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Dennis T Tse, MD, CPC All Rights Reserved D .Tse
• Capitated payment to health plans for Medicare
patients since 1970’s
• Congress passed the Balance Budget Act of 1997
and created Medicare + Choice
• Benefits Improvement protection Act(BIPA 2000)
mandated the use of ambulatory diagnosis in
Medicare risk adjustment. D .Tse
The Medicare Modernization Act of 2003 changed Medicare + Choice to Medicare Advantage
The new Medicare risk adjustment model was gradually phased into Medicare advantage payment calculations starting in 2004 with full implementation in 1/2007)
Developed by researchers at RTI International, Boston University and Harvard medical school, Hierarchical Condition Categories, uses ambulatory and inpatient diagnosis to create a valid risk adjustment methodology to help predict individual expenditure variation among Medicare patients.
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Hierarchical Condition Categories (HCC)
The key concept of HCC documentation is choosing the correct HCC code or diagnosis for the same medical condition.
For CMS, it is the HCC code or diagnosis that determines the level of illness of the patients and the RAF score. In general, the higher level illness is associated with higher HCC weight for that HCC diagnosis
RAF= risk adjustment factor RAF = Demographic Factor + HCC (age, gender, medicaid/ESRD status/county residence, etc)
RAF(total) = demo--RAF + HCC ---RAF
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Risk Adjustment Factor(RAF) 2009-2010 Medicare patient average RAF IS 1.00
2009-2010 California medical group average RAF is 1.35
CMS reimburses 1% HIGHER for every 0.01 RAF increase
I.E. 10% increase payment for RAF 1.10 from 1.0
5
5
DIAGNOSIS
CODING DRIVES
THE RAF SCORES
RAF SCORES
DRIVE THE
REIMBURSEMENT
IMPROPER
DOCUMENTATION
TAKES AWAY THE
REIMBURSEMENT
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Patient care is the number one priority
Care cannot be altered to meet coding strategies. After care is given, then proper coding becomes important.
Face to face encounter with physician(medical provider) needed
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Documentation must be legible
All chart notes must contain:
1. Patient ID
patient name, DOB and other unique
identifier must appear on every page
2 Date of Service
3 Signature should include credential (MD, DO, etc)
4 Electronic signatures must be authenticated. Typed or
stamped signatures are not acceptable.
A diagnosis can only be coded when it is
explicitly worded in the documentation. “rule
out”, “probable” or “consistent with”, cannot be
coded as actually having the disease.
Coding should be supported by documentation.
Diagnosis must be documented to the highest
level of specificity.
(“atherosclerosis of aorta” VS “atherosclerosis”)
Linkage between 2 different diagnoses should
be documented in the chart with words such as
“due to” “associated with” ,“secondary to” or
“with” (applies mostly to DM)
The terms “probable”, “more than likely” do not
provide linkage
History of”.. is the appropriate documentation in
the assessment only if the patient has been
cured. It means the patient no longer has the disease.
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Medical decision making
Assessment (HCC diagnosis)
Status (new, stable, controlled, etc)
Plan
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Listing of diagnoses is
not acceptable
VALIDATION AUDITS
1. Each year, CMS conducts Risk Adjustment Data
Validation (RADV) audits to determine if
submitted diagnoses are documented in the
medical record.
2. Health plans, hospitals and physician offices
must submit medical records that are requested
for audit.
3. Improperly documented diagnoses may result in
loss of reimbursement.
