june 14, 2011 approval code: in361 ingenix insite provider user group

June 14, 2011

Approval Code: IN361

Ingenix InSite Provider User

Group

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Ingenix InSite User Group: Welcome

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Ingenix InSite User Group: Agenda

10:00 AM Welcome

10:03 AM InSite Operations Announcements

10:10 AM CMS County Rate Methodology Change

10:30 AM Documentation and Coding Focus On:

Skin Ulcers

10:55 AM Q & A

InSite Operations Announcements – UHG’s Health Services Re-Branding to Optum

Per 4/11/11 Ingenix press release, UnitedHealth Group announced “Optum” master brand for its Health Services Businesses

– OptumHealth™ will continue to be

– Ingenix™ is now

– Prescription Solutions™ is now

This brand unification is focused on making it easier for the broad health services marketplace to understand and access the company’s full range of capabilities that help participants throughout the health care system improve health, increase efficiency and create a better overall experience for consumers.

This change reflects increased coordination and collaboration among three leading health services companies that are committed to addressing meaningful and positive change across the health care system

InSite Operations Announcements

Presented By

Jerry Gauchat

InSite Operations Announcements – Data Refresh Update

Data Refresh Update

– Data refreshed June 6th– Next monthly data refresh is scheduled for July 5th

InSite Operations Announcements –Q2 2011 Release

Upcoming InSite Updates

– New HEDIS/STARS PAF Versions• No changes to PAF Management functionality

– Summary of Accepted HCCs (SOAH) Modifications• Modify query to access report more quickly• Upon export - HCC and description will match

– Systematic User Entitlement

– Changing default sort on Custom List to default to PCP Name

– Learning & Resources Tab • Adding April, May & June 2011 Ingenix Insiders• Removing all 2010 Ingenix Insiders• Removing 2010 ICD-9 Brochure• Updating RAF Calculator to include updated FFS Normalization value• Updating Chart Mechanics for Data Validation document• Adding Understanding & Coding Medicare Preventive Services document

InSite Operations Announcements –Q3 2011 Release (Sep/Oct 2011)

Planned* InSite Updates– Adding Rendering provider logic impacting

• Population Report• PAF• CSI / Problem List

– Adding new Health Plan Summary report• Prevalence by Plan PBP

– Adding HCC RAF to Group & Provider Summary Report– Adding plan filters to Management Problem List and Custom List– Adding logic to the report list screen to allow for re-accessing without

logging out

*Planned – not confirmed

CMS County Rate Methodology Changes

Presented By

Nick Chiechi

2012 Payment Year Changes

Health Care Reform Bill (Affordable Care Act) Introduced Changes Impacting Medicare Advantage CMS Payments For 2012 and Beyond

Changes Impact CMS Determination of County Rates and Calculation of Rebates

– Changes Were Made to Methodology and/or Associated Values Within Existing Methodologies

2012 County Rate Methodology

CMS Introduced a New Methodology For Determining County Rates

– New Methodology Will Be Phased in Over Two to Six Years (Varies By County)

• New Methodology: “Specified Amount”• Pre-2012 Methodology: “Applicable Amount”

– STARS Quality Bonus Prominently Impacts County Rates• STARS Impacts Both New and Pre-2012 Methodologies

Transition Periods For New Methodology

2012 County Rate is Blend of “Applicable Amount” and “Specified Amount”

– Plans <=2.5 Stars Capped at Pre-CA Value Applicable (old) and Specified (new) Amounts Are

Independently Calculated Blended Based on Transition Schedule

– Transition Schedule Will Vary By County• Based on a One-Time CMS Calculation Using the 2010

Applicable Amount

Transition Schedule

Applicable Specified Applicable Specified Applicable Specified2012 50% 50% 75% 25% 83% 17%2013 100% 50% 50% 67% 33%2014 100% 25% 75% 50% 50%2015 100% 100% 33% 67%2016 100% 100% 17% 83%2017 100% 100% 100%

Payment Year

Two Year Transition Four Year Transition Six Year Transition

Applicable Amount (Old Methodology)Overview

Greater of:– 2012 FFS Rate

- OR -

– 2011 Applicable Amount Adjusted For 2012 National Per Capita MA Growth Percentage

