmonary edema (lungs) Pulmonary effusion (lungs) Ascites (swelling in the abdomen) Edema of the feet and ankles

Other symptoms include tiredness, weakness, cough, and shortness of breath Codes are identified by Acute, Chronic, or Acute on Chronic CHF is also identified in coding by Systolic or Diastolic Ascites

According to ICD-10 coding guidelines, coders are instructed to code the following additional conditions are coded with CHF and when present Heart failure complicating abortion or ectopic or molar pregnancy (O00-O07, O08.8) Heart failure following surgery (I th digit) Heart failure due to hypertension (I11.0) Heart failure due to hypertension with Chronic Kidney Disease (I13.-4th digit) Obstetric surgery and procedures (O75.4) Rheumatic heart failure (I09.81)

Description ICD-10 Code HCC Category HCC Value HCC $ Value Left Ventricular failure Cardiac asthma Edema of lung with heart disease NOS Left heart failure Pulmonary edema with heart failure NOS Pulmonary edema with heart failure I50.1 85 0.323 $3,101 Systolic (congestive) heart failure I50.2 – Diastolic (congestive) heart failure I50.3 – Combined systolic (congestive) and diastolic (congestive) heart failure I50.4 – Heart failure, unspecified Biventricular (heart) failure NOS Cardiac, heart or myocardial failure NOS Congestive heart disease Congestive heart failure NOS Right ventricular failure (secondary to left heart failure) I50.9

Cor Pulmonale Cor Pulmonale is a Pulmonary heart disease which is an enlargement of the right ventricle of the heart It is caused by high blood pressure or pulmonary hypertension in the lungs brought on by diseases such as: Chronic lung disease Vascular changes from tissue damage Chronic hypoxic pulmonary vasoconstriction Can be with or without heart failure Chronic cor pulmonale can result in right ventricular hypertrophy (RVH) which is a thickening of the walls of the right ventricule. Acute cor pulmonale can result in dilation or stretching

Cor Pulmonale Coding includes acute vs. chronic and/or if pulmonary embolism is present Cor Pulmonale Description ICD-10 Code HCC Category HCC Value HCC $ Value Other pulmonary embolism with acute core pulmonale Acute cor pulmonale NOS I26.09 85 0.323 $3,101 Other specified pulmonary heart diseases Cor pulmonale (chronic) Cor pulmonale NOS Excludes 1 Acute cor pulmonale (I26.0-) I27.81

Deep Vein Thrombosis (DVT)
DVT is a blood clot in a deep vein. Usually found in the lower extremities and may not have any symptoms. Signs include: Pain, swelling, redness, warmness, and engorged veins in the legs Thrombosis is a clot inside a blood vessel DVT often has no symptoms

Coding for DVT is dependent on weather the DVT is current, past, or prophylactic. Medication for current DVT can be Coumadin or Warfare but this can also be used as a prophylactic measure so it is important to identify which. Complexity and depth of the clot determining factors in risk adjustment. Coding for DVT is also determined by acute vs. chronic as well as right vs. left and the appropriate vessel Thrombosis is a clot inside a blood vessel DVT often has no symptoms

Description ICD-10 Code HCC Category HCC Value HCC $ Value Acute embolism and thrombosis of deep veins of lower extremity I82.4- 108 0.298 $2,861 Chronic embolism and thrombosis of deep veins of the lower extremity I82.5- Acute embolism and thrombosis of veins I82.6- Chronic embolism and thrombosis of veins and upper extremities I82.7- Embolism and thrombosis of other specified veins I82.8-

Dementia Coding for dementia is determined on weather or not the patient has other conditions such as: Dementia with or without behavioral issues Vascular dementia Dementia associated with other diseases The more complex the condition, the higher the risk score Thrombosis is a clot inside a blood vessel DVT often has no symptoms

Dementia Dementia Description ICD-10 Code HCC Category HCC Value
Vascular Dementia F01.5- -- $0.00 Dementia in diseases classified elsewhere . Code first underlying conditions: Alzheimer’s disease (G30.-) Cerebral lipidosis (E75.4) Creutzfeldt-Jakob (A81.0-) Dementia with Lewy bodies (G31.83) Epilepsy and recurrent seizures (G40.-) Frontotemporal dementia (G31.09) Hepatolenticular degeneration (E83.0) HIV disease (B20) Hypercalcemia (E83.52) Hypothyroidism, acquired (E00-E03.-) Intoxications (T36-T65) Multiple sclerosis (G35) Neurosyphilis (A52.17) Niacin deficiency [pellagra] (E52) Parkinson’s disease (G20) Pick’s disease (G31.01) Polyarteritis nodosa (M30.0) Systemic lupus erythematosus (M32.-) Typanosomiasis (B56.-, B57.-) Vitamin B deficiency (E53.8) F02.8-

