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SCIENCE OF

DOCUMENTATION AND

CODING

MEDICARE RISK ADJUSTMENT

HCC

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INTRODUCTION

• Medicare Risk

Adjustment/HCC

• Documenting and choosing

the correct diagnosis code

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VOCABULARY

• ICD-9-CM – International Classification

of Diseases 9th Revision (Diagnosis

Codes)

• HCC – Hierarchical Condition

Categories

• CMS – Centers for Medicare and

Medicaid Services

• Blue codes = HCC

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MEDICARE RISK ADJUSTMENT

• Prior to 2003 payments made to the health plan were based solely

on demographics

• Change in payment methodology mandated by the Balance

Budget Act of 1997 – MRA was implemented in 2003

• Between 2003 and 2007 phase in project and since 2007 payment

is based 100% based on a set of acute and chronic diagnosis

codes (HCC’s)

• Risk Adjustment pays more accurately for the predicted health

cost expenditures by adjusting payments based on health status

as well as demographics

• Accurate chart documentation and diagnosis reporting determines

reimbursement!

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MRA PAYMENTS

• Payment is made to Medicare Advantage Health

Plans (not individual providers)

• Per HCC category (not per diagnosis code)

• The payments mentioned in the presentation are

based on the patient being enrolled with the health

plan for 12 continuous months

• No matter how many times in the year the diagnosis

codes is reported it is just one payment

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MEDICARE RISK ADJUSTMENT

• Approximately 70 Hierarchical Condition

Categories (HCC’S)

• Approximately 3600 Diagnosis codes within

these categories

• Mostly chronic but some acute codes

• Provider must see the patient once a year at

a minimum and document how they are

treating, managing or assessing the chronic

problems

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S O A P NOTE

• Subjective: Documents the CC, HPI and ROS, PFSH (History)

• Objective: Documents the vitals, physical examination and results of diagnostic tests (Examination)

• Assessment: Documents physician’s determination of the patient’s condition based on information in the S&O (MDM)

• Plan: Documents plan of care (MDM)

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CHOOSING A DIAGNOSIS

CODE• A joint effort between the health care

provider and the coder is essential to achieve

complete and accurate documentation, code

assignment, and reporting of diagnoses and

procedures.

• Annual code changes are implemented by

the government and are effective Oct 1 of

every year and valid through Sept 30 of the

following year.

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THINK OUT OF THE BOX!

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CHRONIC KIDNEY DISEASE

(CKD)

Code 585, chronic kidney disease, has four digits. The fourth digit indicates the stage

– CKD 1 & 2 need additional evidence of kidney damage such as urine abnormality, ultrasound or biopsy

• 585.1 CKD Stage I (GFR >90 + evidence of kidney damage)

• 585.2 CKD Stage II (mild) (GFR 60-89 + evidence of kidney damage)

• 585.3 CKD Stage III (moderate)(GFR 30-59)

• 585.4 CKD Stage IV (severe)(GFR 15-29)

• 585.5 CKD Stage V (End Stage but not on Dialysis) (GFR < 15)

• 585.6 ESRD (on Dialysis)

• 585.9 CKD unspecified

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ESRD – BUDDY CODE

• When a patient is on dialysis it requires two codes

– 585.6 ESRD $2870

– V45.11 Renal Dialysis Status $10,522

• ESRD on Hemodialysis due to Diabetes

– 250.40 Diabetes w/ renal manifestations

– 585.6 CKD stage VI (ESRD)

– V45.11 Renal Dialysis Status

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CKD and HTN Multiple Coding

Technique• Chronic Kidney Disease and Hypertension

– IT IS an assumed cause-and-effect relationship between CKD and Hypertension 585.X and 403.90 (not 401.9)

– Even though the description for 403.90 is “Hypertensive Chronic Kidney Disease”….you must also code the Chronic Kidney Disease 585.X

