Risk Adjustment Training - Peninsula Professionalpeninsulaprofessionalcoders.com/September_Seminar/6A-Risk... · 1 Risk Adjustment Training HCC, CDPS, and Hybrid models ! ©"ionHealthcare,"LLC"All"rights"reserved."For"educaon"&"discussion"purposes."Permi?ed"use

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Risk Adjustment Training HCC, CDPS, and Hybrid models

© ionHealthcare, LLC All rights reserved. For educa:on & discussion purposes. Permi?ed use via contractual agreement/purchase. !

Education provided by: Brian Boyce, BSHS, CPC, CPC-I Proprietor & Managing Consultant, ionHealthcare, LLC

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No part of this presentation may be reproduced or transmitted in any form or by any means (graphically, electronically, or mechanically, including photocopying, recording, or taping) without the expressed written permission of AAPC or ionHealthcare, LLC.

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Foundations of RA Models

What is Risk Adjustment?

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Introduction •  Risk Adjustment is a methodology of adjusting estimated or

perceived risks as they relate to diagnosis codes of patients •  Understanding each current illness or diagnosis a patient has helps

to estimate needed funding for future years and in some models, applies to payments for treating those illnesses

•  There are different forms of risk adjustment models, to include:

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HCC CDPS Hybrid


Introduction •  Within risk adjustment models, there are usually two branches of risk

reviewed: 1.  Diagnosis-‐based risk adjustment examples:

•  Chronic illness and Disability Payment Systems (CDPS) – Medicaid •  Hierarchical Co-‐Exis:ng Condi:ons (HCC-‐C) – Medicare •  Diagnosis Related Groups (DRG) – Inpa:ent •  Adjusted Clinical Groups (ACG) – Outpa:ent

2.  Prescrip:on-‐based risk adjustment examples: •  MedicaidRx (UCSD) •  RxGroups (DxCG) •  Hierarchical Co-‐Exis:ng Condi:ons (HCC-‐D)

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Why It Matters •  For Medicare Advantage Plans ①  Risk Adjustment (RA) identifies patients who may need disease

management interventions and ②  RA establishes the financial allotment from CMS toward the annual care

of each patient; with more dollars allocated for those with higher risk scores

•  For Medicaid and Commercial Plans ①  Risk Adjustment (RA) identifies patients who may need disease

management interventions and ②  RA establishes the “overall state of the population” by aggregating

diagnoses; which assists in financial forecasting for future medical need

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General RA Guidelines •  These programs operate on similar rules and

guidelines to include: – Specific diagnoses must be documented in a face-to-

face visit by the treating licensed provider (showing credentials: MD, DO, PA, NP, OT, CRNA, MSW, and similar master’s level providers) and the documentation must be signed by the treating provider to be accepted

– Diagnoses must be clearly stated on the DOS (Date Of Service) as a current problem

– Diagnoses must be documented each year, ongoing as each year is evaluated without historical context influence


Acceptable Provider Specialties

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CODE SPECIALTY CODE SPECIALTY CODE SPECIALTY

01 General Prac:ce 25 Physical Medicine & Rehabilita:on 67 Occupa:onal Therapist

02 General Surgery 26 Psychiatry 68 Clinical Psychologist

03 Allergy/Immunology 27 Geriatric Psychiatry 72 Pain Management

04 Otolaryngology 28 Colorectal Surgery 76 Peripheral Vascular Disease

05 Anesthesiology 29 Pulmonary Disease 77 Vascular Disease

06 Cardiology 33 Thoracic Surgery 78 Cardiac Surgery

07 Dermatology 34 Urology 79 Addic:on Medicine

08 Family Prac:ce 35 Chiroprac:c 80 LCSW

09 Interven:onal Pain Management (IPM) 36 Nuclear Medicine 81 Cri:cal Care (Intensivists)

10 Gastroenterology 37 Pediatric Medicine 82 Hematology

11 Internal Medicine 38 Geriatric Medicine 83 Hematology/Oncology

12 Osteopathic Manipula:ve Therapy 39 Nephrology 84 Preventa:ve Medicine

13 Neurology 40 Hand Surgery 85 Maxillofacial Surgery

14 Neurosurgery 41 Optometry (optometrists) 86 Neuropsychiatry

15 Speech Language Pathologist 42 Cer:fied Nurse Midwife 89 Cer:fied Clinical Nurse Specialist

16 Obstetrics/Gynecology 43 CRNA 90 Medical Oncology

17 Hospice and Pallia:ve Care 44 Infec:ous Disease 91 Surgical Oncology

18 Ophthalmology 46 Endocrinology 92 Radia:on Oncology

19 Oral Surgery (Den:sts only) 48 Podiatry 93 Emergency Medicine

20 Orthopedic Surgery 50 Nurse Prac::oner 94 Interven:onal Radiology

21 Cardiac Electrophysiology 62 Psychologist 97 Physician Assistant

22 Pathology 64 Audiologist 98 Gynecologist/Oncologist

23 Sports Medicine 65 Physical Therapist 99 Unknown Physician Specialty

24 Plas:c & Reconstruc:ve Surgery 66 Rheumatology C0 Sleep Medicine

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Diagnosis Code Value •  In risk adjustment models diagnosis codes carry a risk

adjustment value (RAF or “risk adjustment factor” in the HCC model)

•  This is similar to the concept of RVU (Relative Value Units) assigned to CPT® codes

•  The more severe or complex a diagnosis, the higher its value •  If two or more diagnoses are documented from the same

category, the diagnosis that is more severe or complex will “trump” any others

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Financial Matters No Condi6ons Coded

(Demographics Only) Some Condi6ons Coded

(Claims Data Only) All Condi6ons Coded

(Chart Review by Cer6fied Coder)

76 year old female .468 76 year old female .468 76 year old female .468 Medicaid Eligible .177 Medicaid Eligible .177 Medicaid Eligible .177 DM Not Coded DM (no manifesta:ons) .118 DM with Vascular

Manifesta:ons .368

Vascular Disease not coded

Vascular Disease without complica:on

.299 Vascular Disease with complica:on

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CHF not coded CHF not coded CHF coded .368 No interac:on No interac:on + Disease Interac:on

bonus RAF (DM + CHF) .182

Pa:ent Total RAF .645 Pa:ent Total RAF 1.062 Pa:ent Total RAF 1.973 PMPM Payment for Care $452 PMPM Payment for Care $743 PMPM Payment for Care $1,381 Yearly Reserve for Care $ 5,418 Yearly Reserve for Care $8,921 Yearly Reserve for Care $16,573


Hierarchical Categories •  Families or hierarchical groups/categories are used in risk adjustment •  More severe or complicated illnesses (by ICD code) in the family or

hierarchy will trump all others in the category or family •  Sometimes codes which are trumped by others from a medical

management perspective (Part C) may still carry value from a prescription drug perspective (Part D)

