Coding for Risk Adjustment New England MGMA Regional

Coding for Risk Adjustment New England MGMA Regional

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 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 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

History of CMS - HCC Model Prior to 2000 Adjusted Avg per Capita Cost (AAPCC) 2000-2003 Principal Inpatient Diagnostic Cost Group (PIP DCG) 2004-2008 CMS- Hierarchical Condition Categories (HCC) 2009-2011 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

Types of Risk Adjustment Reviews 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. Types of Risk Adjustment Reviews 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. 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 (DxGs) Diagnosis Groups and Condition Categories (CCs) 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 1. Diagnostic categories should be clinically meaningful. 2. Diagnostic categories should predict medical expenditures. 3. Diagnostic categories should have adequate sample size to estimate expenditures accurately. 4. HCCs should be used to characterize the persons illness level within each disease process, while effects of unrelated disease processes accumulate. 5. Diagnostic classification should encourage specific coding. Principles of HCC Risk Adjustment 6. Diagnostic classification should not reward coding proliferation. 7. Providers should not be penalized for recording additional diagnoses (monotonicity) 8. Classification system should be internally consistent (transitive). 9. The diagnostic classification should assign all ICD-9-CM or ICD-10-CM codes 10. 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 Licensed Practical Nurse (LPN) Licensed Vocational Nurse (LVN) Medical Assistant (MA or CMA) Nursing Assistant (NA or CAN) Registered Nurse (RN) OT, PT CNM Radiologist

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

Hospice Outpatient Data allowed Covered Facilities Non-covered Facilities Short-term hospitals Community Health Centers Free-standing Ambulatory Surgical Centers Home Health Care Federally Qualified Health Centers Religious non-medical healthcare institutions Long-term hospitals Free-standing Renal Dialysis Facilities Non-Covered Services Laboratory Services Rehabilitation hospitals Childrens hospitals

Ambulance Durable Medical Equipment Psychiatric hospitals Medical Assistance Facilities/Critical Access Hospitals Rural Health Clinic Prosthetics/Orthotics Supplies Radiology Services Acceptable Specialties (*AAPC) *https://aapc.blackboard.com/bbcswebdav/pid-70986-dt-content-rid-2402333_1/courses/AAPC_CRC_16_MZ/2016-MCT-CRC_TB_Ch6.pdf page 168 Sources for Documentation Acceptable Sources Progress Notes Discharge Summary

Office Notes Consultation Report Post Op Reports Cardiac Cath Report H&P Anesthesia Notes ER Note

Sources for Documentation Unacceptable Sources Signature Log Nursing Notes Pathology Report Problem List Lab Report Medication List EKG, ECHO,Holter Demographic sheet Report Radiology Reports 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 Categorie s HCC-C Model https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/PhysicianFeedbackProgram/Downloads/2016-RiskAdj-FactSheet.pdf How does CMS-HCC work? Each patient is assigned a Risk Adjustment Factor (RAF) score RAF scores are based on: Patients age and sex Medicaid or disability status Total of all chronic conditions and disease interactions

RAF identifies the patients 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 *https://www.cms.gov/Medicare/Health-Plans/MedicareAdvtgSpecRateStats/Risk-Adjustors-Items/Risk2018.html 2017 ICD-10 HCC Mid-Year Weights *https://www.cms.gov/Medicare/Health-Plans/MedicareAdvtgSpecRateStats/Risk-Adjustors-Items/Risk2017.html

2017 ICD-10 HCC Mid-Year Weights *https://www.cms.gov/Medicare/Health-Plans/MedicareAdvtgSpecRateStats/Risk-Adjustors-Items/Risk2017.html 2016 HCC Categories/Weights 2016 HCC Categories/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: https://www.cms.gov/Medicare/Health-Plans/Medi careAdvtgSpecRateStats/Risk-Adjustors.html 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 HCC Description Trumped HCCs 8 Metastatic Cancer and Acute Leukemia 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 17 Diabetes with Acute Complications 18 Diabetes with Chronic Complications 9,10,11,12

Trumped HCCs Always check current Trump lists 18,19 19 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 816 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 Adding in the specified diabetes code along with the CKD stage HCC DX Description RAF Score -- -- 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 Annual Payment 816 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

Adding the CHF and long term use of insulin HCC DX Description RAF Score -- -- 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

Annual Payment 816 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 HCC DX Description -- -- 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 HCC 22 Z68.43 BMI 50-59.9 0.374 $ 3,590 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 RAF Score Annual Payment 816 Inadequate Coding Better Coding Properly Coded