– Hypertensive CKD Stage 4 403.90 and 585.4

– 1. CKD Stage 4 585.4

– 2. HTN 403.90

– 1. CKD Stage 6 (ESRD on Dialysis) 585.6 and V45.11

– 2. HTN 403.91

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CHF and HTN Multiple Coding

Technique• CHF AND HYPERTENSION

– IT IS NOT an assumed cause-and-effect relationship between CHF and Hypertension 428.0 and 401.9

– If the patient has both conditions and you consider the heart failure due to the hypertension then documentation needs to state:

• Hypertensive CHF 402.91 and 428.0

• Hypertensive Heart Failure 402.91 and 428.0

• Hypertension with CHF 402.91 and 428.0

• Heart Failure due to Hypertension 402.91 and 428.9

– *Hypertensive Heart Failure with CKD 404.91, 428.0, 585.9

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DIABETES MELLITUS

• Code 250, Diabetes Mellitus, has five digits which describe w or w/o

complication and Type I or II not stated as uncontrolled or uncontrolled

• Example 250.00 Diabetes Mellitus Type II w/o complication not stated

as uncontrolled or 250.01 Diabetes Mellitus Type I w/o complication

not stated as uncontrolled

• New code for Secondary Diabetes effective October 2008

– Secondary Diabetes 249.00 (Diabetes due to, in, secondary, or

with drug-induced or chemical induced infection)

• According to coding guidelines, the use of insulin in a diabetic patient

has no bearing on which type the patient has

– Type I is Juvenile onset

– Type II is Adult onset

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DIABETES MELLITUS• Explanation of fifth digit

– 250.00 adult onset (type II), not stated as uncontrolled

– 250.02 adult onset (type II), uncontrolled

• Must state in the documentation, uncontrolled or out of control in order to code a 2.

• Poorly controlled or suboptimal control or high glucose reading is not considered uncontrolled so it would be 0.

– 250.01 juvenile onset (type I), not stated as uncontrolled

– 250.03 juvenile onset (type I), uncontrolled

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DIABETES MELLITUS• Explanation of fourth digit:

– 250.00 no complication

– 250.10 ketoacidosis

– 250.20 hyperosmolarity

– 250.30 coma

– 250.40 renal manifestations

– 250.50 ophthalmological manifestation

– 250.60 neurological manifestation

– 250.70 peripheral circulatory disorders

– 250.80 other specified manifestations

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DIABETES WITH MANIFESTATION

– BUDDY CODE

• Use multiple coding techniques “buddy code” for compound

diagnoses

• Diabetes with a manifestation (complication) requires that you

document and code the manifestations as well

– Peripheral Neuropathy due to DM

• 250.60 Diabetes with neurological manifestations

• 357.2 Peripheral Neuropathy in DM

– PVD due to DM

• 250.70 Diabetes with peripheral circulatory disorders

• 443.81 PVD in other diseases

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DIABETES WITH

MANIFESTATION

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DIABETES WITH

MANIFESTATION

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DIABETES WITH

MANIFESTATION• If your patient has diabetes and one of the many complications, make

sure and document the diabetes with the complications throughout

your SOAP note and in your assessment using one of the following

three acceptable ways

– Due to Diabetes or DM

– Secondary to Diabetes or DM

– Diabetic

• Appropriate examples

• Peripheral Neuropathy due to Diabetes

• CKD stage 3 secondary to Diabetes

• Microalbuminuria due to DM

• PVD secondary to DM

• Diabetic Ulcer

• Diabetic Retinopathy

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DIABETES MULTIPLE CODING

TECHNIQUE • Coders are not allowed to assume a cause-and-effect relationship

• If you document like this:

– Assessment

• 1. DM 250.00 $1263

• 2. Peripheral Neuropathy 356.9

• 3. CKD Stage 3 585.3

• These will be coded separately and the highest HCC code will be missed.

• If you document like this, then highest HCC will be captured:

– 1. Diabetic Peripheral Neuropathy 250.60 and 357.2

– 2. CKD Stage 3 due to Diabetes 250.40 $3962 and 585.3

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ULCERS VS WOUNDS• Ulcers vs Wounds

– Ulcers are HCC’s 707.XX – 707.9

– Wounds are not HCC’s 870.X – 897.X

• Providers frequently use the terms ulcer and wound synonymously in describing certain “lesions” on the skin.

