Peer To Peer Coding

Welcome

Bridging the ICD9 Communication Gap

Physician members RPO

Glossary

• CMS – Center for Medicare/Medicaid Services

• MA - Medicare Advantage = capitated Medicare product (ex: Texas Health Springs)

Glossary

• ICD9 coding – International Classification of Diseases, 9th Revision

• E & M coding – Evaluation and Management

• HCC – Hierarchical Condition Category

Communication

Foundation Block of Our Profession

• Ancillary Services• Consult with specialists• Review medical literature

Problem / Diagnoses List

Defines Disease Complexity

Disease Complexity(aka Burden of Disease)

Translate

IntoE & M codes

Non-capitated third party payers

Translate

IntoICD9

codes

Medicare Advantage

Communication to Third Party Payers

Proper Flow of InformationMedicare Advantage

Good coding

Proper Flow of RevenueMedicare Advantage

Gap in Communication

Poor coding

Gap in Flow of Revenue

Bridging the Gap in ICD9Communication

Poor coding

Proper Allocation of Resources

Pitfalls !

• ‘Up-scoring’ = using an ICD9 code without proper documentation

• Up-scoring ICD9 equivalent to Up-coding E&M code– Same penalties – Same risks

Schutzhund Pic/analogy

HMR

• You are verifying condition has been documented and treated in the current fiscal year in a face to face visit

• CMS will periodically audit

ICD9 CodingSimple, but Not Easy

• Simple – attach a number to a diagnosis / condition

• Not Easy = thousands of diagnoses / conditions

Barrier to Proper ICD9 Coding “Information Overload”

• Over 12,000 ICD9 codes

• Only 3000 have HCC value

• 3000 remains overwhelming

Solution

• Concentrate on important conditions in the ICD9 communication ‘gap’

–Major clinical conditions• Leading causes of premature death/disability

–High prevalence• Frequently under-coded/under-diagnosed

Presentation HCC Conditions

• Diabetes complications–Renal–Peripheral circulatory–Neurological–Ophthalmological

Presentation HCC Conditions

• Hypertension complications–Hypertensive Heart Disease–Hypertensive Kidney Disease–Combination HDD & HKD

Presentation HCC Conditions

• COPD

• Old MI / CABG / CAD

Presentation HCC ConditionsCharacteristics

• Leading causes of death & disability

• Under-diagnosed

• Outcome improvement possible

Our Experience

• Have a system in place to process complex data

– History

– Physical findings

– Labs/tests/specialty consultation

Our Experience

• Goal is to use every encounter as an opportunity

• Not practical in a ‘typical’ PCP office

Our SystemDemonstration purposes only – not RPO sanctioned

• Annual Health Review

–No co-pay

–Checklist customized to age, gender, known history

Past Medical Information

Yes No

Have you ever been told your diabetes has damaged your nerves? 6

Have you ever been told your diabetes has damaged your kidneys? 4

Current Symptoms

Do you have a numbness, burning, or tingling in your feet or legs? 6

…………………………

DO NOT WRITE BELOW THIS LINE

Yes No

Patient has loss of sensation with monofilament test or tuning fork 6

Pt has abn urine microalbumin confirmed - 2 specimens over 3 mo’s 4

Pt has decreased eGFR confirmed – 2 measurements over 3 mo’s 4

Our System

• Annual Health Review

–Checklist components• Tied or ‘linked’ to correct ICD9 codes

• EMR / paper (demonstrations to follow)

Our System

• Annual Health Review

–Augment with interactive DVD

• www.crosbyclinic.com

Diabetes as Prototype

• Uncomplicated DM – 250.0x (x = 0-3)

• 250.00 – Type 2, controlled or unk.• 250.01 - Type 1, controlled or unk.• 250.02 - Type 2, uncontrolled• 250.03 – Type 1, uncontrolled