Greater Amount Then Reduced For IME Phase-out New Twist For 2012 and Beyond

– Applicable Amount Will Also Be Adjusted For Each Contract’s STARS Rating

Specified Amount (New Methodology)Overview

A Baseline Amount Is Calculated For Each County– FFS Rate Minus IME Phase-out Amount

For Each County, the Baseline Is Adjusted For the Following:

– “Applicable Percentage”• Based on Newly Designated Quartile

– STARS Quality Bonus Percentage

Specified Amount (New Methodology)Applicable Percentage

Baseline For Each County is Adjusted For A Applicable Percentage

Counties Were Ranked From Highest To Lowest Using Most Recent Rebased FFS Costs

– For 2012, 2009 FFS Costs Were Used

Quartile Applicable Percentage4th (Highest) 95%

3rd 100%2nd 107.5%

1st (Lowest) 115%

STARS Quality Bonus Percentage

Each Contract Achieves a STARS Rating Each Rating Translates To a Bonus Percentage To Be

Applied to Each County’s Calculated County Rate Bonus Is Applied to Both the Applicable Amount (Old

Methodology) and Specified Amount (New Methodology)– Applied Slightly Differently To Specified Amount vs. Applicable

Amount

STARS Quality Bonus Percentage

* Quality Bonus Percentages Will Be Doubled in “Qualifying” Counties– Qualifying County Determined Using 2012 FFS Rate and Size and Penetration

of MA Population

STARS RatingQuality Bonus Payment

Percentage

Less than 3 stars 0%3 stars 3%

3.5 stars 3.5%4 stars 4%

4.5 stars 4%5 stars 5%

Example

Los Angeles County – Quartile: 4– Transition Period: 4 Years– Qualifying County?: No

ABC Health Plan– STARS Rating: 3.5 Stars

Applicable Amount Calculation Example

2012 FFS Rate

Trended 2011 Applicable Amount

Greater of Two Above AmountsQuality Bonus Payment PercentageQuality Adjusted Applicable Amount

$853.34

$959.98

$959.983.5%$993.58

STARS RatingQuality Bonus Payment

Percentage




County Specifc (Not Contract Dependent)

Quartile Applicable Percentage

4th (Highest) 95%

3rd 100%

2nd 107.5%

1st (Lowest) 115%

Specified Amount Calculation Example

2012 FFS Rate

Applicable PercentageQuality Bonus Payment Percentage Quality Adjusted Applicable Percentage

Quality Adjusted Specified Amount

$853.34

95% 3.5% 98.5%

$840.54

Contract Specific (Not County Specifc)

STARS Rating

Quality Bonus Payment Percentage




Applicable Specified Quality Adjusted Amount $993.58 $840.54

2012 Blend % 75% 25%Blend Amount $745.19 $210.14

County Ratebook Amount $955.33

Blended County Ratebook Calculation Example

+

Applicable Specified Applicable Specified Applicable Specified2012 50% 50% 75% 25% 83% 17%2013 100% 50% 50% 67% 33%2014 100% 25% 75% 50% 50%2015 100% 100% 33% 67%2016 100% 100% 17% 83%2017 100% 100% 100%

Payment Year

Two Year Transition Four Year Transition Six Year Transition

Pro Forma Blending

Imperial County2012 2013 2014 2015 2016 2017

<=2.5 Stars $727 $699 $699 $699 $699 $6993.0 Stars $748 $718 $718 $718 $718 $7183.5 Stars $752 $721 $721 $721 $721 $7214.0 Stars $755 $724 $724 $724 $724 $7244.5 Stars $755 $724 $724 $724 $724 $7245 Stars $762 $731 $731 $731 $731 $731

Los Angeles County2012 2013 2014 2015 2016 2017


Monterey County2012 2013 2014 2015 2016 2017


* Pro Forma Example. Assumes Flat Trend For Applicable and Specified Amounts.