– The term “wound” should be used to document traumatic conditions such as an avulsion, cut, laceration or a surgical wound

– The term “ulcer” should be used to document an area of breakdown in the skin. (i.e. Diabetic Ulcerations, Venous Stasis Ulcers)

– It is possible for a condition that started out as a traumatic injury to progress into a ulceration. (Diabetic patients w/ PVD)

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ULCERS• Two types of ulcers,

– a non-pressure or chronic ulcer 707.1X $3502

– decubitus or pressure ulcer 707.0X $8993

• Pressure ulcer (Decubitus) is a higher HCC than a non Pressure ulcer

so important to document correctly

• Pressure ulcers generally can be staged I thru IV

• Two codes are required (buddy code), one for the ulcer and one for

the stage

• Example: Stage 1 Pressure Ulcer Sacrum 707.03 and 707.21

• If you document Diabetic Ulcer on the calf

– 250.80 Diabetes with other specified manifestations

– 707.12 Ulcer of the calf

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COMMONLY MISCODED

DIAGNOSES• CVA – Acute condition that can only be documented and coded during

the initial episode of care – 434.91

– Once the patient is discharged from the hospital, documentation should reflect a past history of CVA such as H/O CVA, Old CVA, S/P CVA – V12.54

– UNLESS THEY HAVE A LATE EFFECT!

• Late effects of CVA if any should be documented and coded as such:

– 438.20 CVA w/hemiplegia/hemiparesis

– 438.82 CVA w/dysphagia

• The following documentation is not acceptable to indicate Hemiparesis

as a result of a CVA

– CVA with weakness

– CVA with R or L sided weakness

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MYOCARDIAL INFARCTION

• Myocardial infarction “MI”- Acute condition that can only be documented and coded as acute during initial episode of care or with a stated duration of 8 weeks or less – 410.90

• If patient had an MI and it is over 8 weeks old then document and code “Old MI”, “S/P MI” or “H/O MI”- 412

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COMMONLY MISCODED

DIAGNOSES

• Arteriosclerosis of the Aorta – Stricture and reduced elasticity of

artery; due to plaque deposits – 440.0

• Pathologic Fracture of the Vertebrae – Fracture due to bone

structure weakening by pathological processes (e.g., osteoporosis,

neoplasm's) – 733.13

– This is not the same as a Compression Fracture of the

Vertebrae, unless it is specified as Non-Traumatic

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PACEMAKER WITH SSS OR

COMPLETE AV BLOCK

• If the patient has had a pacemaker implant then

you do not code the sick sinus syndrome or

complete AV block

• It can and should be documented as

– S/P pacemaker for SSS

– Pacemaker for complete AV block

• You would code V45.01 Pacemaker Status only

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COMMONLY MISCODED

EVENTS

• Cancer – “When a primary malignancy has been previously excised or eradicated from its site and there is no further treatment directed to that site and there is no evidence of any existing primary malignancy, a code from category V10 Personal History of malignant neoplasm, should be used to indicate the former site of the malignancy. Any mention of extension, invasion, or metastasis to another site is coded as a secondary malignant neoplasm to that site.”

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COMMONLY MISCODED

DIAGNOSESTreatment to the site is considered:

Chemotherapy, Radiation or Adjunct therapy

(Considered current cancer if patient elects to not have treatment)

• Breast CA – on Tamoxifan, Arimidex, Femara etc. would be considered adjunct therapy and coded and documented as current –174.9

– Documentation needs to say “Breast Ca on Tamoxifan” if not then H/O Breast Cancer V10.3

• Prostate Ca – on Lupron, Casodex or Zoladex, would be coded and documented as current – 185

– Documentation needs to state “Prostate Ca on Lupron” if not then H/O Prostate Cancer V10.46

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METASTATIC CANCER

• Mets is the highest HCC if you document the site of the metastases!