64 Yr Old Female 0.392 64 Yr Old Female 0.392 64 Yr Old Female 0.392 Medicaid/Disabled Eligible 0.085 Medicaid/Disabled Eligible 0.085 Medicaid/Disabled Eligible 0.085

Diabetes w/no complications 0.121 Type 2 Diabetes Mellitus w/Diabetic CKD 0.378 Type 2 Diabetes Mellitus w/Diabetic CKD 0.378 Chronic Kidney Disease Stage 4 (severe) (Not Coded) 0.000 Chronic Kidney Disease Stage 4

(severe) 0.230 Chronic Kidney Disease Stage 4 (severe) 0.230 Long term use of (current) insulin (Not Coded) 0.000 Long term use of (current) insulin 0.121 Long term use of (current) insulin 0.121 Congestive Heart

Failure (Not Coded) 0.000 Congestive Heart Failure 0.377 Congestive Heart Failure 0.377 Morbid Obesity (Not Coded) 0.000 Morbid Obesity (Not Coded) 0.000 Morbid Obesity 0.374

BMI 50-59.9 (Not Coded) 0.000 BMI 50-59.9 (Not Coded) 0.000 BMI 50-59.9 0.374 Paraplegia, Unspecified (Not Coded) 0.000 Paraplegia, Unspecified (Not Coded) 0.000

Paraplegia, Unspecified 1.078 Total RAF 0.598 Total RAF 1.583 Total RAF 3.409 Annual Payment $5,741 Annual Payment $15,197 Annual Payment

*2016 Weights, *Assumes Medicare payment of $9,600/annual $32,726 Example #2 H/0 Breast Cancer, status-post mastectomy Inadequate Documentation/Coding Right Breast Cancer, S/P bilateral mastectomy, still taking Tomoxifen Proper Documentation/Coding 51 Yr Old Female 0.263 51 Yr Old Female 0.263 Medicaid/Disabled Eligible 0.085 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 0.000 Long term current use of

selective estrogen receptor modulators (SERMS) Z79.811 0.000 Acquired absence of bilateral breast and nipple Z90.13 0.000 Total RAF Annual Payment 0.348 $3,341 Total RAF 0.3638 Annual Payment $3,492

*2016 Weights, * Assumes Medicare payment of $9,600/annual Code all status condition codes Code all status condition codes 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 Z93.2 188 0.571 $5,481 Colostomy, status of Z93.3 188

0.571 $5,481 Cystostomy, status of Z93.50 188 0.571 $5,481 Other artificial openings of GI tract (Jejunostomy, Duodenostomy, etc.) Z93.4 188 0.571 $5,481 Nephrostomy,

Ureterostomy, Urethrostomy, Z93.6 188 0.571 $5,481 Ileostomy with other conditions Often associated with other diseases such as: Crohns disease, Ulcerative Colitis. Colorectal Cancer Ileostomy with other conditions Description ICD-10 Code HCC Category HCC Value HCC $ Value

Crohns Disease, small intestine K50.00 35 0.294 $2,822 Crohns Disease, small intestine, with intestinal obstruction K50.012 33 0.246 $2,361 Ulcerative Colitis, without complications K159.0

35 0.294 $2,822 Ulcerative Colitis, with intestinal obstruction K518.12 33 0.246 $2,361 Malignant neoplasm of colon with rectum C19 11 .301 $2,899

Malignant neoplasm of colon, unspecified C18.9 11 .301 $2,899 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, 14 14. 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 patients provider (i.e., physician or other qualified healthcare practitioner legally accountable for establishing the patients 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 patients provider. If there is conflicting medical record documentation, either from the same clinician or different clinicians, the patients 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. https://www.cdc.gov/nchs/data/icd/10cmguidelines_2017_final.pdf BMI BMI 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 40.0-44.9, adult Z68.41 22 0.273 $2,620 BMI 45.0-49.9, adult Z68.42 22 0.273 $2,620

BMI 50.0-59.9, adult Z68.43 22 0.273 $2,620 BMI 60.0-69.9, adult Z68.44 22 0.273 $2,620 BMI 70.0-or greater, adult Z68.45 22

0.273 $2,620 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 Obesity and Malnutrition Description ICD-10 Code HCC Category HCC Value HCC $ Value

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 22 0.273 $2,620 Protein-calorie malnutrition 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 HCC $ Value Angina pectoris, unspecified or NOS I20.9

88 0.14 $960 Unstable Angina I20.0 88 0.14 $960 Angina w/Atherosclerotic Heart Disease I25.110 87 0.218 $2,093