•  This leads to a strong need for coders to always code diagnoses to their highest specificity so that all current diagnoses are accounted for each encounter

•  ICD guidelines instruct coders to code for a principal diagnosis, but also all other comorbidities during each encounter

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Hierarchical Categories in the HCC Model

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2014 Hierarchical Categories in the HCC Model

Infec:on Blood Cerebrovascular Disease Complica:ons

Neoplasm Substance Abuse Vascular Transplant

Diabetes Psychiatric Lung Openings

Metabolic Spinal Eye Amputa:on

Liver Neurological Kidney Disease Interac:ons

Gastrointes:nal Arrest Skin Disability Status

Musculoskeletal Heart Injury


Hierarchical Categories in the CDPS Model

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2014 CDPS Major Categories

Psychiatric Skin Metabolic

Skeletal Renal Pregnancy

Central Nervous System Substance Abuse Eye

Pulmonary Cancer Cerebrovascular

Gastrointes:nal Developmental Disability AIDS/Infec:ous Disease

Diabetes Genital Hematological


Trump Examples (HCC) If this HCC is found…

**2014 Disease Group Label** …Then Drop these HCC’s:

8 Metasta:c Cancer and Acute Leukemia 9,10,11,12

9 Lung and Other Severe Cancers 10,11,12

10 Lymphoma and Other Cancers 11,12

11 Colorectal, Bladder, and Other Cancers 12

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If this HCC is found…

**2014 Disease Group Label** …Then Drop these HCC’s:

17 Diabetes with Acute Complica:ons 18,19

18 Diabetes with Chronic Complica:ons 19

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Trump Examples (CDPS) •  Cardiovascular Category (4 levels)

1.  CARVH includes 3 Stage 1 groups and 7 diagnoses 2.  CARM includes 13 Stage 1 groups and 53 diagnoses 3.  CARL includes 26 Stage 1 groups and 314 diagnoses 4.  CAREL includes 2 Stage 1 groups and 35 diagnoses

•  Where the suffix of the Cardiovascular Category (CAR) establishes its place in the hierarchy. For example:

–  VH (Very High) (weight 2.037): heart transplants, valves, etc. –  M (Medium) (weight 0.805): heart a?acks, etc. –  L (Low) (weight 0.368): heart disease, etc. –  EL (Extra Low): hypertension etc.

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The HCC Model is Ever-Changing

•  The original DCG/HCC model in 2000 identified 804 costly diagnosis groups, mapped to 189 HCC codes

•  Created a reporting model for reimbursement based on ICD codes within families of conditions. (Hierarchal Categories)

•  There are 2,944 ICD codes carrying Part C HCC value (over 3,000 in 2004) •  There are 1,475 ICD codes carrying Part D HCC value (over 3,000 in 2004) •  978 ICD codes carry both Part C and Part D HCC value (~ 1500 in 2004) •  Major Changes are due for 2014

–  Many Part C’s dropped to Part D only –  Blended model in 2014 (mixing values from 2013 model and 2014 model) –  Many new interactions


If this HCC is found… **2013 Disease Group Label** …Then Drop these HCC’s:

5 Opportunis6c Infec6ons 112

7 Metasta6c Cancer and Acute Leukemia 8, 9, 10

8 Lung, Upper Diges6ve Tract, and Other Severe Cancers 9, 10

9 Lympha6c, Head and Neck, Brain and Other Major Cancers 10

15 Diabetes with Renal Manifesta6ons or Peripheral Circulatory Manifesta6on 16, 17, 18, 19

16 Diabetes with Neurologic or Other Specified Manifesta6on 17, 18, 19

17 Diabetes with Acute Complica6on 18, 19

18 Diabetes with Ophthalmologic or Unspecified Manifesta6ons 19

25 End Stage Liver Disease 26, 27

26 Cirrhosis of Liver 27

51 Drug/Alcohol Psychosis 52

54 Schizophrenia 55

67 Quadriplegia/Other Extensive Paralysis 68, 69, 100, 101, 157

68 Paraplegia 69, 100, 101, 157

69 Spinal Cord Disorders/Injuries 157

77 Respirator Dependence/Tracheotomy Status 78, 79

78 Respiratory Arrest 79

81 Acute Myocardial Infarc6on 82, 83

82 Unstable Angina and Other Acute Ischemic Heart Disease 83

95 Cerebral Hemorrhage 96

100 Hemiplegia/Hemiparesis 101

104 Vascular Disease with Complica6ons 105, 149

107 Cys6c Fibrosis 108

111 Aspira6on and Specified Bacterial Pneumonias 112

130 Dialysis Status 131, 132

131 Renal Failure 132

148 Decubitus Ulcer of Skin 149

154 Severe Head Injury 75, 155

161 Trauma6c Amputa6on 177

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If this HCC is found… **2014 Disease Group Label** …Then Drop these HCC’s:

8 Metasta:c Cancer and Acute Leukemia 9,10,11,12

9 Lung and Other Sever Cancers 10,11,12

10 Lymphoma and Other Cancers 11,12

11 Colorectal, Bladder, and Other Cancers 12

17 Diabetes with Acute Complica:ons 18,19

18 Diabetes with Chronic Complica:ons 19

27 End-‐Stage Liver Disease 28,29,80

28 Cirrhosis of Liver 29

46 Severe Hematological Disorders 48

54 Drug/Alcohol Psychosis 55

57 Schizophrenia 58

70 Quadriplegia 71,72,103,104,169

71 Paraplegia 72,104,169

72 Spinal Cord Disorders/Injuries 169

82 Respirator Dependence/Tracheostomy Status 83,84

83 Respiratory Arrest 84

86 Acute Myocardial Infarc:on 87,88

87 Unstable Angina and Other Acute Ischemic Heart Disease 88

99 Cerebral Hemorrhage 100

103 Hemiplegia/Hemiparesis 104

106 Atherosclerosis of the Extremi:es with Ulcera:on or Gangrene 107,108,161,189

107 Vascular Disease with Complica:ons 108

110 Cys:c Fibrosis 111,112

111 Chronic Obstruc:ve Pulmonary Disease 112

114 Aspira:on and Specified Bacterial Pneumonias 115

134 Dialysis Status 135,136,137

135 Acute Renal Failure 136,137

136 Chronic Kidney Disease (Stage 5) 137

157 Pressure Ulcer of Skin with Necrosis Through to Muscle, Tendon, or Bone 158,161

158 Pressure Ulcer of Skin with Full Thickness Skin Loss 161

166 Severe Head Injury 80,167


How Does HCC Compare to CDPS? There are various systems using Risk Adjustment beyond HCC for Medicare HMO plans. Some of these include: Diagnosis based programs: • Chronic Illness and Disability Payment Systems (CDPS) - Medicaid • Hierarchical Co-Existing Conditions (HCC-C) - Medicare • Diagnosis Related Groups (DRG) – Inpatient • Adjusted Clinical Groups (ACG) – Outpatient Prescription based programs: • MedicaidRx (UCSD) • RxGroups (DxCG) • Hierarchial Co-Exisiting Conditions (HCC-D) Some add: Patient Functional Abilities (ADL’s)