$17,753

– Breast Cancer on Arimidex with Mets to liver 174.9 and 197.7

– Prostate Cancer on Lupron with bone Mets 185 and 198.5

– H/O Colon Cancer with Mets to the liver V10.05 and 197.7

– If you document like this highest HCC will be missed

• Metastatic Breast Cancer $1622 174.9 and 199.1

• Metastatic Colon Cancer (if colon cancer is under current

treatment) 153.9 and 199.1

• Lung Cancer with Mets (if lung cancer is under current

treatment) 162.9 and 199.1

• H/O Lung Cancer with Mets $1622 V10.11 and 199.1

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ALCOHOL AND DRUG

DEPENDENCE• Alcohol Dependence (Addiction) or Chronic Alcoholism or Alcoholism in

remission 303.90 or 303.93

• This chronic condition is identified by the patient who is unable to cease alcohol use even with detriments to health, social interactions and job performance. These patients generally experience physical signs of withdrawal with any sudden cessation of drinking.

• Drug Dependence (Addiction) or Drug Dependence in remission 304.90 or 304.93

– This chronic mental and physical condition is related to the pattern of the patient’s drug or drug combination intake and is characterized by behavioral and physiological reactions. These reactions are the obsession to take the drug, the need to have the feeling of its psychic effects or the attempt to avoid the discomfort of abstinence. Any sudden cessation typically triggers physical signs of withdrawal. (opiate, anxiolytic, sedative, hypnotic, hallucinogen or amphetamine)

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ALCOHOL AND DRUG ABUSE• Alcohol Abuse 305.0X

– Patients who have been identified as having alcohol abuse

represent those who have developed a problem with drinking,

including those that drink alcohol in excess but have not arrived at

a stage of physical dependency.

• Drug Abuse 305.XX

– Drug abuse includes cases where the individual, for whom no

other diagnosis is possible, has come under medical care because

of the maladaptive effect of a drug on which the patient is not

dependent. In nondependent abuse of drugs, the individual

generally has taken the drug on personal initiative to the detriment

of health or social functioning.

– Patients who have been identified as drug abusers have

developed a problem with drugs including those that take an

excess of drugs but have not arrived at a stage of physical

dependency.

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MALNUTRITION

• Malnutrition 263.X

– Undercoded in the elderly

• Commonly used indicators:

– Albumin < 3.4

– 10% unintentional weight loss in 6-12 months

– 5% unintentional weight loss in 3-6 months

– BMI < 18.5, especially with co-morbidity

– Marked reduction in physical capacity

– Wasting appearance or muscle wasting

– Poor nutrition or loss of appetite or seriously

curtailed food intake

– Cachexia 799.4

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DEEP VEIN THROMBOSIS

• Acute DVT (Initial episode of care)

– 453.40

• Chronic DVT (On an anti-coagulant)

– 453.50

• H/O DVT (No anti-coagulant)

– V12.51

• Need to document “Chronic DVT” if pt is on anti-

coagulant therapy

• Same guidelines for Pulmonary Embolism

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MAJOR DEPRESSION

• Major Depression 296.XX

• Criteria to diagnose Major Depression

– PHQ9 Score > 10

– 5 of 9 DSM IV Criteria• SIGECAPS (sleep, interest, guilt, energy, concentration,

appetite, psychomotor changes and suicidal ideation, plus a depressed mood)

– Other recognized depression screening tool

– “Depression” (Situational, Grief)

311 is not an HCC!

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COMMON OMISSIONS

• Artificial Openings

– Gastrostomy V44.1

– Colostomy V44.3

– Tracheostomy V44.0

– Ileostomy V44.2

• Amputations

– BKA V49.75

– AKA V49.76

– Foot V49.73

– Toe V49.71 or V49.72

• AAA – Abdominal Aortic Aneurysm 441.4 (w/o repair)

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DOCUMENTATION TIPS FOR

ACCURATE CODING

Don’t document “history of” ANY disease that currently exists. The statement “history of” in ICD-9 terms means that the patient no longer has this condition. However, “history of” is ok when documenting some status conditions such as an Amputation.