CMS RAF Payment Calc Rebates

Overarching Methodology and Application of Rebates is Likely Unchanged For 2012

Rebate % Amounts Are Materially Lower in 2012 and Beyond

Rebate as % of Savings

Rebate % Amounts Are Materially Lower in 2012 and Beyond– Three Year Phase-In of Revised Rebate %’s– Percentages Driven by Plan’s STARS Rating

STARS Rating 2011 and Prior 2012 2013 20144.5+ Stars 75% 73.33% 71.67% 70%

3.5 to 4.0 Stars 75% 71.67% 68.33% 60%< 3.5 Stars 75% 66.67% 58.33% 50%

Changes to Rebate %

Example

2011 2012 2013 2014Benchmark 900$ 900$ 900$ 900$ Bid 800$ 800$ 800$ 800$ Savings 100$ 100$ 100$ 100$

Rebate %

4.5+ Stars 75% 73.33% 71.67% 70%3.5 to 4.5 Stars 75% 70.00% 65.00% 60%< 3.5 Stars 75% 66.67% 58.33% 50%

Rebate Amount

4.5+ Stars 75$ 73$ 72$ 70$ 3.5 to 4.5 Stars 75$ 70$ 65$ 60$ < 3.5 Stars 75$ 67$ 58$ 50$

Documentation and Coding for Skin Ulcers

Presented by:

Mary Jo Groome, CCS-P, CPC-HSr. Training and Development Consultant

Diseases of the Skin and Subcutaneous Tissue

Category 707

Chronic Ulcer of Skin

707.0x Pressure ulcer

707.2x Pressure ulcer stages

707.1x Non-pressure ulcer

Pressure Ulcers – 707.0x

Documentation may identify synonymous terms for decubitus ulcers such as bed sores, plaster ulcer, pressure sore or pressure ulcer.

Documentation of pressure ulcer stage is integral to measurement of quality of care by providing a means by which coded records can be used as a part of internal and external health care quality improvement endeavors to promote prevention, healing and reduce the risk of pressure ulcers in the health care environment.

Pressure Ulcers – 707.0x

Two codes are needed to completely describe a pressure ulcer:

– Assign the appropriate code for the site of the ulcer from

subcategory 707.0 with an additional code from

subcategory 707.2 to specify the stage of the ulcer.

The pressure ulcer stage codes will only be used with ulcers

documented as “pressure” ulcers or “decubitus” and not with

other types of ulcers (e.g. stasis ulcers)

Coding Ulcers: Decubitus / Pressure By Site

Pressure Ulcer– Use additional code to identify pressure ulcer stage (707.20-707.25)

– 707.00 – Pressure Ulcer, unspecified site– 707.01 – Pressure Ulcer, elbow– 707.02 – Pressure Ulcer, upper back– 707.03 – Pressure Ulcer, lower back– 707.04 – Pressure Ulcer, hip– 707.05 – Pressure Ulcer, buttock– 707.06 – Pressure Ulcer, ankle– 707.07 – Pressure Ulcer, heel– 707.09 – Pressure Ulcer, other site

Coding Ulcers: Decubitus / Pressure By Stage

Pressure Ulcer Stages– Code first site of pressure ulcer (707.00-707.09)

– 707.20 Pressure ulcer, unspecified stage– 707.21 Pressure ulcer, stage l– 707.22 Pressure ulcer, stage II– 707.23 Pressure ulcer, stage lll– 707.24 Pressure ulcer, stage lV– 707.25 Pressure ulcer, unstageable

Note: It is important to code both the location and the stage (depth).

Pressure Ulcer Staging – 707.2x

707.2x Pressure Ulcer Stages (Code first site of pressure ulcer 707.00-707.09)

TIP: If a pressure ulcer progresses during an encounter from one stage to another, assign only the code for the higher stage; only pressure ulcers are staged.