History of CDPS Model

•  Started in 1996 to tailor current risk adjustment models to better apply to Medicaid programs. Development started using claims from disabled beneficiaries information from the Disability Payment System (DPS) from Colorado, Michigan, Missouri, New York, and Ohio by Rick Kronick and associates

•  Update in 2000 to include disabled and TANF (Temporary Assistance for Needy Families) beneficiaries from California, Georgia, and Tennessee. This upgraded program was then renamed the Chronic Illness and Disability Payment System (CDPS)

•  In 2001, Todd Gilmer and associates developed the Medicaid Rx (MRX) using CDPS information. Based on combining from the Chronic Disease Score (CDS) developed by Von Korff and associates and the RxRisk model by Fishman and associates

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History of CDPS Model

•  In 2008, CDPS and MRX models were updated using Medicaid data from 44 states in 2001 and 2002. Another model was developed employing both diagnostic and pharmacy data called CDPS + Rx

•  Data was supplied by CMS from Medicaid Analytic eXtract (MAX) data system. MAX data consists of patient-level data files with information on Medicaid eligibility, utilization of services, and payments for services

•  More on CDPS: University of California, San Diego website: –  http://cdps.ucsd.edu/


How Does CDPS & MRX Work? •  Mapping of diagnoses and/or pharmaceutical use to a group (vector)

of disease categories •  CDPS maps 16,461 ICD codes to 58 CDPS categories which lead

up to 20 major categories related to major body systems (such as cardiovascular) or type of disease (such as diabetes)

•  MRX maps to 56,236 NDC codes from patient utilization to 45 Medicaid Rx categories

This leads to “Stage 1 Groups” (build CDPS)

•  Groups ICD codes, typically at 3-digit level (for ICD-9) •  Sometimes grouped at 4th or 5th digit when that extra digit describes

a more serious condition or version of a diagnosis


Predictive Modeling

Diagnosis with no

complica:ons

DME; Rx; CPT; Labs; HCPCS;

etc.

Diagnosis with some

complica:on?

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Quality Improvement

•  CMS defines the star ratings in the following manner: 5 Stars = Excellent Performance

4 Stars = Above Average Performance 3 Stars = Average Performance

2 Stars = Below Average Performance 1 Star = Poor Performance

•  Variable weights are given to each measure with those related to outcomes being weighted highest, followed by patient experience measures in the middle, and process measures being lowest


Quality Improvement Medicare Part C Domains for 2014: Quality of Care

Domain 1 Staying Healthy – Screenings, Test, & Vaccines Domain 2 Managing Chronic Conditions Domain 3 Ratings of Plan Responsiveness & Care Domain 4 Member Complaints, Problems Getting Services, & Choosing to Leave the Plan Domain 5 Health Plan Customer Service

Medicare Part D Domains for 2014: Quality of Care

Domain 1 Staying Healthy – Screenings, Test, & Vaccines Domain 2 Managing Chronic Conditions Domain 3 Ratings of Plan Responsiveness & Care Domain 4 Member Complaints, Problems Getting Services, & Choosing to Leave the Plan


Significance to Providers •  Providers have long attempted to establish the

seriousness and severity of the patients they treat through the use of E&M CPT® codes

•  Higher level E&M codes identify serious encounters, utilizing more medical decision making, and are reimbursed at a higher rate

•  In Risk Adjustment scenarios, these CPT® codes have no significance

•  Instead, specific diagnosis codes communicate the seriousness of medical decision making

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Significance to Providers

•  Using specific ICD Diagnosis Codes will help convey the true seriousness of the conditions being addressed in each visit

•  Documenting these carefully involves two main focal points: ①  Identifying the Diagnosis as a current or ongoing problem

as opposed to a PMH (Past Medical History) or previous condition

②  Choosing the most specific Diagnosis Code while also being sure documentation supports it fully


Diagnosis Documentation & Coding

Coding for Risk Adjustment


Documentation

•  Documentation is the only key to collect appropriate diagnosis codes for encounters

•  When appropriate, coders should query the treating provider if possible, however many coders working in risk adjustment cannot query the providers, thus they must only code to the best of their ability based on documentation given

•  ICD guidelines state to code for all existing comorbidities for each encounter that are a part of MDM (Medical Decision Making)

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Documentation •  Providers and Coders are equally guilty of choosing generic,

non-specific codes because they are memorized and easier than stopping to look up a more specific diagnosis code supported by the documentation

•  Documenting complications and comorbidities is also important for risk adjustment purposes

•  Many providers still do not realize that the coding guidelines largely prohibit medical coders from assuming any cause and effect relationships and if these are not clearly documented in the medical record, they are lost in translation

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Documentation •  For example:

1.  A diabetic patient who comes in for a sore throat and is diagnosed with strep throat:

•  Many offices will only use the strep diagnosis code, yet diabetes is still a current diagnosis, and one that surely was considered during treatment options as a part of the Medical Decision Making

2.  A hypertensive patient with CHF comes in to the office for follow up:

•  Many providers do not know that if the CHF and hypertension are related, they must state this, otherwise coders are left to only code them as separate diagnoses. CHF alone and HTN alone may “risk adjust” in models, but “Hypertensive Heart Disease” is more serious

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Documentation

•  Diagnosis specificity is of paramount importance and in many diagnoses, use of the word “chronic” can change the chosen diagnosis code (and its subsequent risk value)

•  Examples include (but are not limited to): –  Chronic Renal Insufficiency vs. Renal insufficiency –  Chronic Hepatitis B vs. Hepatitis B –  Chronic Bronchitis vs. Bronchitis –  Chronic cor pulmonale vs. cor pulmonale

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Documentation •  Avoid homegrown abbreviations and document all cause and

effect relationships •  Include all current diagnoses as part of the current medical

decision making and carry them to the final assessment of the encounter

•  Each note needs a date, signature, & credential (MD, DO, NP, PA, etc.)

•  Document history of heart attack, any amputations, hypoxia, status codes, ostomy, etc., when factual

•  Only document diagnoses as “history of” or “PMH” when they no longer exist or are a current condition

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Documenting Diabetes •  Many providers have memorized the ICD-9-CM code of 250.00 for

diabetes, yet this is often NOT the correct code for many patients •  Diabetes codes in both ICD-9 and ICD-10 have specific codes to

identify diabetes-related manifestations •  In both: The 4th digit tells manifestation and 5th digit tells if controlled

or uncontrolled •  Only diabetics with no manifestations should utilize the generic

diabetes ICD code


Diabetes in ICD-9-CM ICD-‐9 Code Manifesta6on by 4th digit; Stated as: “Due to, with, etc.”