Incorrect Correct

H/O CHF (meds Lasix) Compensated CHF stable on Lasix

H/O Angina (meds nitroquick) Angina stable on Nitro

H/O COPD (meds Advair) COPD controlled w/Advair

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CRITICAL SUCCESS FACTORS –

CODING GUIDELINES

• Completely assess the patient’s health status and

properly document all conditions

• Fully assess all chronic conditions every 6 months

• Accurately document in the medical record all

conditions evaluated during each visit

• Codes marked on the encounter form or reported in

EMR note must be fully supported in the chart note

for the visit

• Document and code to the highest level of specificity

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CRITICAL SUCCESS FACTORS –

CODING GUIDELINES

• A medical record entry must

– Be legible

– Support all diagnoses coded

– Be complete and accurate

– Have a provider signature and credentials

– Identify the patient and date of service

– Document the patient’s progress and results of treatment

– Justify the treatment and level of care

– Use only standard abbreviations and keep them to a minimum

– Promote continuity of care among the healthcare providers

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TMA – TREAT, MANAGE OR ACCESS

• In order for CMS to make the payment, documentation must be from a face to face visit and you must indicate how you are treating, managing or assessing the chronic conditions

• Each diagnosis must have an assessment and a plan

– Sample Language

• Assessment Plan

• Stable Monitor

• Improved D/C med

• Tolerating Meds Continue current meds

• Deteriorating Refer

– Example: Hypertensive CKD 3, stable well controlled. Continue meds

– Example: COPD, stable on Advair

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STRIVE FOR DUCT TAPE NOTES NOT

SCOTCH TAPE NOTES

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DOCUMENTING THE CORRECT

DIAGNOSIS

DON’T REPORT THIS IF THE PATIENT REALLY HAS

(Does Not Risk Adjust) (Does Risk Adjust)

311 Depression 296.XX Major Depression

493.90 Asthma 493.20 Chronic Obstructive Asthma

496 COPD / 492.8 Emphysema

490 Bronchitis 491.9 Chronic Bronchitis

414.01 CAD 413.9 Angina, 411.1 Unstable Angina

412 Old MI

427.89 Cardiac Dysrhythmia 427.31 AFib / 427.32 AFlutter

805.8 Fracture of Vertebrae

(Initial episode of care) 733.13 Pathological FX of Vertebra

577.0 Pancreatitis 577.1 Chronic Pancreatitis

070.70 Hepatitis C 070.54 Chronic Hepatitis C

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CRITICAL SUCCESS FACTORS –

CODING GUIDELINES

• “Probable”, “suspected”, “questionable”,

“R/O”, “versus”, “working diagnosis”, “?”,

“likely” etc cannot be coded!

• Code the condition to the highest degree of

certainty for that encounter/visit, such as

symptoms, signs, abnormal test results, or

other reason for the visit.

• “Resolved” or “Healed” cannot be coded.

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TOP 10 HCC GROUPS• 1. COPD

– 496 COPD

– 493.20 Asthma w/Chronic COPD

– 491.9 Chronic Bronchitis

– 492.8 Emphysema

• 2. CHF

– 428.0 CHF

– 425.4 Primary Cardiomyopathy (Ischemic is not an HCC)

– 402.91 Hypertensive Heart Disease w/Heart Failure

• 3. VASCULAR DISEASE

– 443.9 Peripheral Vascular Disease

– 443.81 PVD in other diseases (diabetes)