Angina w/CABG or Transplanted Heart I25.700 87 0.218 $2,093 I23.7 87 0.218 $2,093 Post-Infarction Angina 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 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

Conductiv e 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 96 0.268 $2,573 Paroxysmal tachycardia, unspecified I47.9 96 0.268 $2,573 Cardiac conductive disorders

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

96 0.268 $2,573 Chronic Atrial Fibrillation I48.2 96 0.268 $2,573 Unspecified Atrial Fibrillation I48.91 96 0.268 $2,573

Typical Atrial Flutter I48.3 96 0.268 $2,573 Atypical Atrial Flutter I48.4 96 0.268 $2,573 Unspecified Atrial Flutter I48.92 96 0.268

$2,573 Cardiac conductive disorders 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 84 0.302 $2,899 Cardiac conductive disorders 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 No HCC No Value $0.00 AV Block, complete I44.2 96

0.268 $2,573 Cardiomyopathy Three Types Dilated Hypertrophic Restrictive Cardiomyopathy Three Types 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 85 0.323 $3,101 Cardiomyopathy due to drug and external agent

I42.7 85 0.323 $3,101 Alcoholic Cardiomyopathy I42.6 85 0.323 $3,101 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 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 0.263 $2,525 I67.0 107 0.4

$3,840 Monoplegia, Other Paralytic Syndromes I69.031I69.969 104 0.395 $3,792 Hemiplegia/Hemiparesis I69.051I69.969 103 0.538 $5,165 Vascular Disease with complications 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 HCC $

Value 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 No HCC

No Value $0.00 Hypertension I10-I15 No HCC No Value $0.00 Occupational exposure to environmental tobacco smoke Z57.31 No HCC No Value $0.00 Tobacco dependence

F17.- No HCC No Value $0.00 Tobacco use Z72.0 No HCC No Value $0.00 Alcohol abuse and dependence 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. Chronic Kidney Disease (CKD) 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 Chronic Kidney Disease (CKD) CKD 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 No HCC No Value $0.00 CKD, stage 3 (moderate)

N18.3 No HCC No Value $0.00 CKD, stage 4 (severe) N18.4 137 0.237 $2,275 CKD, stage 5 N18.5 136 0.237

$2,275 ESRD (End Stage Renal Disease) Requires chronic dialysis N18.6 136 0.237 $2,275 CKD, unspecified N18.9 No HCC No Value $0.00 CMS/HCC PACE/ESRD in V21. 2017 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.- 134 0.422 $405.12 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 AV Fistula, acquired (due to disease

or trauma) AV Fistula, congenital AV Fistula, complication ICD-10 Code HCC Category HCC Value HCC $ Value I77.0 108 0.298 $2,861 Q24-Q28 --

0.00 $0.00 T82.9 -- 0.00 $0.00 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 Chronic

Obstructive Pulmonary Disease (COPD) Advanced COPD can lead to other co morbidities such as pulmonary hypertension, cur pulmonale (right sided heart failure), cachexia, osteoporosis, heart disease, and depression Chronic Obstructive Pulmonary Disease (COPD) 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 Obstructive Pulmonary Disease (COPD) 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 Chronic Obstructive Pulmonary Disease (COPD) COPD Description ICD-10 Code HCC Category HCC Value HCC $ Value

J40 No HCC No Value $0.00 Simple chronic bronchitis J41.0 111 0.328 $3,149 Mucopurulent chronic bronchitis J41.1 111 0.328

$3,149 Mixed simple and mucopurulent chronic bronchitis J41.8 111 0.328 $3,149 J42 111 0.328 $3,149 Unilateral Pulmonary Emphysema J43.0 111

0.328 $3,149 Panlobular Emphysema J43.1 111 0.328 $3,149 Centrilobular Emphysema J43.2 111 0.328 $3,149 Other Emphysema J43.8

111 0.328 $3,149 Emphysema, unspecified J43.9 111 0.328 $3,149 COPD with acute lower respiratory infection J44.0 111 0.328 $3,149

COPD with acute exacerbation J44.1 111 0.328 $3,149 COPD, unspecified J44.9 111 0.328 $3,149 Bronchitis, NOS Unspecified Chronic Bronchitis 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.- 176 0.597 $5,731 Complications of internal orthopedic prosthetic devices, implants, and grafts T84.- 176

0.597 $5,731 Complications of internal prosthetic devices, implants, and grafts T85.- 176 0.597 $5,731 Complications of transplanted organs and tissues T86.- 186 1.00 $9,600 Complications of peculiar to reattachment and amputation