250.0x DM, no men6on of complica6on

250.1x DM, with Ketoacidosis

250.2x DM, with hyperosmolarity

250.3x DM, with coma/insulin coma

250.4x DM, with renal manifesta6ons

250.5x DM, with ophthalmic manifesta6ons

250.6x DM, with neurological manifesta6ons

250.7x DM, with peripheral circulatory disorders

250.8x DM, with other specified manifesta6ons

250.9x DM, with unspecified complica6ons

Cause & Effect rela6onships must be documented by the provider when DM is the reason for any manifesta6on. (Only excep6on is gangrene in DM may be assumed related.)

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Diabetes in ICD-10-CM Type 1 Type 2 Other Specified (*No Unspecified code)

E10.1x-‐[Check 5th] with ketoacidosis

E11.0x-‐[Check 5th] with hyperosmolarity

E13.0x-‐-‐[Check 5th] w/ hyperosmolarity

E13.1x-‐-‐[Check 5th] w/ ketoacidosis

E10.2x-‐[Check 5th] w/kidney complica6ons

E11.2x-‐[Check 5th] w/kidney complica6ons

E13.2-‐[Check 5th] w/kidney complica6ons

E10.3x-‐[Check 5-‐6th] w/ ophthalmic comp.

E11.3x-‐[Check 5-‐6th] w/ ophthalmic comp.

E13.3-‐[Check 5-‐6th] w/ ophthalmic comp.

E10.4x-‐[Check 5th] w/ neuro. complica6ons

E11.4x-‐[Check 5th] w/ neuro. complica6ons

E13.4-‐[Check 5th] w/ neuro. complica6ons

E10.5x-‐[Check 5th] w/ circulatory comp.

E11.5x-‐[Check 5th] w/ circulatory comp.

E13.5-‐[Check 5th] w/ circulatory comp.

E10.6x-‐[Check 5-‐6th] w/ other spec. comp.

E11.6x-‐[Check 5-‐6th] w/ other spec. comp.

E13.6-‐[Check 5-‐6th] w/ other specified complica6ons

E10.8 w/ unspecified complica6ons



E10.9 without complica6ons E11.9 without complica6ons E13.9 without complica6ons


Documen:ng & Coding Diabetes

•  Under-documenting DM communicates a less serious DM case, which affects value of care

•  Any manifestations must be documented as a cause and effect relationship, for example: ①  Assessment: 1. DM 2. Polyneuropathy

§  Can only code: 250.00 and 356.9 (ICD-9-CM) §  E11.9 and G62.9 (ICD-10-CM) [Lower Value DM]

②  Assessment: 1. DM with Polyneuropathy §  Can code: 250.60 and 357.2 §  E11.42 (ICD-10-CM) [Higher Value DM]


Documenting & Coding HTN

•  Under-documenting HTN communicates a less serious HTN case, which affects value of care

•  Any manifestations must be documented as a cause and effect relationship (CKD is an exception)

Hypertension Type ICD-‐9-‐CM ICD-‐10-‐CM

HTN (primary, benign, essen:al, malignant)

401.x I10

“with” Heart Disease 402.xx I11.x

“with” CKD 403.xx I12.x

“with” heart & kidney disease 404.xx I13.x

Hypertension, secondary 405.xx I15.x

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Documenting & Coding Cancers •  Per guidelines, cancers are coded by their location and may

only be coded as active when current treatment is being directed to the cancer, or if the cancer is active and treatment was refused

•  Radiation, Chemotherapy, and Hormonal treatments used specifically for a given cancer qualify as current treatment

•  Without current treatment, the patient only has a personal history of cancer (V code) and these typically do not risk adjust

•  Helpful to know if cancer is primary, metastatic, and what treatments are ongoing in order to code


Documenting & Coding Depression

•  Patients who are on anti-depressant therapy are considered to have “major depression” clinically

•  Providers rarely document it this way, often only noting “depression”

•  Coders can only code what is documented and “depression” alone defaults to “situational depression” such as bereavement or job loss or other temporary depression

•  Depression assessment tools are often used to validate or support moderate to severe or “major depression” but when patients are receiving therapy these scores may not reflect the diagnosis and this should be noted


Provider Signatures

•  Providers must always sign or authenticate their records •  CMS has clarified that this may be a full signature or initials or

other mark, however is the signature or mark is illegible, then there must be some other way to determine the providers name, such as a printed name on the encounter, such as on letterhead

•  When more than one provider is listed on letterhead, the treating provider should be marked in some fashion

•  Documentation which lacks proper signature or credential of the treating provider may still be coded, as this can be obtained later

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Choosing Diagnoses From Various Portions of the Encounter

Where Current Diagnoses May Be Documented


Current Diagnoses

•  While most will readily agree that the assessment and plan portions of any encounter will have solid documentation on current diagnoses, these areas may be missing diagnoses, or combined data that may be found elsewhere

•  In most all other forms of coding, ICD codes are selected by choosing those diagnoses which were “addressed” or fit the primary diagnosis, or even the local coverage determination for a procedure

•  When coding for risk adjustment purposes, it is appropriate to code for all current diagnoses in each encounter

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Current Diagnoses •  Some organizations may choose a conservative approach and

prefer that there be some form of treatment or acknowledgment of the diagnosis in the encounter, however there are many diagnoses in risk adjustment models which may never be treated or acknowledged because they just exist: –  Old MI (having had an heart attack) carries value –  Amputations carry value –  Drug Addiction codes carry value –  “Family and personal history of” codes carry value in the CDPS

model –  Etc.

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Code for All Diagnoses

•  Risk adjustment models allow for collection of diagnoses from face-to-face visits from outpatient and inpatient encounters

•  Diagnoses should not be collected from radiological or other diagnostic test orders or reports or laboratory requests or results with the exception of pathology, which is considered a consult

•  When diagnoses are noted within the face-to-face encounter, such as a summary of findings or results noted, then those diagnoses may be collected

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Code for All Diagnoses •  Some coders may confuse E&M guidelines for diagnosis

reporting as it pertains to the selection of the E&M level of service codes

•  When choosing a level of service for E&M, diagnosis codes should only be counted toward the level of service when they are documented how they were evaluated or addressed

•  This is entirely related to selection of level of service for E&M purposes, and does not change the fact that ICD coding guidelines instruct coders to include all comorbidities for each encounter

