dennis t tse, md, cpc - aapcstatic.aapc.com/a3c7c3fe-6fa1-4d67-8534-a3c9c8315... · 19 diabetes...

• Capitated payment to health plans for Medicare

patients since 1970’s

• Congress passed the Balance Budget Act of 1997

and created Medicare + Choice

• Benefits Improvement protection Act(BIPA 2000)

mandated the use of ambulatory diagnosis in

Medicare risk adjustment. D .Tse

The Medicare Modernization Act of 2003 changed Medicare + Choice to Medicare Advantage

The new Medicare risk adjustment model was gradually phased into Medicare advantage payment calculations starting in 2004 with full implementation in 1/2007)

Developed by researchers at RTI International, Boston University and Harvard medical school, Hierarchical Condition Categories, uses ambulatory and inpatient diagnosis to create a valid risk adjustment methodology to help predict individual expenditure variation among Medicare patients.

All Rights Reserved D .Tse

Hierarchical Condition Categories (HCC)

The key concept of HCC documentation is choosing the correct HCC code or diagnosis for the same medical condition.

For CMS, it is the HCC code or diagnosis that determines the level of illness of the patients and the RAF score. In general, the higher level illness is associated with higher HCC weight for that HCC diagnosis

RAF= risk adjustment factor RAF = Demographic Factor + HCC (age, gender, medicaid/ESRD status/county residence, etc)

RAF(total) = demo--RAF + HCC ---RAF


Risk Adjustment Factor(RAF) 2009-2010 Medicare patient average RAF IS 1.00

2009-2010 California medical group average RAF is 1.35

CMS reimburses 1% HIGHER for every 0.01 RAF increase

I.E. 10% increase payment for RAF 1.10 from 1.0

5

5

DIAGNOSIS

CODING DRIVES

THE RAF SCORES

RAF SCORES

DRIVE THE

REIMBURSEMENT

IMPROPER

DOCUMENTATION

TAKES AWAY THE

REIMBURSEMENT

D. Tse

Patient care is the number one priority

Care cannot be altered to meet coding strategies. After care is given, then proper coding becomes important.

Face to face encounter with physician(medical provider) needed


Documentation must be legible

All chart notes must contain:

1. Patient ID

patient name, DOB and other unique

identifier must appear on every page

2 Date of Service

3 Signature should include credential (MD, DO, etc)

4 Electronic signatures must be authenticated. Typed or

stamped signatures are not acceptable.

A diagnosis can only be coded when it is

explicitly worded in the documentation. “rule

out”, “probable” or “consistent with”, cannot be

coded as actually having the disease.

Coding should be supported by documentation.

Diagnosis must be documented to the highest

level of specificity.

(“atherosclerosis of aorta” VS “atherosclerosis”)

Linkage between 2 different diagnoses should

be documented in the chart with words such as

“due to” “associated with” ,“secondary to” or

“with” (applies mostly to DM)

The terms “probable”, “more than likely” do not

provide linkage

History of”.. is the appropriate documentation in

the assessment only if the patient has been

cured. It means the patient no longer has the disease.


Medical decision making

Assessment (HCC diagnosis)

Status (new, stable, controlled, etc)

Plan


Listing of diagnoses is

not acceptable

VALIDATION AUDITS

1. Each year, CMS conducts Risk Adjustment Data

Validation (RADV) audits to determine if

submitted diagnoses are documented in the

medical record.

2. Health plans, hospitals and physician offices

must submit medical records that are requested

for audit.

3. Improperly documented diagnoses may result in

loss of reimbursement.