Diabetes as Prototype

• Uncomplicated – 250.0x

• Renal – 250.4x + manifestation code

• Ophthalmic – 250.5x + manifestation code

• Neuropathy – 250.6x + manifestation code

• PVD – 250.7x + manifestation code

Diabetes Renal Complications

• History – ask - checklist

• Physical exam– Limited value

Past Medical Information

Yes No

Have you ever been told your diabetes has damaged your nerves? 6

Have you ever been told your diabetes has damaged your kidneys? 4

Current Symptoms

Do you have a numbness, burning, or tingling in your feet or legs? 6

…………………………

DO NOT WRITE BELOW THIS LINE

Yes No

Patient has loss of sensation with monofilament test or tuning fork 6

Pt has abn urine microalbumin confirmed - 2 specimens over 3 mo’s 4

Pt has decreased eGFR confirmed – 2 measurements over 3 mo’s 4

Diabetes Renal Complications

• History – ask - checklist

• Physical exam– Limited value

Diabetes Renal Complications

• Proteinuria detection

–Microalbumin-to-creatinine ratio• Spot collection = less collection error• May be transient – MUST be confirmed– ADA: + 2 of 3 over 3-6 months

Diabetes Renal Complications

• Proteinuria detection

– Timed collection – 24 hr/ 10 hr overnight• Prone to collection error• Cumbersome for patient and staff

Diabetes Renal Complications

• Estimated glomerular filtration rate (eGFR)

(Definition CKD from the National Kidney Foundation’sKidney Disease Outcomes Quality Initiative)

– GFR below 60 mL. per minute per 1.73 m2 for three

or more months (Stage 3 or greater)

Diabetes Renal Complications

• Estimated glomerular filtration rate (eGFR) – Labs routinely providing eGFRs

– http://nkdep.nih.gov/professionals/gfr_calculators/

Diabetes Renal Complications

• Once DM with renal complication verified:

–250.4x …… PLUS

– Manifestation Code• Most common = CKD 585.1-9

Diabetes Renal Complications

• Type 2 DM - (eGFR 52 - A1c 8.3)

250. 42 • 4 = renal• 2 = Type 2/uncontrolled

Diabetes Renal Complications

• Type 2 DM - (eGFR 52 - A1c 8.3) –250.42

–PLUS - 585.3 • 3 = Stage 3 CKD

Diabetes Renal Complications

What IF?

• Type 2 DM - (eGFR 52 - A1c 8.3)