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ICD-9 Coding Guidelines ICD-‐9-‐CM: Sec+on IV. Diagnos+c Coding and Repor+ng Guidelines for Outpa+ent Services H. ICD-‐9-‐CM code for the diagnosis, condi+on, problem, or other reason for encounter/visit List first the ICD-‐9-‐CM code for the diagnosis, condi8on, problem, or other reason for encounter/visit shown in the medical record to be chiefly responsible for the services provided. List addi8onal codes that describe any coexis8ng condi8ons. In some cases the first-‐listed diagnosis may be a symptom when a diagnosis has not been established (confirmed) by the physician. (ICD-‐9-‐CM, 2013) K. Code all documented condi+ons that coexist Code all documented condi8ons that coexist at the 8me of the encounter/visit and require or affect pa8ent care treatment or management. Do not code condi8ons that were previously treated and no longer exist. However, history codes (V10-‐V19) may be used a secondary codes if the historical condi8on or family history has an impact on current care or influences treatment. (ICD-‐9-‐CM, 2013)

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ICD-10 Coding Guidelines ICD-‐10-‐CM: Sec+on IV. Diagnos+c Coding and Repor+ng Guidelines for Outpa+ent Services G. ICD-‐10-‐CM code for the diagnosis, condi+on, problem, or other reason for encounter/visit List first the ICD-‐10-‐CM code for the diagnosis, condi8on, problem, or other reason for encounter/visit shown in the medical record to be chiefly responsible for the services provided. List addi8onal codes that describe any coexis8ng condi8ons. In some cases the first-‐listed diagnosis may be a symptom when a diagnosis has not been established (confirmed) by the physician. (ICD-‐10-‐CM, 2013 DraO) J. Code all documented condi+ons that coexist Code all documented condi8ons that coexist at the 8me of the encounter/ visit and require or affect pa8ent care treatment or management. Do not code condi8ons that were previously treated and no longer exist. However, history codes (categories Z80-‐Z87) may be used as secondary codes if the historical condi8on or family history has an impact on current care or influences treatment. (ICD-‐10-‐CM, 2013 DraO)

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CMS Guidelines •  Medicare has also recommended that coders follow official

coding guidelines, as well as Coding Clinic® determinations •  The Coding Clinic® is a division of the AHA (American

Hospital Association) and they make all final determinations on the appropriate utilization of diagnosis codes

•  The Coding Clinic® has several rules that pertain to Risk Adjustment that will be covered later

•  The CMS Risk Adjustment Participant Guide also supports coding for all current diagnoses

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CMS Participant Guide Excerpts 6.4.1 Co-Existing and Related Conditions : The instructions for risk adjustment implementation refer to the official coding guidelines for ICD-9-CM, published at www.cdc.gov/nchs/icd9.htm and in the Coding Clinic. Physicians should code all documented conditions that co-exist 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 (V10-V19 not in HCC model) may be used as secondary codes if the historical condition or family history has an impact on current care or influences treatment. • Co-existing conditions include chronic, ongoing conditions such as diabetes (250.XX, HCCs 15-19), congestive heart failure (428.0, HCC 80), atrial fibrillation (427.31, HCC 92), chronic obstructive and pulmonary disease (496, HCC 108). These diseases are generally managed by ongoing medication and have the potential for acute exacerbations if not treated properly, particularly if the patient is experiencing other acute conditions. It is likely that these diagnoses would be part of a general overview of the patient’s health when treating co-existing conditions for all but the most minor of medical encounters.

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CMS Participant Guide Excerpts •  Co-‐exis8ng condi8ons also include ongoing condi8ons such as mul8ple sclerosis (340, HCC 72),

hemiplegia (342.9X, HCC 100), rheumatoid arthri8s (714.0, HCC 38) and Parkinson’s disease (332.0, HCC 73). Although they may not impact every minor healthcare episode, it is likely that pa8ents having these condi8ons would have their general health status evaluated within a data repor8ng period, and these diagnoses would be documented and reportable at that 8me.

•  MA organiza8ons must submit each required diagnosis at least once during a risk adjustment repor8ng period. Therefore, these co-‐exis8ng condi8ons should be documented by one of the allowable provider types at least once within the data repor8ng period. (CMS Par8cipant Guide, 2008)

•  The above excerpts give several examples on how to review diagnoses for Risk Adjustment purposes

•  CMS also acknowledges the common issue of diagnoses marked as “history of”

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CMS Participant Guide Excerpts •  Use of “history of.” In ICD-9-CM, “history of” means the patient no longer has the

condition and the diagnosis often indexes to a V code not in the HCC models. A physician can make errors in one of two ways with respect to these codes. One error is to code a past condition as active. The opposite error is to code as “history of” a condition when that condition is still active. Both of these errors can impact risk adjustment. (CMS Participant Guide, 2008)

•  Because the purpose is to code for all known diagnoses for each patient in risk adjustment models, diagnoses from any portion of the record should be valid, provided that they are accurately documented as current diagnoses

•  This includes current diagnoses from the CC (Chief Complaint) or HPI (History of Present Illness); PMH (Past Medical History) when still current; Current, Ongoing, or Active Problem Lists; ROS (Review of Systems); Exam; and Assessment and Plan portions

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Coding from Chief Complaint or HPI •  Entries from the CC/HPI portion of any record should be carefully

evaluated by the wording used by the treating provider •  All documented diagnoses should be coded and any that are only noted

as historical, should be left as PMH (Past Medical History) or questionable (which is covered later in this chapter)

•  In the next slide there are two examples of how wording can influence the selection of current diagnoses from the CC or HPI portion of the record

•  Coders must carefully review how diagnoses are documented, a history of statement can be interpreted as historical only and no longer existing, or can also be interpreted as a current ongoing problem that has been present for a long time for the patient

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Coding from Chief Complaint or HPI Example 1: CC: Ms. Jones is a 70 year old female who comes in today for her follow up of her diabetes and COPD. She has a history of DVT and peripheral vascular disease. She has had no issues or complaints since her last visit to the office. • RATIONALE: The CC clearly states the pa8ent is here for the diabetes and COPD, while the DVT and PVD are merely men8oned as historical in nature and are not clear to be current condi8ons. Addi8onally, these 2 condi8ons are not known to be permanent and life-‐long and therefore should not be coded as current.

Example 2: CC: Ms. Jones is a 70 year old female with a history of diabetes and COPD and she is here today for a follow up on her blood sugar control and to evaluate her inhaler effec8veness. • RATIONALE: This CC lists both condi8ons as “historical” yet it also affirms that they are current condi8ons being treated and therefore are appropriate to code as current.

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Coding from PMH (Past Medical History) •  PMH (Past Medical History) is one of the biggest areas of contention

when reviewing medical records •  CMS (per the above excerpt) has even recognized that providers may

sometimes incorrectly list a current diagnosis as PMH or vice versa. –  “One error is to code a past condition as active. The opposite error is to code

as “history of” a condition when that condition is still active” (CMS Participant Guide, 2008).

•  Per our coding guidelines, as well as CMS guidance, coder cannot code for conditions that were previously treated and no longer exist.

•  If a condition is not listed as current and only as historical, there must be a way to identify those diagnoses that are still valid separate from those which are truly historical.