HCC

Team


Guided introductory

tour of HCC

By Dennis Tse, MD, CPC

2 sections of diagnoses

25 disease groups of diagnoses

70 categories of diagnoses

Over 3100 HCC diagnoses

7 disease groups have

subgroups

Itinerary of HCC Tour


• Psych—170 dx • CVD (Cerebrovascular disease) • Neuro---86 dx • Eye • Spinal • Heart • Vascular • Lung • Arrest • Liver • Gastrointestinal • Urinary • Musculoskeletal • Amputation • Skin • blood

Section 1- Organ Systems

H C

C

I’m Mr. Doe

You can stare

But don’t touch


Section 2- Conditions • Metabolic

• Diabetes-primary or secondary

• Infections -42 dx

• Substance abuse

• Transplant

• Opening

• Neoplasm

• Injury

• Complication


MD IS TONIC

H

C

C

N

a

v

i

g

a

t

o

r

Psych 54 Schizophrenia 0.478 60 dx

55 Major depressive , bipolar and paranoid disorder

0.322 110 dx

HCC– major depressive disorder, single episode 296.1x Recurrent major depression, recurrent episode 296.3x Non HCC diagnosis—depression NOS 311 dysthymic disorder 300.4

If multiple diagnosis are used within the group, only the highest HCC -RAF weight code will count

HCC

RAF

category


CVD (Cerebrovascular disease)

95 Cerebral hemorrhage--includes Subarachnoid

hemorrhage, extradural hemorrhage, subdural hemorrhage,

intracranial hemorrhage 0.296

• 96 Ischemic or unspecified stroke -- includes Occlusion of artery, cerebral thrombosis, CVA, and aborted

CVA 0.242

100 Hemiplegia/hemiparesis includes hemiplegia,

And late-effect hemiplegia 0.399

101 Cerebral palsy and other paralytic syndrome ---includes monoplegia, late-effect monoplegia and paralysis -nos 0.164

Diagnoses from different hierarchical tress are additive


Non HCC diagnosis (No risk adjustment)

TIA 354.9

muscle weakness 728.87,

Other late effects of CVD, apraxia---438.81

Other late effects of CVD, dysarthria---438.82

Other late effects of CVD, facial droop---

438.83


NEURO 70 Muscular dystrophy 0.361 3 dx

71 Polyneuropathy 0.299 47dx

Includes autonomic neuropathy alcoholic/diabetic/idiopathic and

polyneuropathy due to other drugs

72 Multiple sclerosis 0.547 5 dx

73 Parkinson’s and Huntington’s disease 0.540 4 dx

74 Seizure disorders and convulsions 0.244 22 dx

75 Coma, brain compressive/anoxic damage 0.379 5 dx


EYE

119 Proliferative diabetic retinopathy and

vitreous hemorrhage 0.230

Spinal

67 Quadriplegia, other extensive paralysis 0.923

68 Paraplegia 0.907

69 Spinal cord disorders/injuries 0.509

includes late effect of spinal cord injury, neurogenic bladder, cauda

equina and cerebellar ataxia


Heart 80 Congestive heart failure 0.374

81 Acute myocardial infarction 0.328

82 Unstable angina and other acute

ischemia heart disease 0.259

83 Angina pectoris/old myocardial infarction

0.223

92 Specified heart arrhythmia 0.269


HEART Category 80—CHF Systolic and diastolic heart failure , acute cor pulmonale, chronic pulmonary heart disease(pulm hypertension), pulmonary artery anurysm, myocarditis

Category 81-83-ischemic heart disease Acute MI of various locations to old MI, chordae tendinae/papillary muscle rupture,angina(controlled) Acute MI becomes “old MI” after 8 wks

Category 92—specific heart arrythmia AV block, PAT, PVT, Afib, Aflutter, sinoatrial node dysn (pacemaker patients)

Non-HCC CAD - 414.01 Cardiac dysrythmia -- 427.9


Vascular

104 Vascular disease with complications

0.557

105 Vascular disease 0.288


vascular disease with complications category 104

Arterial/vein Embolism/occlusion

Dissection of artery

Aneurysm with rupture

Acute vascular insuffciency of intestine

Renal vascular disorder

Gangrene

Gas gangrene

Various locations By CT ,Xray or UTZ


vascular disease category 105

Arterial ectasisa/atherosclerosis

Aneurysm without rupture

chronic vascular insuffciency of intestine

Acquire arteriovenous fistula

PVD (ABI or clinical dx)