– 707.20 Pressure ulcer, unspecified stage• Healing pressure ulcer NOS• Healing pressure ulcer, unspecified stage

– 707.21 Pressure ulcer stage I• Healing pressure ulcer, stage I• Pressure pre-ulcer skin changes limited to persistent focal erythema

– 707.22 Pressure ulcer stage II• Healing pressure ulcer, stage II• Pressure ulcer w abrasion, blister, partial thickness skin loss involving

epidermis and/or dermis

Pressure Ulcer Staging – 707.2x

707.2x Pressure Ulcer Stages

– 707.23 Pressure ulcer stage III• Healing pressure ulcer, stage III• Pressure ulcer with full thickness skin loss involving damage or

necrosis of subcutaneous tissue

– 707.24 Pressure ulcer stage IV• Healing pressure ulcer, stage IV• Pressure ulcer with necrosis of soft tissue through to underlying

muscle, tendon or bone

– 707.25 Pressure ulcer, unstageable• TIP: Assign only if ulcer is covered by eschar, has been treated with skin or

other graft, or is documented as a deep tissue injury but not documented as due to trauma.

Know the Difference

Code 707.20 Pressure ulcer, unspecified stage – Should be assigned when there is no documentation regarding

the stage of the pressure ulcer

Code 707.25 Pressure ulcer, unstageable– Should be used for pressure ulcers whose stage cannot be

clinically determined (e.g. the ulcer is covered with eschar or has been treated with a skin or muscle graft).

– Pressure ulcers that are documented as deep tissue injury but not documented as due to trauma.

Example

Non-surgical pressure ulcer located on left heel measuring about 2.5cm. Unable to classify (stage) because of area of black tissue (necrosis) on 100% of ulcer base. Surrounding tissue has bruising extending about 1.5cm out towards the toes. Tenderness noted when bruised area is touched.

Coding Scenario – Pressure Ulcer

A patient is seen for treatment of Stage II healing pressure ulcer of the left buttock.

– Code assignment • 707.05 Pressure ulcer, buttock• 707.22 Pressure ulcer stage II

Coding Scenario – Pressure Ulcer

An elderly patient is being seen in an extended care facility for treatment of a stage III pressure ulcer of the heel. The NP also identifies the patient as a Type I diabetic with related progressive PVD.

– Code assignment:

• 707.07 Pressure ulcer, heel• 707.23 Pressure ulcer, stage III• 250.71 DM w peripheral circulatory disorders, Type I, unspec• 443.81 Peripheral angiopathy in diseases classified elsewhere

Examples

Unfortunately, some patients may suffer from more than one pressure ulcer, and these ulcers may be at the same or different sites and stages. Here are some examples of documentation and coding:

– Pressure ulcer both buttocks, both stage II• 707.05 (buttock) and 707.22 (stage II)

– Pressure ulcer both buttocks, one stage II and one stage III• 707.05 (buttock), 707.22 (stage II) and 707.23 (stage III)

– Pressure ulcer of left buttock and left elbow both stage II• 707.05 (buttock), 707.01 (elbow) and 707.22 (stage II)

– Admitted with stage II pressure ulcer of buttocks, which advanced to stage III during encounter

• 707.05 (buttock) and 707.23 (stage III)

Pressure Ulcer Example

Recurrent Decubitus Ulcer with Failed Graft:

– A recurrent pressure ulcer that has had a failed graft(s) is reported with 996.52 Mechanical complication of device implant or graft and a code from the 707.0 subcategory

Look up:

Complications

graft

skin

infection or inflammation 996.69

rejection 996.52

Pressure Ulcers

Care should be taken to distinguish between:

– pressure ulcers documented as “healed” (no code assigned)– and “healing” (assign the appropriate code for the site and the

stage documented).

Diseases of the Skin and Subcutaneous Tissue

Category 707

Chronic Ulcer of Skin

707.1x Non-pressure ulcer

707.1 Ulcer of Lower Limb, except pressure ulcer

707.1x Ulcer of lower limbs, except pressure ulcer– Ulcer, chronic

• Neurogenic• Trophic

Causal condition…code first:

atherosclerosis of the extremities w ulceration (440.23 + ulcer code)

diabetes mellitus (250.80-250.83/249.80-249.83 + ulcer code)

Coding Ulcers: Chronic, Ischemic, Lower Extremity

Subcategory 707.1x Ulcer of lower limbs, exceptpressure ulcer

▪ First: Code any underlying or causal conditionExample:

- 440.23 – Atherosclerosis of Extremities w/ Ulceration

- 250.8x – Diabetes w/ Other Chronic Manifestations

▪ Second: Code associative ulcers to the highest level of specificity Example:

• 707.10 – Ulcer of lower limb, unspecified• 707.11 – Ulcer of thigh• 707.12 – Ulcer of calf• 707.13 – Ulcer of ankle• 707.14 – Ulcer of heel and midfoot• 707.15 – Ulcer of other part of foot• 707.19 – Ulcer of other part of lower limb

Chronic ulcer of unspecified site – 707.9

Varicose ulcer (lower extremity, any part) – 454.0

707.1x Ulcer of lower limbs, except pressure ulcer

If ulceration is associated with arteriosclerosis of the extremities code:

– 440.23, Atherosclerosis of the extremities with ulceration– Additional code from 707.10-707.19 (non-pressure ulcer)

– 707.10 Ulcer of lower limb, unspecified– 707.11 Ulcer of thigh– 707.12 Ulcer of calf– 707.13 Ulcer of ankle– 707.14 Ulcer of heel and midfoot– 707.15 Ulcer of other part of foot

– Toes– 707.19 Ulcer of other part of lower limb

Nursing Facility Example

Case 3

89 yo female with hx of PVD,Hypertensive Heart Disease

Vascular PE: Bilat severe rubor noted. R ankle noted to have ulcer to lateral malleolus. Ulcer improved from last assessment. Continues 1 cm diameter open area with slight area of redness around ulcer. Redness has improved from last week.

Diagnosis 440.23 Atherosclerosis of native arteries of the extremities with ulceration

Chronic: Pt with obvious PVD. Ulcer to R outer malleolous to be treated with Bactroban and covered with window dressing to let wnd breath. Staff states wnd is improving. Continue to monitor progress of wnd and staff to inform NP/PCP of any increased drainage, redness, heat to area.

Documentation & Coding PAD / PVD

A condition potentially related to PAD is

atherosclerosis.

– Atherosclerosis of native arteries of the extremities is classified to code 440.2x. A fifth-digit subclassification is required to differentiate the type of atherosclerosis as follows:

Atherosclerosis of the extremities,» With ulceration 440.23Use additional code for any associated ulceration (707.10-707.9)

» With gangrene 440.24Use additional code for any associated ulceration (707.10-707.9)

707.1x Ulcer of lower limbs, except pressure ulcer

The underlying cause of foot ulcers in a diabetic patient may be diabetic neuropathy (250.6x), diabetic peripheral vascular disease (250.7x) or “other specified diabetic ” (250.8x) depending on documentation.

e.g. Patient has diabetic neuropathy and an associated ulcer of the left great toe.

– Codes 250.60, 357.2 and 707.15

e.g. Patient’s diabetic PVD has resulted in an ulcer of the right midfoot.– Codes 250.70, 443.81 and 707.14

e.g. Patient has a diabetic ulcer of the left ankle– Codes 250.80 and 707.13

Be Specific

▪ Wound Care

Do not choose the word “open wound” or “lesion” in your documentation if you really mean “pressure” or other forms of non-healing ulcers.

● Wound – open (by cutting or piercing instrument)(by firearms) (cut) (dissection) (incised) (laceration) (penetration) (perforating) (puncture) (with initial hemorrhage, not internal) ICD-9 notation

● Ulcer, Ulceration – a local defect/excavation of the surface of an organ or tissue produced by sloughing of necrotic inflammatory tissue

● Pressure Ulcer – bed sore, plaster ulcer, decubitus ulcer

Be Specific

▪ Wound Care for the Leg

– The chart documentation and choice of words determines the coding:

Open WoundKnee, leg (except thigh)

ankle

Ulcer Pressure Ulcer(code Stage also)

891.0 w/o comp. 707.10 lower, unsp 707.01 elbow

891.1 complicated 707.11 thigh 707.02 upper back

891.2 w/ tendon involvement

707.12 calf 707.03 lower back

707.13 ankle 707.04 hip

707.14 heel/midfoot 707.05 buttock

707.15 other part of foot (toes)