HCC
Team
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Guided introductory
tour of HCC
By Dennis Tse, MD, CPC
2 sections of diagnoses
25 disease groups of diagnoses
70 categories of diagnoses
Over 3100 HCC diagnoses
7 disease groups have
subgroups
Itinerary of HCC Tour
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• Psych—170 dx • CVD (Cerebrovascular disease) • Neuro---86 dx • Eye • Spinal • Heart • Vascular • Lung • Arrest • Liver • Gastrointestinal • Urinary • Musculoskeletal • Amputation • Skin • blood
Section 1- Organ Systems
H C
C
I’m Mr. Doe
You can stare
But don’t touch
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Section 2- Conditions • Metabolic
• Diabetes-primary or secondary
• Infections -42 dx
• Substance abuse
• Transplant
• Opening
• Neoplasm
• Injury
• Complication
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MD IS TONIC
H
C
C
N
a
v
i
g
a
t
o
r
Psych 54 Schizophrenia 0.478 60 dx
55 Major depressive , bipolar and paranoid disorder
0.322 110 dx
HCC– major depressive disorder, single episode 296.1x Recurrent major depression, recurrent episode 296.3x Non HCC diagnosis—depression NOS 311 dysthymic disorder 300.4
If multiple diagnosis are used within the group, only the highest HCC -RAF weight code will count
HCC
RAF
category
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CVD (Cerebrovascular disease)
95 Cerebral hemorrhage--includes Subarachnoid
hemorrhage, extradural hemorrhage, subdural hemorrhage,
intracranial hemorrhage 0.296
• 96 Ischemic or unspecified stroke -- includes Occlusion of artery, cerebral thrombosis, CVA, and aborted
CVA 0.242
100 Hemiplegia/hemiparesis includes hemiplegia,
And late-effect hemiplegia 0.399
101 Cerebral palsy and other paralytic syndrome ---includes monoplegia, late-effect monoplegia and paralysis -nos 0.164
Diagnoses from different hierarchical tress are additive
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Non HCC diagnosis (No risk adjustment)
TIA 354.9
muscle weakness 728.87,
Other late effects of CVD, apraxia---438.81
Other late effects of CVD, dysarthria---438.82
Other late effects of CVD, facial droop---
438.83
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NEURO 70 Muscular dystrophy 0.361 3 dx
71 Polyneuropathy 0.299 47dx
Includes autonomic neuropathy alcoholic/diabetic/idiopathic and
polyneuropathy due to other drugs
72 Multiple sclerosis 0.547 5 dx
73 Parkinson’s and Huntington’s disease 0.540 4 dx
74 Seizure disorders and convulsions 0.244 22 dx
75 Coma, brain compressive/anoxic damage 0.379 5 dx
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EYE
119 Proliferative diabetic retinopathy and
vitreous hemorrhage 0.230
Spinal
67 Quadriplegia, other extensive paralysis 0.923
68 Paraplegia 0.907
69 Spinal cord disorders/injuries 0.509
includes late effect of spinal cord injury, neurogenic bladder, cauda
equina and cerebellar ataxia
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Heart 80 Congestive heart failure 0.374
81 Acute myocardial infarction 0.328
82 Unstable angina and other acute
ischemia heart disease 0.259
83 Angina pectoris/old myocardial infarction
0.223
92 Specified heart arrhythmia 0.269
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HEART Category 80—CHF Systolic and diastolic heart failure , acute cor pulmonale, chronic pulmonary heart disease(pulm hypertension), pulmonary artery anurysm, myocarditis
Category 81-83-ischemic heart disease Acute MI of various locations to old MI, chordae tendinae/papillary muscle rupture,angina(controlled) Acute MI becomes “old MI” after 8 wks
Category 92—specific heart arrythmia AV block, PAT, PVT, Afib, Aflutter, sinoatrial node dysn (pacemaker patients)
Non-HCC CAD - 414.01 Cardiac dysrythmia -- 427.9
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Vascular
104 Vascular disease with complications
0.557
105 Vascular disease 0.288
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vascular disease with complications category 104
Arterial/vein Embolism/occlusion
Dissection of artery
Aneurysm with rupture
Acute vascular insuffciency of intestine
Renal vascular disorder
Gangrene
Gas gangrene
Various locations By CT ,Xray or UTZ
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vascular disease category 105
Arterial ectasisa/atherosclerosis
Aneurysm without rupture
chronic vascular insuffciency of intestine
Acquire arteriovenous fistula
PVD (ABI or clinical dx)
Chronic and acute DVT
HCC- atherosclerosis of aorta 440.0
Non HCC unspecified atherosclerosis 440.9
Various locations By CT ,Xray or UTZ
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Lung
107 Cystic fibrosis 0.364
108 COPD/emphysema/obstruct asth
0.364 (bronchitis does not risk adjust)
111 Aspiration and specified pneumonia 0.642
112 Pneumococcal pneumonia , empyema, lung abscess
0.227
ARREST
77 Respiratory dependence/tracheostomy status 1.704
78 Respiratory arrest 0.988
79 Cardio-respiratory failure and shock 0.528
Includes chronic respiratory failure and hypoxemia
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Liver