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Past Medical History (PMH)

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CC/HPI: Mr. Jones is here today for follow up of his

diabetes, CHF, and PVD. PMH: MI in 2002 CHF PVD A/P: 1. Diabetes

CC/HPI: Mr. Jones is here today for his diabetes, he has a known CHF, and PVD. PMH: MI in 2002 CHF PVD A/P: 1. Diabetes

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Coding from PMH (Past Medical History) •  If a coder believes any diagnosis is current, but it is only listed as PMH

or historical, coders should ask themselves: “Did the provider TAMPER™ (Treatment, Assessment, Monitor/Medicate, Plan, Evaluate, or Referral) with the diagnosis in that DOS (date of service)”?

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Coding from PMH (Past Medical History) •  Most organizations collect diagnoses, even if they are “PMH only” so

that they might have something to send in case of a RADV audit •  CMS has said in RADV training that they accept diagnoses listed in

PMH listings when they are interpreted as still being current or ongoing for the patient

•  There are some diagnoses, however that should never be collected as PMH only because they have their own history of codes:

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Fractures Cancers CVA MI HIV Amputa:ons Anything noted as resolved Anything noted as repaired


Coding from Lists (Current, Ongoing, Active, Chronic, etc.)

•  Coders must use caution when given diagnosis lists •  While it is appropriate to code for all known current diagnoses, caution

should be exercised to avoid improperly coding any diagnosis in such a list which could not be current, is not believed to be current, or appears to be mistakenly brought forward from a past visit documentation

•  In general, if diagnoses are listed as current, ongoing, active, chronic, etc., they may be coded, especially if there is another specific separate listing of PMH diagnoses

•  Conditions that resolve and have no additional mention in the record should not be coded unless TAMPER™ guidance is met

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Coding from Lists (Current, Ongoing, Active, Chronic, etc.) Example: Chronic Problems: A-‐Fib (on Coumadin) Acute Pancrea88s (admieed 2002) Old MI CVA (2000) CKD (Followed by Dr. Jones, nephrology) Prostate CA • RATIONALE: The above list may be 8tled as “chronic condi8ons, but not all of the condi8ons listed are current. This is a common problem for coders. The A-‐Fib is clearly current as there is current medical treatment, the acute pancrea88s appears to be historical only, the Old MI may be coded as factual, the CVA is not only historical (one could code a history of code and any related residual condi8ons if noted, but an ac8ve CVA code cannot be coded once a pa8ent has been discharged for the CVA anyway, CKD is clearly s8ll under treatment, and Prostate CA lacks any current ongoing treatment that would be necessary to code a cancer as current.

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Coding from ROS (Review of Systems) •  Some coders have voiced concerns about coding diagnoses from the

ROS (Review of Systems) portion of the record and this hesitation can be related back to the E&M coding guidelines

•  While this portion of the medical record documentation’s intention is for the purpose of documenting any talking points with the patient for feedback on how they are doing by systems, many providers will still document accurate diagnoses in this section of a record

•  The main warning in this area is to avoid coding for any “patient-stated” conditions

•  Conditions or diagnoses that are only reported by the patient as recounting to the current provider are not acceptable without provider validation.

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Coding from ROS (Review of Systems)

Example 1: ROS: Respiratory: COPD, Hypoxia, on inhaler and home oxygen Cardiovascular: no complaints of SOB, no palpita8ons, MI 1992

• RATIONALE: The above ROS annotates that the pa8ent is on current treatment for the COPD and there is a valid Old MI noted during the ROS as well that is valid.

Example 2: ROS: Respiratory: pa8ent states her PCP told her she has COPD • RATIONALE: The above ROS merely annotates a pa8ent stated condi8on that is not confirmed by the current trea8ng provider. It is ‘diagnosis hearsay’ and should not be coded.

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Coding from the Exam

•  The exam portion of the medical record’s purpose is a placeholder to document the actual physical exam portion of the encounter between the patient and the treating provider

•  Many providers may still also list valid diagnoses in this section of the record and any diagnoses documented, as current should be coded appropriately

•  Often this may be the only area where amputations, an ostomy, or other important factors may be noted

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Coding from the Exam

Example 1: Exam: Extremi8es: Good Lt. pedal pulses; Rt. Above Knee Amputa8on (2006).

• RATIONALE: In the above exam, the provider merely uses the exam por8on to annotate that there is a above the knee amputa8on. The code for amputa8on status would be appropriate to code.

Example 2: Exam: Appearance: Appears cachec8c. • RATIONALE: In the above exam, the provider is merely annota8ng an appearance and not making a diagnosis of cachexia. “Appears” is the same as “likely” which is not a diagnosis.

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Coding from the Assessment & Plan

•  The assessment and plan portions of any record are the final portions of documentation for each encounter

•  These should generally always be coded, with one word of caution, in that many providers will list items in the assessment, which have resolved or are no longer current. –  Examples of potential improper diagnoses in assessment/plan:

•  Stroke: Should only be coded as current up to discharge of care for stroke in inpatient setting. Outpatient follow up visits should be coded as “history of stroke”

•  Cancers: Many providers are unclear if cancers are still current and cancers may only be coded as current if there is current ongoing chemo, radiation, or hormonal treatment toward the cancer, or if the cancer id present and the patient has refused treatment or “watchful waiting” has been chosen

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Clinical Documentation Barriers

For Risk Adjustment Purposes


Provider Signatures •  Most organizations flag signature issues so that they can

improve provider documentation with feedback to providers •  The lack of a signature or credential does not make the

diagnosis untrue and should still be captured when appropriate

•  In a RADV (Risk Adjustment Data Validation) audit by CMS, the printed name, credential, and signature may all be validated during the audit via an attestation

•  Diagnoses themselves however cannot be authenticated during such an audit

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Signature Issues

Unacceptable Signature/ Authen6ca6on

Acceptable Signature/ Authen6ca6on

“Signed but not read” Handwri?en signature or ini:als of trea:ng provider

“Dictated but not signed/ read”, etc. Electronic signature/ authen:ca:on (e.g. “authen:cated by”, “completed by”, “finalized by”, “validated by”, “a?ested by”, “sealed by”, etc.