Chronic and acute DVT

HCC- atherosclerosis of aorta 440.0

Non HCC unspecified atherosclerosis 440.9

Various locations By CT ,Xray or UTZ


Lung

107 Cystic fibrosis 0.364

108 COPD/emphysema/obstruct asth

0.364 (bronchitis does not risk adjust)

111 Aspiration and specified pneumonia 0.642

112 Pneumococcal pneumonia , empyema, lung abscess

0.227

ARREST

77 Respiratory dependence/tracheostomy status 1.704

78 Respiratory arrest 0.988

79 Cardio-respiratory failure and shock 0.528

Includes chronic respiratory failure and hypoxemia


Liver

25 End-stage liver disease 0.893

includes esophgeal varices, Hepatic encephalopathy,

Portal Hypertension, and hepatorenal, and other

Sequela of chonic liver disease(ascites, coagulopathy)

26 Cirrhosis of liver 0.371

Includes alcohol and nonalcoholic cirrhosis, and biliary cirrhosis

27 Chronic hepatitis 0.371

Includes hepatitis B/C ,autoimmune hepatitis and

NASH (Nonalcoholic steatohepatitis)

Do not write “Hepatitis B/C” or “carrier of hepatitis B/C”


Gastrointestinal

31 Intestinal obstruction/perforation 0.284

Includes peritonitis, stomach/duodenal perforation, fecal

impaction and ileus

32 Pancreatic disease 0.368

Include celiac disease, tropical spru and intest postop nonabsorb

33 Inflammatory bowel disease 0.220

Includes ulcerative colitis and crohn’s disease

Non- HCC Constipation, unspecified 564.00


Urinary

130 Dialysis status 1.232

131 Renal failure –including CKD

And Acute Renal Failure(AKI) 0.336

132 nephritis- including nephrotic

syndrome and glomerulonephritis 0.114

Non-HCC renal insufficiency 593.9

renal sclerosis 587

small kidney, unspecified 589.9

proteinuria 791.0


CKD STAGES

GFR Description

CKD Stage 1 > 90 Normal kidney

function but urine

findings or structural

abnormalities or

genetic trait point to

kidney disease

CKD Stage 2 60-89 Mildly reduced kidney

function, and other

findings

CKD Stage 3 30-59 Moderately reduced

kidney function

CKD Stage 4 15-29 Severely reduced

kidney function

CKD Stage 5 < 15 Very severely or end-

stage kidney failure

D.Tse

Musculoskeletal

37 Bone /joint/muscle infections/necrosis--

Including polio osteopathy pyogenic/bacterial/viral/dysenteric

Mycotic/helminth/infectious arthritis and chronic

And acute osteomyelitis and aseptic necrosis 0.488

38 Rheumatoid arthritis and inflammatory

connective tissue disease –includes polymyalgia

Rheumatica, sicca syndrome, polymyositis 0.316

Amputation(extremities)

177 Amputation status, lower limb/amputation

complications –must be documented q yr for CMS 0.619

Includes great toe, toes, foot, ankle, above/below knee, hip


Skin

148 Decubitus ulcer of skin –must document site and

stage stage 1.053

SITE---elbow, upper/lower back, hip, buttock, ankle, heel

Decubitus stages

Stage 1– non blanching erythema

Stage 2 -abrasion , blister, shallow crater, partial thickness skin loss

Stage 3- full thickness skin loss involving damages of necrosis into

subcutaneous soft tissue

Stage 4-full thickness loss with necrosis of soft tissue to the muscle, tendons

or bones

149 Chronic ulcer of skin of various locations, except

decubitus 0.410

150 Extensive third degree burns 1.293


Coding Corner 36

Stage I sacral pressure ulcer.