25 End-stage liver disease 0.893
includes esophgeal varices, Hepatic encephalopathy,
Portal Hypertension, and hepatorenal, and other
Sequela of chonic liver disease(ascites, coagulopathy)
26 Cirrhosis of liver 0.371
Includes alcohol and nonalcoholic cirrhosis, and biliary cirrhosis
27 Chronic hepatitis 0.371
Includes hepatitis B/C ,autoimmune hepatitis and
NASH (Nonalcoholic steatohepatitis)
Do not write “Hepatitis B/C” or “carrier of hepatitis B/C”
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Gastrointestinal
31 Intestinal obstruction/perforation 0.284
Includes peritonitis, stomach/duodenal perforation, fecal
impaction and ileus
32 Pancreatic disease 0.368
Include celiac disease, tropical spru and intest postop nonabsorb
33 Inflammatory bowel disease 0.220
Includes ulcerative colitis and crohn’s disease
Non- HCC Constipation, unspecified 564.00
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Urinary
130 Dialysis status 1.232
131 Renal failure –including CKD
And Acute Renal Failure(AKI) 0.336
132 nephritis- including nephrotic
syndrome and glomerulonephritis 0.114
Non-HCC renal insufficiency 593.9
renal sclerosis 587
small kidney, unspecified 589.9
proteinuria 791.0
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CKD STAGES
GFR Description
CKD Stage 1 > 90 Normal kidney
function but urine
findings or structural
abnormalities or
genetic trait point to
kidney disease
CKD Stage 2 60-89 Mildly reduced kidney
function, and other
findings
CKD Stage 3 30-59 Moderately reduced
kidney function
CKD Stage 4 15-29 Severely reduced
kidney function
CKD Stage 5 < 15 Very severely or end-
stage kidney failure
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Musculoskeletal
37 Bone /joint/muscle infections/necrosis--
Including polio osteopathy pyogenic/bacterial/viral/dysenteric
Mycotic/helminth/infectious arthritis and chronic
And acute osteomyelitis and aseptic necrosis 0.488
38 Rheumatoid arthritis and inflammatory
connective tissue disease –includes polymyalgia
Rheumatica, sicca syndrome, polymyositis 0.316
Amputation(extremities)
177 Amputation status, lower limb/amputation
complications –must be documented q yr for CMS 0.619
Includes great toe, toes, foot, ankle, above/below knee, hip
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Skin
148 Decubitus ulcer of skin –must document site and
stage stage 1.053
SITE---elbow, upper/lower back, hip, buttock, ankle, heel
Decubitus stages
Stage 1– non blanching erythema
Stage 2 -abrasion , blister, shallow crater, partial thickness skin loss
Stage 3- full thickness skin loss involving damages of necrosis into
subcutaneous soft tissue
Stage 4-full thickness loss with necrosis of soft tissue to the muscle, tendons
or bones
149 Chronic ulcer of skin of various locations, except
decubitus 0.410
150 Extensive third degree burns 1.293
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Coding Corner 36
Stage I sacral pressure ulcer.
Diagnosis ICD-9 HCC
RAF
Pressure Ulcer Lower Back 707.03 1.053
Pressure Ulcer Stage I 707.21 1.053
Total HCC RAF 1.053
HCC diagnosis ICD-9
Atherosclerosis of extremity 440.20
Ulcer, lower limb 707.10
Non HCC diagnosis
Atherosclerosis
Open wound, bed sore, pressure sore
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Blood
44 Severe hematologic disorders 0.927
Includes myelodysplastic syndrome, thalasemia, sickle cell
disease, hemolytic/aplastic anemia, pancytopenia and splenic
sequestration
45 Disorders of immunity 0.833
Includes neutropenia and hypogammaglobulinemia
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Section 2- Conditions • Metabolic
• Diabetes-primary or secondary
• Infections -42 dx
• Substance abuse
• Transplant
• Opening
• Neoplasm
• Injury
• Complication
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MD IS TONIC
Metabolic
21 Protein –calorie malnutrition 0.781
Many chronic and acute conditions that can result in malnutrition
include:
Cancer
Pancreatitis
Alcohol abuse and/or dependence
Liver Disease, Alcoholic hepatitis, cirrhosis
CHF, COPD
ESRD
Depression
Non HCC dx- failure to thrive
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Diabetes –primary or secondary
15 Diabetes with renal or peripheral circulatory
manifestation 0.464
16 Diabetes with neurological or other specified
manifestation 0.372
17 Diabetes with acute complications 0.309
18 Diabetes with ophthalmic or unspecified
manifestations 0.236
19 Diabetes without complication 0.148
Linkage of diagnoses can be established in the chart with terms such as the specific
disease, “with”, “due to”, “associated with” or “secondary to” diabetes
The terms “probable, “more than likely” do not provide linkage All Rights Reserved D .Tse
Coding Corner 51 year old man with type II DM,well controlled on januvia
with elevated urine microalbumin/creatinine three months
apart CrCL of 65 cc/min
DM II with renal
manifestations
not stated
uncontrolled
250.40 0.464
CKD stage 2 585.2 0.336
Total HCC weight 0.800
DM II w/o
complications not
stated
uncontrolled
250.00 0.148
Proteinuria 791.0 0