Signed by someone other than the trea:ng provider (nurse, transcrip:onist, etc.) on providers behalf Signature stamps were phased out effec:ve 12/31/2008. (Note that some EMR systems affix a JPEG that may look like a signature stamp and these are approved)

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Using Signs and/or Symptoms instead of making a Diagnosis

•  Coding guidelines instruct it may be appropriate to code for signs and or symptoms, when the trea:ng provider has not yet established a diagnosis

ICD-‐9-‐CM: Sec+on IV. Diagnos+c Coding and Repor+ng Guidelines for Outpa+ent Services E. Codes that describe symptoms and signs •  Codes that describe symptoms and signs, as opposed to diagnoses, are acceptable for repor8ng purposes

when a diagnosis has not been established (confirmed) by the provider. Chapter 16 of the ICD-‐9-‐CM, Symptoms, Signs, and Ill-‐Defined Condi8ons (Codes 780.0 – 789.9) contain many, but not all codes for symptoms. (ICD-‐9-‐CM, 2013)

ICD-‐10-‐CM: Sec+on IV. Diagnos+c Coding and Repor+ng Guidelines for Outpa+ent Services D. Codes that describe symptoms and signs •  Codes that describe symptoms and signs, as opposed to diagnoses, are acceptable for repor8ng purposes

when a diagnosis has not been established (confirmed) by the provider. Chapter 18 of the ICD-‐10-‐CM, Symptoms, Signs, and Abnormal Clinical and Laboratory Findings Not Elsewhere Classified (Codes R00 – R99) contain many, but not all codes for symptoms. (ICD-‐10-‐CM, 2013 DraO)

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Uncertain Diagnosis - Outpatient

Cannot Use in Outpa6ent Records:

May Use in Outpa6ent Records:

Sugges:ve of / Symptoms of / Likely Early / Underlying Consistent With / Compa:ble With Evidence of Suspicious for / Pending Element of Probable / Suspect / Tendency / Possible Component of Presumed / Sign(s) of / Suspect Significant Pre-‐______ / or ______ vs. ______ Compensated Rule-‐Out / Perhaps / Ques:onable Results show ___________

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Uncertain Diagnosis - Inpatient •  Uncertain diagnoses are handled differently in the inpatient vs.

outpatient settings •  Diagnoses that are still uncertain in an inpatient encounter, and

are still uncertain at the time of discharge may be reported, however, if during the inpatient stay, tests and other evaluation determine that the diagnosis is not accurate then it may not be coded

•  Thus, a probable or possible heart attack, if still uncertain at the time of discharge, may be coded as a heart attack and a possible heart attack that was ruled out by discharge cannot be coded as a heart attack

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“Consistent with…”

•  Many providers, especially in pathology use the phrase “consistent with” when describing a diagnosis or condition

•  The provider may feel that they are diagnosing the condition to the best of their ability based on known data and therefore use this phrase to establish their relative certainty with a very small margin of error

•  However, The Coding Clinic® has ruled that this terminology means the same as “suspected” and that the provider is still unsure of the diagnosis and therefore it is not acceptable wording to establish a diagnosis

•  “Consistent with” diagnoses may be coded in inpatient settings if the diagnosis is still uncertain at the time of discharge

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Use of Up and Down Arrows [↑ or ↓] •  Coding Clinic® issued a 2011 answer on the use of up and

down arrows for diagnosis coding purposes (e.g. ↑ cholesterol, ↓ thyroid) and per the Coding Clinic®, “it is not appropriate for the coder to report a diagnosis based upon up and down arrows

•  Diagnosing a patient’s condition is solely the responsibility of the provider

•  “Up and down arrows can have variable interpretations and do not necessarily mean “abnormal”. They could simply be indicating change (including improvement) over past results”. (Coding Clinic®, 2011)

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Overview •  Risk Adjustment is a method to collect all known current diagnoses

for each patient to improve disease management, forecast for financial needs, and establish payment in some cases

•  Coders should follow ICD coding guidelines to code for all coexisting conditions while also following Coding Clinic® determinations

•  Some entities may only be focused on HCC relevant codes, while others may be more global, such as CDPS

•  Some entities may choose a conservative approach in the collection of codes, while being mindful of costs

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Risk Adjustment Coding

•  Risk Adjustment coding takes a slightly different mindset from coding for Fee-For-Service encounters

•  There are often difficult decisions that can be encountered in risk adjustment diagnosis collection, but if coders adhere to the TAMPER™ guideline, these can become easier

•  There may be other entities with policies and procedures that may be inconsistent with this teaching, however this presentation is congruent with the concepts and purposes of risk adjustment data collection

•  Look for more information on Risk Adjustment from AAPC and ionHealthcare in the future

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THANK YOU Brian Boyce, BSHS, CPC, CPC-‐I CEO, Proprietor and Managing Consultant www.linkedin.com/in/boycebrian/ [email protected]

Contact Us at: www.ionHealthcareLLC.com

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Applying Concepts Quiz

1.  Mr. Jones came in for follow up visit with his PCP. A full SOAP note was documented and signed by the trea:ng MD.

Assessment: 1.  DM with polyneuropathy 2.  Hypertension 3.  Heartburn Can the coder document GERD in the above note? a)  Yes b)  No

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1.  Answer: b) No

Ra:onale: The documenta:on of “heartburn” is only a symptom and does not risk adjust. The diagnosis of GERD (gastro-‐esophageal reflux disease) must be made specifically.

This example illustrates the importance of documen:ng actual diseases as

opposed to their symptoms if they are a current true diagnosis.



2.  Ms. Smith came in for follow up visit with her PCP. A full SOAP note was documented and signed by the trea:ng MD.

Assessment: 1.  Diabetes (DM) Type II 2.  Peripheral Neuropathy 3.  Hypertension What are the proper codes for the diabetes & neuropathy listed above? a)  250.00, 357.2 b)  250.60, 356.9 c)  250.00, 356.9 d)  250.60, 357.2



2.  Answer: c) 250.00, 356.9

Ra:onale: In this example, There is no “cause & effect” demonstrated between the diabetes and the peripheral neuropathy. If the provider has documented the cause & effect rela:onship such as: “DM with peripheral neuropathy”, “Peripheral neuropathy due to diabetes”, “Diabe:c peripheral (or poly) neuropathy”, etc., then the codes would be jus:fied for a 250.60 and a 357.2.

This example illustrates the importance of documen:ng all cause & effect rela:onships, especially in diabetes.

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3.  Mr. Chung came in for follow up visit with his PCP. A full SOAP note was documented and signed by the trea:ng MD.

CC/HPI: Mr. Chung is here for follow up of his COPD, Diabetes, HTN. He has a history of prostate cancer. Medica6ons: Singulair, Albuterol inhaler, Actos, NPH insulin, sliding scale, HCTZ, Atenolol. Assessment: 1. COPD, 2. Diabetes, 3. Hypertension

Can the coder code for prostate cancer as an ac:ve diagnosis? a)  Yes b)  No



3.  Answer: b) No

Ra:onale: Prostate cancer is only listed as a “history of” in the CC/HPI of this record. In this scenario, a “Personal history of prostate cancer” would be appropriate but not an ac:ve prostate cancer code. Guidelines require that in order for cancers to be coded as current/ac:ve, there must be treatment directed to the cancer. If the pa:ent had been on radia:on, chemo, or hormonal treatment for his prostate cancer, then it could be coded as a current diagnosis.

This example is a reminder of cancer coding guidelines.