Dementia Dementia Description ICD-10 Code HCC Category HCC Value
Unspecified Dementia Presenile dementia NOS Presenile psychosis NOS Primary degenerative dementia NOS Senile dementia depressed or paranoid type Senile psychosis NOS Excludes 1: Senility NOS (R41.81) F03.9- -- $0.00

Depression Can be a temporary condition of low state or mood or a more serious major depression Major depression can be a single episode or recurrent Depression Description ICD-10 Code HCC Category HCC Value HCC $ Value Major depressive disorder, single episode F32.- 58 0.395 $3,792 Major depressive disorder, recurrent episode F33.-

Diabetes Diabetes is the inability for the body to make it’s own insulin – Insulin allows the body to use sugar as energy Type I patients require insulin injection daily Type II patients may take insulin orally or by injection and may be able to regulate blood sugar Hemoglobin A1C is the test that diabetic patients have use to test their blood sugar levels over a period of time. A1C levels at a 7 or under are usually considered controlled. Levels over 7 may require insulin adjustment

Diabetes Coding for Diabetes is critical for risk adjustment
Manifestations are required for diabetic complications with the exception of gangrene. If gangrene is documented in the same encounter, this may be assumed. The 4th digit in ICD-10 is related to the manifestation and the 5th is used to identify the type of diabetes.

Diabetes Diabetes Type I Description ICD-10 Code HCC Category
HCC Value HCC $ Value With Ketoacidosis E10.1x- 17 0.318 $3,053 With Kidney complications E10.2x- 18 With Ophthalmic complications E10.3x- With Neurological complications E10.4x- With Circulatory complications E10.5x- With other specified complications E10.6x- With unspecified complications E10.8 Without complications E10.9 19 0.104 $998

Diabetes Diabetes Type II Description ICD-10 Code HCC Category
HCC Value HCC $ Value With Hyperosmolarity E11.0x- 17 0.318 $3,053 With Kidney complications E11.2x- 18 With Ophthalmic complications E11.3x- With Neurological complications E11.4x- With Circulatory complications E11.5x- With other specified complications E11.6x- With unspecified complications E11.8 Without complications E11.9 19 0.104 $998

Diabetes Other Specified Diabetes Description ICD-10 Code HCC Category
HCC Value HCC $ Value With Hyperosmolarity E13.0x- 17 0.318 $3,053 With Ketoacidosis E13.1x- 18 With Kidney complications E13.2x- With Ophthalmic complications E13.3x- With Neurological complications E13.4x- With Circulatory complications E13.5x- With other specified complications E13.6x- With unspecified complications E13.8 Without complications E13.9 19 0.104 $998

Secondary Diabetes Secondary Diabetes can be caused by other health conditions such as: Chronic pancreatitis (K86.1) – a disease in which digestive enzymes attack the pancreas. Main causes are alcoholism, blockage of pancreatic duct, trauma, cyst, or heredity Cushing’s disease (E24.-4th) – is a hormonal disorder caused by exposure to Cortisol either produced by the adrenals or steroid hormones Cystic fibrosis (E84.-4th or 5th) – is a genetic disease which can lead to Type 2 Diabetes Adenocarcinomas – cancer in the lining of the inside of organs Drugs – chemically induced cancer

Epilepsy Epilepsy is hyperactivity of the neurons in the brain caused by: Brain disorders or brain trauma Stroke Brain cancer Drug or alcohol abuse Conditions such as convulsions, new-onset seizure, single seizure, and hysterical seizure are non-epileptic Coded by incidental vs. recurrent (seizure disorder/Epilepsy)

Epilepsy 5th digit classification is reported by the following:
Without mention of intractable epilepsy – use 0 With intractable epilepsy – use 1 Pharmacoresistent Poorly controlled Refractory (medically) Treatment resistant According to Coding Clinic 2008, coders should report symptoms for seizure or single seizure vs Epilepsy unless the provider documents seizure disorder, repetitive seizures, or recurrent seizures. In those cases a seizure disorder or Epilepsy code should be coded (Coding Clinic 2008)

Epilepsy Epilepsy Description ICD-10 Code HCC Category HCC Value
Unspecified convulsions R56.9 79 0.309 $2,966 Epilepsy, unspecified, not intractable, without status epilepticus G40.909

Gastroesophageal reflux disease (GERD)
GERD is a common condition with painful symptoms of the esophagus such as heartburn. It is a reflux of stomach acid which flows backward into the esophagus. Acidic foods, alcohol, caffeine, and aging all contribute to GERD. Coding for GERD is distinguished between GERD with or without esophagitis. If documentation does not specify, code would default to GERD NOS. Barrett’s Esophagus could develop from GERD that is either left untreated or does not respond to treatment.