707.06 ankle

707.19 other part of lower limb

707.07 heel707.09 other site

Documentation Makes the Difference

1. Patient’s ulcer appears to be healing. 707.9

2. Patient’s pressure ulcer appears to be healing. 707.00, 707.20

3. Patient’s stage III decubitus ulcer appears to healing. 707.00, 707.23

4. Patient’s decubitus stage II heel ulcer appears to be healing. 707.07, 707.22

5. The patient’s open wound on the left heel appears to be healing. 892.0

6. Physical exam reveals varicosities on the right lower leg that have ulcerated. 454.0

7. Varicose veins with ulceration and hemorrhage. 454.0

8. The patient’s left heel ulcer has healed nicely. No code

Sample Documentation

History states: “PVD with ulcers” Exam states: “SKIN: Current Status: Bilateral ace wraps to legs in

place.” “CARDIOVASCULAR: BASELINE: Regularly irregular rhythm. S1, S2. No M/C/R. 2+ BLE nonpitting edema. No JVD. Ace wraps BLE. Current Status: RRR S1 S2. No murmur.”

Diagnosis : 443.9 - Unspecified peripheral vascular disease Treatment Plan : PVD is most likely secondary to long history of HTN and CAD. Continue with supportive care of chronic wounds and edema management. Consult wound nurse with AMT prn. Recurrence of wounds expected. Continue with podiatry care.

Diagnosis : 707.10 - Ulcer of lower limb, unspecified

Medications : Zinc Sulfate; Treatment Plan : refer to 443.9 Comments: This represents correct coding for the PVD and ulcers based on the documentation. We cannot

code the causal condition when it is documented as “most likely secondary to”.

– If the documentation had stated “PVD is secondary to long history of HTN and CAD”, we would code 401.9 (HTN), 414.00 (CAD) and 443.81 (peripheral angiopathy in diseases classified elsewhere).

– If the documentation had stated ulcer due to arteriosclerosis or arteriosclerotic ulcer, we would code 440.23 (atherosclerosis of the native arteries of the extremities with ulceration) and 707.10.


His R foot has a 2.5 cm x 1.2 ulceration weeping sero-sanguinous drainage after podiatry debrided 2 days ago.

Comments: Because we do not know the type of the ulcer, we can only code by site 707.15 – Ulcer of other part of foot.


History states: “Skin: Decubitus ulcer, 2007” Exam states: “Skin:…. Decubitus ulcer to sacrum/buttocks,

followed by treatment nurse.” Treatment plan states: “…, resident with coccyx/sacral ulcer,

open area from hospitalization in July, exact measurements in wound care nurses records.”

Diagnosis: does not mention ulcer

Comments: – Code 707.03 – Pressure ulcer, sacrum – and code 707.05 – Pressure

ulcer, buttock – should be added to reported diagnoses. – We are unable to code the specific stage of the ulcer due to lack of

documentation, so we would code also 707.20 – Pressure ulcer, unspecified stage.

Coding Ulcers: A Summary

Pressure ulcer documentation needs to address the site (707.0x) of the pressure ulcer and the stage (707.2x). Both risk adjust but are bundled into each other (HCC 148).

If documentation indicates a “healed” ulcer, no code is assigned. A “healing” ulcer is coded to the correct category.

Non-pressure ulcers of the lower limb code to subclassification 707.1x.

If the ulcer is due to a causal condition such as diabetes or atherosclerosis, the causal condition is coded first.

Coding Ulcers: A Summary

Based on Causal Condition:

Arteriosclerosis of extremities with ulceration – 440.23– Use additional code for any associated ulceration (707.10 –

707.9)

Diabetic ulcer – 250.8x, 707.9– Specify site and code specifically to site: 250.8x, (707.10 –

707.9)– If provider documents diabetic ulcer as a neurologic

manifestation or a peripheral circulatory manifestation, code to 250.6x or 250.7x respectively

Varicose ulcer (lower extremity, any part) – 454.0

For More Information…

Revised Future Documentation & Coding Topics

July – no meeting August – Venous Thrombosis September – Major Depression October – Peripheral Artery Disease November – Cirrhosis December - COPD

june 14, 2011 approval code: in361 ingenix insite provider user group

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