T87.- 173 0.266 $2,554 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 Congestive Heart Failure (CHF) 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 Congestive Heart Failure (CHF) 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 (I97.13-6th 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) Congestive Heart Failure (CHF) CHF Description ICD-10 Code HCC Category

HCC Value HCC $ Value I50.1 85 0.323 $3,101 Systolic (congestive) heart failure I50.2 85 0.323 $3,101 Diastolic (congestive) heart failure

I50.3 85 0.323 $3,101 Combined systolic (congestive) and diastolic (congestive) heart failure I50.4 85 0.323 $3,101 I50.9 85 0.323 $3,101

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 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) 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 85 0.323 $3,101 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 Deep Vein Thrombosis (DVT) 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 Deep Vein Thrombosis (DVT) Deep Vein Thrombosis (DVT) 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-

108 0.298 $2,861 Acute embolism and thrombosis of veins I82.6- 108 0.298 $2,861 Chronic embolism and thrombosis of veins and upper extremities I82.7- 108 0.298 $2,861

Embolism and thrombosis of other specified veins I82.8- 108 0.298 $2,861 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 Dementia Dementia Description ICD-10

Code HCC Category HCC Value HCC $ Value Vascular Dementia F01.5- -- $0.00 $0.00 Dementia in diseases classified elsewhere . Code first underlying conditions: Alzheimers 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) Parkinsons disease (G20) Picks disease (G31.01) Polyarteritis nodosa (M30.0) Systemic lupus erythematosus (M32.-) Typanosomiasis (B56.-, B57.-) Vitamin B deficiency (E53.8) F02.8- -- $0.00 $0.00 Dementia

Dementia Description ICD-10 Code HCC Category HCC Value 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 $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.- 58 0.395 $3,792 Diabetes Diabetes is the inability for the body to make its 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 0.318 $3,053

With Ophthalmic complications E10.3x- 18 0.318 $3,053 With Neurological complications E10.4x- 18 0.318 $3,053 With Circulatory complications E10.5x- 18 0.318

$3,053 With other specified complications E10.6x- 18 0.318 $3,053 With unspecified complications E10.8 18 0.318 $3,053 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 0.318 $3,053 With Ophthalmic complications E11.3x- 18 0.318 $3,053 With Neurological complications

E11.4x- 18 0.318 $3,053 With Circulatory complications E11.5x- 18 0.318 $3,053 With other specified complications E11.6x- 18 0.318 $3,053

With unspecified complications E11.8 18 0.318 $3,053 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 0.318

$3,053 With Kidney complications E13.2x- 18 0.318 $3,053 With Ophthalmic complications E13.3x- 18 0.318 $3,053 With Neurological complications E13.4x-

18 0.318 $3,053 With Circulatory complications E13.5x- 18 0.318 $3,053 With other specified complications E13.6x- 18 0.318 $3,053 With unspecified complications

E13.8 18 0.318 $3,053 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 Cushings 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 HCC $ Value Unspecified convulsions R56.9 79 0.309 $2,966 G40.909 79 0.309 $2,966 Epilepsy, unspecified, not intractable,

without status epilepticus 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. Barretts 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 E03.9 Hypothyroidism, unspecified F32.9 Major depressive disorder, single episode, unspecified I48.91 Unspecified atrial fibrillation E66.9 Obesity, unspecified J45.909 Unspecified asthma, uncomplicated

F41.9 Anxiety disorder, unspecified I50.9 Heart failure, unspecified D64.9 Anemia unspecified L53.9 Erythematous condition, unspecified Common Coding or Documentation Errors 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 Common Coding or Documentation Errors 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. Common Coding or Documentation Errors 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 Alcohol and/or drug dependency Ectasia Amputations Morbid Obesity (BM > 40) Aneurysm Atherosclerosis of Aorta CHF Chronic psychiatric conditions COPD Congenital conditions

Malnutrition Multiple Sclerosis Organ Transplant Ostomies Parkinsons disease Rheumatoid Arthritis Coding Concepts and Guidelines Coding Concepts and Guidelines CMS Risk Adjustment Guidance Follow Official ICD Guidelines https://www.cms.gov/Medicare/Coding/ICD10/ Downloads/2018-ICD-10-CM-Coding-Guideline s.pdf Follow AHA Coding Clinic https://www.codingclinicadvisor.com/ Follow CMS Risk Adjustment Guidance 2008 Risk Adjustment Data Technical Assistance For Medicare Advantage Organizations Participant Guide https://www.csscoperations.com/Internet/Cssc 3.Nsf/files/2013_RA101ParticipantGuide_5CR