Applying Concepts Quiz 4.  Ms. Hernandez came in for follow up visit with her PCP. A full SOAP note

was documented and signed by the trea:ng MD. CC/HPI: Ms. Hernandez is here for follow up of her Diabetes, HTN, and Depression with anxiety. Medica6ons: Actos, NPH insulin, sliding scale, HCTZ, Atenolol, Prozac, Clonazepam. Assessment: 1. Depression, 2. Diabetes, 3. Hypertension

What is (are) the right code(s) for depression and anxiety above? a)  296.20, 300.00 b)  300.00, 311 c)  300.4

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Applying Concepts Quiz 4.  Answer: c) 300.4

Ra:onale: In this example, the documenta:on only states depression with anxiety. Even though she is on an an:-‐depressant medica:on, the diagnosis of “major depression” has not been made, and coders may not assump:ve code. The 311 depression code would be correct if depression alone were her problem or if depression and anxiety were listed separately. However, in the example she is stated to have “depression with anxiety”. The 300.4 combina:on code would be correct for these two together.

This example highlights depression vs. major depression & anxiety coding.



5.  Mr. Davis came in for follow up visit with his PCP. A full SOAP note was documented and signed by the trea:ng MD.

Assessment: 1. Diabetes, 2. Hypertension, 3. Kidney Disease

What is (are) the right code(s) for kidney disease noted above? a)  585.9 b)  593.9 c)  584.9 d)  585.1



5.  Answer: b) 593.9

Ra:onale: In this example, the provider did not use specific documenta:on for the kidney disease. Had the provider noted it as “chronic”, then a 585.9 code would be correct for unspecified staging. Without the descrip:on of the kidney disease, the default code would be the unspecified code of 593.9, “unspecified disorder of kidney and ureter”. This is the same default code when “chronic” is not used to describe a renal insufficiency as well.

This example covers the needed specificity in kidney disease coding.

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6.  Ms. White came in for follow up visit with her PCP. A full SOAP note was documented and signed by the trea:ng MD.

CC/HPI: Ms. White is here for follow up of her Atrial Fibrilla8on, COPD, HTN, and Depression. She has a past history of DVT. Medica6ons: Coumadin, Singulair, Advair, Actos, HCTZ, Tarka, Abilify. Assessment: 1. Depression, 2. COPD, 3. Hypertension, 4. A-‐Fib

May the coder code for the DVT men:oned above as an ac:ve diagnosis? a)  Yes b)  No



6.  Answer: b) No Ra:onale: In this example, the DVT is only listed as a “history of” and there is

a personal history code for this that would be appropriate. The pa:ent is on Coumadin, owen used for DVT treatment, however she also has A-‐Fib., and it is more likely that this medica:on is being used for the ongoing atrial fibrilla:on.

This example illustrates the cri:cal thinking necessary for reviewing current

medica:ons as they pertain to PMH diagnoses in order to iden:fy them as current or ac:ve problems.



7.  Mr. Green came in for follow up visit with his PCP. A full SOAP note was documented and signed by the trea:ng MD.

CC/HPI: Mr. Green is here for follow up of his hypertension. Medica6ons: Digoxin, HCTZ, Nitrostat Sublingual, prn PMH: Angina Assessment: 1. HTN

May the coder code angina men:oned above as an ac:ve diagnosis? a)  Yes b)  No

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7.  Answer: a) Yes

Ra:onale: While angina is listed as “PMH” (Past Medical History), the pa:ent is currently on nitro-‐stat (which is used to manage angina) and this makes the angina recognized as a current or ac:ve condi:on. The provider should have annotated the angina in the assessment to remove any ques:on of the diagnosis, but under this situa:on, the code may s:ll be captured.

This example illustrates the use of PMH to iden:fy ac:ve diagnoses when specific medica:ons support the diagnosis as ongoing or current.



8.  Ms. Fudd came in for follow up visit with her PCP. A full SOAP note was documented and signed by the trea:ng MD.

CC/HPI: Ms. Fudd is here for follow up of Rt. Lower leg pain. Medica6ons: Coumadin PMH: Compartmental syndrome status post surgery 2 years ago. Assessment: 1. Rt. Leg pain (NOTE: Duplex Doppler report of lower extremi8es

from radiologist shows findings of: “consistent with DVT”.

May the coder code DVT men:oned above as an ac:ve diagnosis? a) Yes b) No



8.  Answer: b) No Ra:onale: The Coding Clinic (a department within the AHA-‐ American Hospital

Associa:on) issues formal rulings on diagnosis coding. One of those rulings states that any diagnosis described as “consistent with” cannot be coded as ac:ve or current as the descrip:on is too vague and a specific diagnosis is not being made with this wording choice. [Similar wordings which pose problems include: “appears to be”, “is likely”, “probable”, “suspect”, “may be”, etc.

This example highlights the rules around coding unspecific diagnoses when described as “consistent with”.

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9.  Mr. Bird came in for follow up visit with his PCP. A full SOAP note was documented and signed by the trea:ng MD.

CC/HPI: Mr. Bird is here for follow up weakness in leO leg status post CVA 2 weeks ago. Assessment: 1. Lt. leg weakness 2. insomnia

What is/are the proper code(s) for the Lt. leg weakness listed above? a)  342.80 b)  728.87 c)  438.20 d)  434.91, 438.20


Applying Concepts Quiz 9.  Answer: b) 728.87 Ra:onale: In this example, there is only a “lew weakness noted”. Another

Coding Clinic determina:on states that the word “hemiplegia” must be used to gain this diagnosis code. Even with the history of CVA, the coder is unable to pair these two condi:ons without specific cause and effect as well as specific wording. Also note that CVA’s may only be coded up to the point of discharge for the treatment of the CVA and awerward only a personal history of CVA may be coded.

This example shows the importance of both cause and effect documenta:on as well as specific wording to code correctly. It also highlights the rule for CVA coding.


Applying Concepts Quiz 10.  The following assessment is found in a Hand-‐wri?en note:

What is/are the proper code(s) for the assessment above? a)  305.1, 272.4, 401.9, 250.00 b)  272.4, 401.9, 250.00 c)  272.4, 401.9 d)  401.9

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Applying Concepts Quiz 10.  Answer: d) 401.9

Ra:onale: The HTN is the only code that can be obtained from this example. Posi:ve history of smoking cannot translate to tobacco dependence (it must be stated), so the 305.1 code is incorrect. The diabetes is very ques:onable due to legibility, so it should not be coded. The cholesterol is listed as “↑ chol”. The Coding Clinic has a determina:on that coders may not code from up and down arrows ↑ or ↓, as these are not defini:ve and may only mean improved or decompensated from last visit.

This example illustrates coding clinic rules on up and down arrows, illegible notes, and clinical documenta:on specificity.


CEU CODE: CUBS242 Contact Us at: www.ionHealthcareLLC.com

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