Diagnosis ICD-9 HCC

RAF

Pressure Ulcer Lower Back 707.03 1.053

Pressure Ulcer Stage I 707.21 1.053

Total HCC RAF 1.053

HCC diagnosis ICD-9

Atherosclerosis of extremity 440.20

Ulcer, lower limb 707.10

Non HCC diagnosis

Atherosclerosis

Open wound, bed sore, pressure sore

D.Tse

Blood

44 Severe hematologic disorders 0.927

Includes myelodysplastic syndrome, thalasemia, sickle cell

disease, hemolytic/aplastic anemia, pancytopenia and splenic

sequestration

45 Disorders of immunity 0.833

Includes neutropenia and hypogammaglobulinemia


Section 2- Conditions • Metabolic

• Diabetes-primary or secondary

• Infections -42 dx

• Substance abuse

• Transplant

• Opening

• Neoplasm

• Injury

• Complication


MD IS TONIC

Metabolic

21 Protein –calorie malnutrition 0.781

Many chronic and acute conditions that can result in malnutrition

include:

Cancer

Pancreatitis

Alcohol abuse and/or dependence

Liver Disease, Alcoholic hepatitis, cirrhosis

CHF, COPD

ESRD

Depression

Non HCC dx- failure to thrive


Diabetes –primary or secondary

15 Diabetes with renal or peripheral circulatory

manifestation 0.464

16 Diabetes with neurological or other specified

manifestation 0.372

17 Diabetes with acute complications 0.309

18 Diabetes with ophthalmic or unspecified

manifestations 0.236

19 Diabetes without complication 0.148

Linkage of diagnoses can be established in the chart with terms such as the specific

disease, “with”, “due to”, “associated with” or “secondary to” diabetes

The terms “probable, “more than likely” do not provide linkage All Rights Reserved D .Tse

Coding Corner 51 year old man with type II DM,well controlled on januvia

with elevated urine microalbumin/creatinine three months

apart CrCL of 65 cc/min

DM II with renal

manifestations

not stated

uncontrolled

250.40 0.464

CKD stage 2 585.2 0.336

Total HCC weight 0.800

DM II w/o

complications not

stated

uncontrolled

250.00 0.148

Proteinuria 791.0 0

Total HCC weight 0.148

Although only the highest diabetes with complication HCC weight will count,

the associated manifestations are additive All Rights Reserved D .Tse

Infection

1 HIV/AIDS 0.863 3 dx

2 Septicemia/septic shock 0.693 24 dx

5 Opportunistic infections 0.274 15 dx

Substance abuse

51 Drug/alcohol Psychosis 0.250

INCLUDES ALCHOHOL -WITHDRAWAL/SLEEP DISORDER/MENTAL DISORDER,

DELIRUM TREMEN

52 Drug/alcholol dependence 0.250

Includes opioid, seditive/hypnotic, cocaine, cannabis, amphetamine, and

hallucinogen


Transplant

174 Major organ transplant status 0.644

Includes heart, lung, liver, pancreas, intestine and bone marrow

transplant

Opening

176 Artificial openings for feeding or elimination

0.604

Includes gastrostomy, colostomy, ileostomy, enterostomy,

cystostomy, cutaneus-vesico status and urinostomy

Must reported every year


Neoplasm -primary or secondary

7 Metastatic cancer to various organs. acute leukemia with active disease or remission

2.078

8 Cancer of Lung upper digestive tract and

other severe cancers 0.961

Includes other leukemias in with active disease or remission

9 Lymphatic, head and neck, brain and other

major cancers 0.725

Includes M myelona and other leukemia with active disease or remission

10 Breast , prostate, colorectal and other

cancers and tumors 0.190

Includes benign neoplasm of brain, cranial nerve(acoustic neuroma), spinal cord, Pituitary, and pineal gland


Active malignancy diagnosis should continue until the patient has completed definitive treatment that includes surgery, chemotherapy and radiation therapy that is aimed at eradicating the malignancy

Patient who have completed therapy can only be given a “personal history of cancer” diagnosis, even if they are undergoing surveillance for re-occurrence of the malignancy

Patients who have not received definitive treatment for the their malignancy should continue to have an active malignancy diagnosis

Patients on adjuvant therapy (tamoxifen, lupron, casodex and 5-FU) are coded as if they have active disease. Eg-breast cancer, prostate cancer.