_081513.pdf/$File/2013_RA101ParticipantGui de_5CR_081513.pdf Coding Concepts and Guidelines 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 Parkinsons Disease Hemiplegia Rheumatoid Arthritis *2008 Risk Adjustment Data Technical Assistance For Medicare Advantage Organizations Participant Guide 6.4.1 Co-existing and Related Conditions Coding Concepts and Guidelines 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 6.4.3 Clinical Specificity in Documentation Coding Concepts and Guidelines 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 patients historical problem list is not necessarily the same for every encounter AHA Coding Clinic: Volume 30, 3rd Qtr, Number 3, 2013, Page 27. Coding Concepts and Guidelines 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 firstlisted diagnosis may be a symptom when a diagnosis has not been established (confirmed) by the physician Coding Concepts and Guidelines 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. Coding Concepts and Guidelines 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 Coding Concepts and Guidelines 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. https://www.cms.gov/Medicare/Coding/ICD10/Downloads/2018-ICD-10-CM-Coding-Guidelines.pd f Coding Concepts and Guidelines https://www.cms.gov/Medicare/Coding/ICD10/Downloads/2018-ICD-10-CM-Coding-Guidelines.pd f

Coding Concepts and Guidelines 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.) https://www.cms.gov/Medicare/Coding/ICD10/Downloads/2018-ICD-10-CM-Coding-Guidelines.pd f Coding Concepts and Guidelines 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. Coding Concepts and Guidelines 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 Coding Concepts and Guidelines 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) https://www.cdc.gov/nchs/data/icd/10cmguidelines_2017_final.pdf Coding/Documentation Tips 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 Coding/Documentation Tips 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 Coding/Documentation Tips Follow all ICD-10-CM guidelines https://www.cdc.gov/nchs/data/icd/10cmguideline s_2017_final.pdf Refer to AHA, Coding Clinic for guidance http://www.ahacentraloffice.org/ Sources https://www.cdc.gov/nchs/data/icd/10cmguidelines_2017 _final.pdf https://www.cms.gov/Medicare/Coding/ICD10/Downloads /2018-ICD-10-CM-Coding-Guidelines.pdf CMS, March, 2011, Evaluation of the CMS-HCC Risk Adjustment Model, https://www.cms.gov/Medicare/Health-Plans/MedicareAd vtgSpecRateStats/Downloads/Evaluation_Risk_Adj_Mod el_2011.pdf CMS, March, 2011, Methodology for Determining Shared Savings and Losses under the Medicare Shared Savings Program, https://www.cms.gov/Medicare/Medicare-Fee-For-Service -Payment/sharedsavingsprogram/Downloads/ACO_Meth odology_Factsheet_INC907405.pdf CMS, March, 2011, Accountable Care Organizations:

What Providers Need to Know, Sources https://www.cms.gov/Medicare/Health-Plans/Me dicareAdvtgSpecRateStats/Downloads/RiskAdj2 017ProposedChanges.pdf https://www.cms.gov/Medicare/Health-Plans/Me dicareAdvtgSpecRateStats/Risk-Adjustors.html https://www.cms.gov/Regulations-and-Guidance /Guidance/Manuals/Downloads/mc86c08.pdf http://www.hcpro.com/content.cfm?dp=HIM&con tent_id=280642&publication=8160& https://oig.hhs.gov/oas/reports/region6/6090001 2.pdf https://www.cms.gov/Medicare/Health-Plans/Me dicareAdvtgSpecRateStats/Downloads/Evaluati on_Risk_Adj_Model_2011.pdf Sources https://www.cdc.gov/nchs/data/icd/10cmguidelines_201 7_final.pdf https://www.cms.gov/CCIIO/Resources/Forms-Reportsand-Other-Resources/Downloads/RA-March-31-WhitePaper-032416.pdf https://aapc.blackboard.com/bbcswebdav/pid-70986-dtcontent-rid-2402333_1/courses/AAPC_CRC_16_MZ/20 16-MCT-CRC_TB_Ch6.pdf https://www.cms.gov/CCIIO/Resources/Presentations/D ownloads/hie-risk-adjustment-methodology.pdf https://www.cms.gov/Medicare/Health-Plans/MedicareA

dvtgSpecRateStats/Risk-Adjustors-Items/Risk2017.html 2013 National Technical Assistance Risk Adjustment 101 Participant Guide CMS https://www.csscoperations.com/Internet/Cssc3.Nsf/files /2013_RA101ParticipantGuide_5CR_081513.pdf/$File/

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