– 453.40 Acute DVT

– 453.50 Chronic DVT

– 440.0 Atherosclerosis of Aorta

– 441.4 Abdominal Aortic Aneurysm

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TOP 10 HCC GROUPS

• 4. CANCER

– All malignant neoplasm's including Melanoma but not skin cancer

– All secondary malignant neoplasm's

• Highest HCC if site is documented

• 5. SPECIFIED HEART ARRHYTHMIA

– 426.0 Complete AV Block

– 427.31 Atrial Fibrillation

– 427.81 Sick Sinus Syndrome

• 6. DIABETES

– All Diabetes (250.XX) and most of the manifestations

• 7. ISCHEMIC OR UNSPECIFIED STROKE

– 436 CVA

– 434.91 Unspecified Cerebral Artery Occlusion, w/infarction

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TOP 10 HCC GROUPS

• 8. ANGINA/OLD MI

– 413.9 Angina

– 412 OLD MI

• 9. RHEUMATOID ARTHRITIS & INFLAMMATORY CONNECTIVE

TISSUE DISEASE

– 714.0 Rheumatoid Arthritis

– 710.0 Systemic Lupus Erythematosus

– 725 Polymyalgia Rheumatica

– 720.2 Sacroiliitis

• 10. ISCHEMIC HEART DISEASE

– 411.1 Unstable Angina

– 410.91 Acute Myocardial Infarction

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OTHER COMMON HCC

DIAGNOSIS CODES– 340 Multiple Sclerosis

– 332.0 Parkinson's

– 345.90 Seizure Disorder

– 362.02 Proliferative Diabetic Retinopathy

– 344.1 Paraplegia

– 344.00 Quadriplegia

– 042 HIV

– 571.5 Liver Cirrhosis without mention of alcohol

– 555.9 Crohn’s Disease

– 359.1 Muscular Dystrophy

– 340 Multiple Sclerosis

– 343.9 Cerebral Palsy

– 277.00 Cystic Fibrosis

– Transplants – Heart, Liver, Lung, Pancreas, Intestines, Bone Marrow, Stem Cell

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Common Synonyms

• PVD (Peripheral Vascular Disease) = Peripheral Angiopathy = PAD (Peripheral Artery Disease) = Claudication = 443.9

• Polyneuropathy = Peripheral Neuropathy = 356.9

• Major Depression = Depressive Psychosis = 296.20

• Parkinson’s = Paralysis Agitans = 332.0

• Unstable Angina = Intermittent Coronary Syndrome = 441.1

• Sick Sinus Syndrome (SSS) = Sinoatrial Node Dysfunction = Chronic Sinus Bradycardia = 427.81

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ACUTE CODES

• Septicemia/Sepsis

• Intestinal Obstruction/Perforation

• Coma, Brain Compression

• Respiratory Arrest

• Cardio – Respiratory Failure and Shock

• Cerebral Hemorrhage

• Aspiration, Bacterial and Pneumococcal Pneumonias

• Third Degree Burns

• Head Injuries

• Complications or Malfunctions of device, implant or graft

• Opportunistic Infections

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CASE SCENARIO– Mrs. Smith, an 85 year old white female who lives at home alone.

– Patient presents with symptoms consistent with UTI. Patient feels

more tired and has less energy, poor appetite. She had a heart

attack (MI) a year ago. Patient has mild degree of malnutrition, frail

and has lost 30 lbs within 6 mos. A urinalysis was performed which

shows white cells and leukocyte esterase and microalbuminuria.

Serum creatinine 1.4 Patient is complaining of urinary discomfort,

weakness, has dry and itching skin last 6 mos. PMH: Diabetic

Nephropathy, R BKA status – stable and UTI. Her serum

creatinine 6 mos before that was 1.3, lab findings revealed CKD III.

– Plan : DM – Glyburide 2.5mg po QD, UTI – Cipro, Malnutrition –

Ensure supplements. Rtn in 3 mos. Refer to Nephrologist for CKD

– Assessment : DM 250.00 & UTI 599.0

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RAF (Risk Adjusted Factor)

DIFFERENCE!• DM 250.00 .162

• UTI 599.0 0

• Demographic .454

• TOTAL RAF .616 $4805

• What the documentation says and how to appropriately document these diagnoses in the progress note?

– Added to the assessment: CKD III due to DM, R BKA status due to DM

– DM w/ renal manifestations 250.40 .508

– CKD III 585.3 .368

– Malnutrition 263.9 .856

– DM w/ peripheral circulatory 250.70

– BKA V49.75 .678

– Old MI 412 .244

– Demographic .454

– TOTAL RAF 3.108 $24,242

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CONTACT INFORMATION

• Susan Wyatt, CPC, CPC-I, CPMA

• HCC Risk, Auditor and Education

Manager

• CareMore Health Plan

• 562-622-2850

• Susan.wyatt@caremore.com