250.00 vs. 250.42 + 585.3

RPO/THS Under-funded by CMS

Diabetes Renal ComplicationsWhat if THS is under-funded

• Patient suffers

• THS vulnerable

• You are undercompensated

Pitfall Reminder

• Goal is accurate ICD9 coding

• Up-scoring ICD9 equivalent to Up-coding E&M code– Same penalties – Same risks

Coding Memorization

• Impossible to recall all variations

– ICD9 ‘text’ – gold standard

– Laminates / linked checklists

– EMR

• EMR demonstration

Past Medical Information

Yes No

Have you ever been told your diabetes has damaged your nerves? 6

Have you ever been told your diabetes has damaged your kidneys? X 4

Current Symptoms

Do you have a numbness, burning, or tingling in your feet or legs? 6

…………………………

DO NOT WRITE BELOW THIS LINE

Yes No

Patient has loss of sensation with monofilament test or tuning fork 6

Pt has abn urine microalbumin confirmed - 2 specimens over 3 mo’s 4

Pt has decreased eGFR confirmed – 2 measurements over 3 mo’s X 4

(4) Diabetes – Renal Manifestations

Diabetes Renal Code

Type 2 – controlled/ukn

Type 1 – controlled/ukn

Type 2 – Uncontrolled

Type 1 – Uncontrolled

250.40 250.41 250.42 250.43

Manifestation Code

I GFR > 90 II – 60-89 III – 30-59 IV – 15-29 V- <15 Elevated microalbumin

585.1 585.2 585.3 585.4 585.5 585.9

(6) Diabetes – Neurologic Manifestations

Diabetes Neuro -

Code

Type 2 – controlled/ukn

Type 1 – controlled/ukn

Type 2 – Uncontrolled

Type 1 – Uncontrolled

250.60 250.61 250.62 250.63

Manifestation Codes

Polyneuropathy (most common) = 357.2Peripheral autonomic neuropathy = 337.1

Diabetes Peripheral Vascular Complications

• History – Symptoms• Claudication• Pallor, skin changes

Diabetes Peripheral Vascular Complications

• Physical Exam:– Pedal pulses – Skin / color / hair

• Ankle-brachial index (ABI)– <0.9

– ***Dr. Sid King – Living Well

Diabetes Peripheral Vascular Complications

• Once DM with PVD verified: – 250.7x …… PLUS

– Manifestation Code• Most common = Peripheral angiopathy 443.81

Diabetes Neurological Complications

• History – Symptoms• Burning, numbness• Diabetic Neuropathy Score

Diabetes Neurological Complications

• Physical exam

–Monofilament test

Diabetes Neurological Complications

• Physical exam

– Tuning fork 128 Hz

Diabetes Neurological Complications

• Once DM with neuropathy verified: – 250.6x …… PLUS

– Manifestation Code• Most common = Polyneuropathy 357.2

Diabetes Ophthalmic Complications

• History – ask checklist

• Physical exam– If skilled with ophthalmoscope

• Ophthalmology consult

Diabetes Ophthalmic Complications

• Retinopathy

• Cataract

• Glaucoma

Diabetes Ophthalmic Complications

• Blindness

• Macular / retinal edema

Diabetes Ophthalmic Complications

• Once DM with ophthalmic pathology verified: – 250.5x …… PLUS

– Manifestation Code• Most common = Peripheral retinopathy• 362.01-362.07

Hypertension Complications

• Hypertensive Heart Disease

• Hypertensive Kidney Disease

• Hypertensive Heart & Kidney Disease

Hypertension

• Essential – 401.x

• Hypertensive heart disease – 402.xx

• Hypertensive kidney disease – 403.xx

• Hypertensive heart & kidney disease – 404.xx

Hypertension Complications

• Major factors

–Duration of hypertension

– Level of control of HTN

Hypertension Complications

• Hypertensive Heart Disease without CHF

– Left ventricular hypertrophy

• LVH present in 30% adult hypertensives

• 90% with severe uncontrolled HTN

• ECG criteria

• ECHO

Hypertension Complications

• Hypertensive Heart Disease without CHF

– ??? AAA

• PE: pulsation below umbilicus

• U/S all smokers/former smokers > age 65

Hypertension Complications

• Hypertensive Heart Disease with CHF

– CHF may, of course, present without HTN

– CHF coding is used with or without HTN

CHF

• History– Risk factors • Hypertension, CAD, valvular disease, etc.

– Symptoms• Dyspnea• Edema• Fatigue

CHF

• Physical Exam – Edema

– Lungs

– Neck veins

CHF

• Testing:

– BNP

– ECHO

– Cardiology consult

CHF

• Isolated diastolic CHF:

– Symptoms of CHF with normal ejection fraction

– ICD9 = 428.3x

Hypertension Complications

• Hypertensive Heart Disease with CHF

–Use appropriate 402.xx HDD code

–Use additional CHF code – 428.x

Hypertension Complications

• Hypertensive Kidney Disease

– Same diagnostic tools as DM• Microalbumin-to-creatinine ration• eGFR• Imaging

Hypertension Complications

• Hypertensive Kidney Disease

– Code Hypertension by stage – 403.xx• Stage I-IV• Stage V-ESRD

– Use additional CKD code – 585.x

Hypertension Complications

• Hypertensive Heart & Kidney Disease

– Use appropriate HDD 404.xx code

– Use additional CV code (CHF, etc.)

– Use additional CKD code

COPD

• History –Ask: checklist

–Risk factors:• Smoker• Asthma• Toxic exposure• Alpha1 antitrypsin

COPD

• History

–Chronic bronchitis – most common• Chronic sputum production (3 mo/2yrs)

COPD

• Physical Exam

– Increased AP diameter

– Blue bloater

– Pink puffer

COPD

• Pulmonary Function Testing

– Test all with strong historical risk factor or symptoms• 20 pack year history• Toxic exposures• Asthma

COPD

• Acute exacerbation of chronic bronchitis – Increasing sputum production

– Increasing sputum color (white>yellow, etc)

– Increasing dyspnea

CAD/Old MI

• Old MI - 412

• CABG – 414.04

• CAD – 414.01

Tools

• Use symmetry report to identify high risk candidates

• “no encounter list” Legg VA my experience

Tools

• Use EVERY encounter to search for short list codes

• Build on knowledge of short list

• Codes Secondary– Dialysis ?DM– Decubitus– Paralysis ?? 67 VS hemiplegia 100– Amputation ?DM– Rheumatology 38– Chronic hepatitis 27– Seizures 74– Cancer 10– Drug abuse 52 **alcohol