Gastroesophageal reflux disease (GERD)
Other conditions related to GERD include: Hiatal hernia Obesity Zollinger-Ellison syndrome (pancreatic tumor) Hypercalcemia (high calcium) Scleroderma and systemic sclerosis (connective tissue disease) Long term use of prednisolone Viceroptosis Eosinophilic Esophagitis Rheumatoid arthritis Autoimmune disorders

Common Coding or Documentation Errors

Often missed diagnoses
Z68.4x BMI E78.5 Hyperlipidemia, unspecified E11.9 Type 2 diabetes mellitus without complications E Hypothyroidism, unspecified F32.9 Major depressive disorder, single episode, unspecified I Unspecified atrial fibrillation E66.9 Obesity, unspecified J Unspecified asthma, uncomplicated F41.9 Anxiety disorder, unspecified I Heart failure, unspecified D64.9 Anemia unspecified L53.9 Erythematous condition, unspecified

Missing diagnosis codes No documentation to support diagnosis billed Chronic conditions not coded or assessed Not enough specificity of disease Patient is diabetic and on insulin – documentation does not indicate patient has Type 1 or type 2 Cause and effect coding not present “Due to”, “associated with”, “manifested by”, “secondary to” Use of “history of” when current condition exists

Diagnosis listed on problem list but not noted in the note Medication listed in Medication List but condition not mentioned or linked in the note Lisinopril but HTN not documented or coded Codes not properly sequenced BMI status and level of Obesity missing Status of cancer is not clear or no treatment is documented

Common Coding/Documentation Errors
Active health status missing CABG, amputation, congenital diseases, Downs syndrome, transplant status Long term use of medication for chronic diseases missing Coumadin, ASA, insulin, etc… Pertinent family and social elements family history of cancer, DM, HTN, MI, sudden cardiac death, congenital diseases Acquired organs or Amputations are not documented Kidneys, toes, feet, etc….

Documentation does not indicate that the diagnoses are being Monitored, Evaluated, Assessed, or Treated (MEAT) Medical record does not have legible signature or appropriate credentials Electronic Medical Record was not authenticated or signed appropriately

Chronic Conditions often missed
Ectasia Malnutrition Morbid Obesity (BM > 40) Multiple Sclerosis Organ Transplant Ostomies Parkinson’s disease Rheumatoid Arthritis Alcohol and/or drug dependency Amputations Aneurysm Atherosclerosis of Aorta CHF Chronic psychiatric conditions COPD Congenital conditions

Coding Concepts and Guidelines

CMS Risk Adjustment Guidance Follow Official ICD Guidelines Follow AHA Coding Clinic Follow CMS Risk Adjustment Guidance 2008 Risk Adjustment Data Technical Assistance For Medicare Advantage Organizations Participant Guide 2008 RADV Participant Guide These diseases are generally managed by ongoing medication and have the potential for acute exacerbation 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.

CMS Risk Adjustment Guidance Co-existing conditions include chronic conditions such as: Diabetes Atrial Fibrillation Congestive Heart Failure (CHF) Chronic Obstructive Pulmonary Disease (COPD) Co-existing conditions include ongoing conditions such as: Multiple sclerosis Parkinson’s Disease Hemiplegia Rheumatoid Arthritis *2008 Risk Adjustment Data Technical Assistance For Medicare Advantage Organizations Participant Guide Co-existing and Related Conditions These diseases are generally managed by ongoing medication and have the potential for acute exacerbation 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.

CMS Risk Adjustment Guidance “Past Medical History” and “History of” CMS recognizes many errors in this area Providers use “PMH” to identify past and present conditions but coding rules only allow PMH to be historical and no longer part of MDM Providers use “history of” to mean past or present condition, while coding guidelines require history of to mean condition is resolved. Review on case by case basis *2008 RADV Participant Guide Clinical Specificity in Documentation

AHA Coding Clinic Guidance Stand-Alone Encounter Documentation for the current encounter should clearly reflect those diagnoses that are current and relevant for that encounter Conditions documented on previous encounters may not be clinically relevant on the current encounter The provider is responsible for diagnosing and documenting all relevant conditions. A patient’s historical problem list is not necessarily the same for every encounter AHA Coding Clinic: Volume 30, 3rd Qtr, Number 3, 2013, Page 27.