Patient who have completed therapy can only be coded with a “personal history of cancer” diagnosis code, even if they are undergoing surveillance for re-occurrence of the malignancy

ONCOLOGY

Injury

154 Severe head injury 0.379

155 Major head injury 0.097

Includes late effect of intracranial injury and skull/face fx

157 Vertebral fractures (open or close) without spinal

cord injury 0.404

158 Hip fracture/dislocation 0.392

161 Traumatic amputation 0.619


Complications

164 Major complications of medical care and trauma

0.270

Includes malfunction of various prosthesis, grafts, devices,

catheter. Think organ system and MD IS TONIC

CVD/Neuro, eye, heart, vascular, breast, GI, urinary,

musculoskeletal, skin, diabetes, injury

996.7x Complication of internal prosthetic device, implants

and graft—cardiac, renal, vascular, nervous system, GU

996.64 infection and inflammatory reaction due to

indwelling urinary catheter


DISEASE INTERACTION 48

Disease Interaction

Interaction Chronic Condition HCC RAF

1 DM/CHF# 0.154

2 DM/CVD 0.102

3 CHF/COPD 0.219

4 COPD/CVD/CAD 0.173

5 RF/CHF# 0.231

6 RF/CHF/DM# 0.477 # RF/CHF/DM is hierarchical to CHF and DM/CHF


HCC

Team


We have concluded the tour of HCC. Please exit the bus carefully and start the HCC

exercises.

Coding Exercise 50

A patient is seen with Insulin Dependent Type II Diabetes

and secondary progressive nephropathy that requires

Peritoneal dialysis.

Diagnosis ICD-9 HCC

Weight

Diabetes with renal manifestation, Type II 250.40 0.455*

ESRD requiring chronic dialysis 585.6 0.329

Dialysis Status V45.11 1.208 *

Long term use of insulin V58.67 0.148

TOTAL HCC RAF 1.663

* Diagnoses included for total RAF


Coding Excercise

51

A patient is seen with Insulin Dependent Type II Diabetes

and secondary progressive nephropathy that requires

Peritoneal dialysis. Co-morbidities of CHF and renal artery

atherosclerosis

Diagnosis ICD-9

HCC RAF

Diabetes with renal manifestation, Type II 250.40 0.455

ESRD requiring chronic dialysis 585.6 0.329

Dialysis Status V45.11 1.208

Long term use of insulin V58.67 0.148

Renal artery atherosclerosis 440.1 0.288

CHF 428.0 0.374

TOTAL HCC RAF 1.663 + 0.662 2.325


Case history Mr. Brown is a 56 year old male who came to request refills of pain

medication because of persistent back pain for a long time. He

takes 2 vicodins Bid for pain control for long time. Thoracic spine X-ray showed compression fracture at T-5 in the past.

He has had major depression since age of 40. He takes

medication for depression. He became disabled since he had

back surgery that lead to spinal cord injury and led him to have

paraplegia with neurogenic bladder and made him wheel chair

dependent. On further questioning, Mr. Brown admitted to have

history of cocaine dependence until 20 years ago. He was actually

admitted to detox unit to stop cocaine abuse. Patient has not used

cocaine since. Mr. Brown also developed a residual speech

impediment since he had a subdural hematoma 4 years after he fell out of the wheel chair


Physical exam VS BP 130/70 pulse 60 resp 20

HEENT- NC/AT

Neck- no adenopathy

Lungs—clear

Card– RRR

Abdomen—soft and nontender no HSM

Ext 2+ bilat d pedis no leg swelling

Neuro—pt not able to move legs

CN 2-12 intact pt noted to speak very slow and at

times speech is slight slurred. This is unchanged for long

time per patient


HCC-Assessment Cocaine dependence, in remission 0.250 52

Paraplegia 0.907 68

Neurogenic bladder (0.509) 69

Late effect of Spinal cord injury (0.509) 69

Late effect of intracranial injury 0.097 155

Major depressive disorder, recurrent 0.322 55

Fracture of thoracic vertebra 0.404 157

HCC RAF total- 1.980

Status and plan needed for every assessment (diagnosis)


dennis t tse, md, cpc - aapcstatic.aapc.com/a3c7c3fe-6fa1-4d67-8534-a3c9c8315... · 19 diabetes...

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