What can be coded vs. not coded? ICD-10-CM Section IV: Diagnostic Coding and Reporting Guidelines for Outpatient Services 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

What can be coded vs. not coded? Section IVJ 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.

Differential Diagnosis not to be coded Risk Factors Smoking is a risk factor for lung cancer CAD as risk factor for stroke or MI Co morbidities Additional diagnoses in addition to the primary procedure Diabetes, COPD, CAD, Neuropathy

ICD Official Guidelines 2018 Guideline Change – “With” – The word “with” or “in” should be interpreted to mean “associated with” or “due to” when it appears in a code title, the Alphabetic Index, or an instructional note in the Tabular List. These codes should be coded as related even in the absence of provide documentation linking them, unless the provider explicitly states that they are unrelated or if another guideline exists that specifically requires a documented linkage between the two conditions. (e.g., sepsis guideline for “acute organ dysfunction that is not clearly associated with sepsis”) The guidelines presume a causal relationship between the two conditions linked by these terms.

ICD Official Guidelines Body Mass Index (BMI) – Z68 As with all other secondary diagnosis codes, the BMI codes should only e assigned when they meet the definition of a reportable diagnosis (see Section III, Reporting Additional Diagnoses.)

ICD Official Guidelines Acute vs. Chronic Acute is current, new condition Chronic usually life lasting but could improve Guideline – Section 1.B.8. Acute and Chronic If the same condition is described as both acute (sub acute) and chronic, and separate subentries exist in the Alphabetic index at the same indention level, code both and sequence the acute (sub acute) code first.

Late effects Condition that produces after the acute phase of another illness or injury No time limit to when it occurs result of, due to, because of, secondary to, related to Be sure to code these as long as there is documentation to support. See guidelines next page

10. Sequela (Late Effects) A sequela is the residual effect (condition produced) after the acute phase of an illness or injury has terminated. There is no time limit on when a sequela code can be used. The residual may be apparent early, such as in cerebral infarction, or it may occur months or years later, such as that due to a previous injury. Examples of sequela include: scar formation resulting from a burn, deviated septum due to a nasal fracture, and infertility due to tubal occlusion from old tuberculosis. Coding of sequela generally requires two codes sequenced in the following order: the condition or nature of the sequela is sequenced first. The sequela code is sequenced second. An exception to the above guidelines are those instances where the code for the sequela is followed by a manifestation code identified in the Tabular List and title, or the sequela code has been expanded (at the fourth, fifth or sixth character levels) to include the manifestation(s). The code for the acute phase of an illness or injury that led to the sequela is never used with a code for the late effect. See Section I.C.9. Sequelae of cerebrovascular disease See Section I.C.15. Sequelae of complication of pregnancy, childbirth and the puerpurium See Section I.C.19. Application of 7th characters for Chapter 19 * Section 1.B.10. Sequela (Late effects)

Coding/Documentation Tips

Document all current conditions evaluated Document and code the status of all chronic conditions at least annually Ex. COPD, CHF, Diabetes Ex. Controlled, Uncontrolled, Stable, improving, worsening Only code signs/symptoms if definitive diagnosis does not exist Code to highest level of specificity Ex. Major depressive disorder vs. depression Ex. Morbid Obesity vs. Obese or Overweight Code all co-existing acute conditions Ex. Protein calorie malnutrition Code pertinent past conditions Ex. Old MI

Document conditions for prescriptions given Ex. 20 mg Lisinopril for HTN Ex. 5 mg Prednisone PO daily for asthma. Ex. 20 mg Citalopram for major depression Document conditions for tests ordered Document conditions for referrals given Code all status conditions Ex. Amputee, Acquired limb, Dialysis, HIV status Ex. Angina, stable on Nitro Ex. Compensated CHF, stable on Lasix Ex. CPOD controlled with Avair

Follow all ICD-10-CM guidelines Refer to AHA, Coding Clinic for guidance

Sources CMS, March, 2011, “Evaluation of the CMS-HCC Risk Adjustment Model”, CMS, March, 2011, “Methodology for Determining Shared Savings and Losses under the Medicare Shared Savings Program”, CMS, March, 2011, “Accountable Care Organizations: What Providers Need to Know”, CMS, February,

Sources

Sources 2013 National Technical Assistance Risk Adjustment 101 Participant Guide – CMS Some materials from AAPC Course on Risk Adjustment cited on slides

Coding for Risk Adjustment

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