Total HCC weight 0.148
Although only the highest diabetes with complication HCC weight will count,
the associated manifestations are additive All Rights Reserved D .Tse
Infection
1 HIV/AIDS 0.863 3 dx
2 Septicemia/septic shock 0.693 24 dx
5 Opportunistic infections 0.274 15 dx
Substance abuse
51 Drug/alcohol Psychosis 0.250
INCLUDES ALCHOHOL -WITHDRAWAL/SLEEP DISORDER/MENTAL DISORDER,
DELIRUM TREMEN
52 Drug/alcholol dependence 0.250
Includes opioid, seditive/hypnotic, cocaine, cannabis, amphetamine, and
hallucinogen
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Transplant
174 Major organ transplant status 0.644
Includes heart, lung, liver, pancreas, intestine and bone marrow
transplant
Opening
176 Artificial openings for feeding or elimination
0.604
Includes gastrostomy, colostomy, ileostomy, enterostomy,
cystostomy, cutaneus-vesico status and urinostomy
Must reported every year
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Neoplasm -primary or secondary
7 Metastatic cancer to various organs. acute leukemia with active disease or remission
2.078
8 Cancer of Lung upper digestive tract and
other severe cancers 0.961
Includes other leukemias in with active disease or remission
9 Lymphatic, head and neck, brain and other
major cancers 0.725
Includes M myelona and other leukemia with active disease or remission
10 Breast , prostate, colorectal and other
cancers and tumors 0.190
Includes benign neoplasm of brain, cranial nerve(acoustic neuroma), spinal cord, Pituitary, and pineal gland
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Active malignancy diagnosis should continue until the patient has completed definitive treatment that includes surgery, chemotherapy and radiation therapy that is aimed at eradicating the malignancy
Patient who have completed therapy can only be given a “personal history of cancer” diagnosis, even if they are undergoing surveillance for re-occurrence of the malignancy
Patients who have not received definitive treatment for the their malignancy should continue to have an active malignancy diagnosis
Patients on adjuvant therapy (tamoxifen, lupron, casodex and 5-FU) are coded as if they have active disease. Eg-breast cancer, prostate cancer.
Patient who have completed therapy can only be coded with a “personal history of cancer” diagnosis code, even if they are undergoing surveillance for re-occurrence of the malignancy
ONCOLOGY
Injury
154 Severe head injury 0.379
155 Major head injury 0.097
Includes late effect of intracranial injury and skull/face fx
157 Vertebral fractures (open or close) without spinal
cord injury 0.404
158 Hip fracture/dislocation 0.392
161 Traumatic amputation 0.619
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Complications
164 Major complications of medical care and trauma
0.270
Includes malfunction of various prosthesis, grafts, devices,
catheter. Think organ system and MD IS TONIC
CVD/Neuro, eye, heart, vascular, breast, GI, urinary,
musculoskeletal, skin, diabetes, injury
996.7x Complication of internal prosthetic device, implants
and graft—cardiac, renal, vascular, nervous system, GU
996.64 infection and inflammatory reaction due to
indwelling urinary catheter
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DISEASE INTERACTION 48
Disease Interaction
Interaction Chronic Condition HCC RAF
1 DM/CHF# 0.154
2 DM/CVD 0.102
3 CHF/COPD 0.219
4 COPD/CVD/CAD 0.173
5 RF/CHF# 0.231
6 RF/CHF/DM# 0.477 # RF/CHF/DM is hierarchical to CHF and DM/CHF
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HCC
Team
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We have concluded the tour of HCC. Please exit the bus carefully and start the HCC
exercises.
Coding Exercise 50
A patient is seen with Insulin Dependent Type II Diabetes
and secondary progressive nephropathy that requires
Peritoneal dialysis.
Diagnosis ICD-9 HCC
Weight
Diabetes with renal manifestation, Type II 250.40 0.455*
ESRD requiring chronic dialysis 585.6 0.329
Dialysis Status V45.11 1.208 *
Long term use of insulin V58.67 0.148
TOTAL HCC RAF 1.663
* Diagnoses included for total RAF
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Coding Excercise
51
A patient is seen with Insulin Dependent Type II Diabetes
and secondary progressive nephropathy that requires
Peritoneal dialysis. Co-morbidities of CHF and renal artery
atherosclerosis
Diagnosis ICD-9
HCC RAF
Diabetes with renal manifestation, Type II 250.40 0.455
ESRD requiring chronic dialysis 585.6 0.329
Dialysis Status V45.11 1.208
Long term use of insulin V58.67 0.148
Renal artery atherosclerosis 440.1 0.288
CHF 428.0 0.374
TOTAL HCC RAF 1.663 + 0.662 2.325
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Case history Mr. Brown is a 56 year old male who came to request refills of pain
medication because of persistent back pain for a long time. He
takes 2 vicodins Bid for pain control for long time. Thoracic spine X-ray showed compression fracture at T-5 in the past.
He has had major depression since age of 40. He takes
medication for depression. He became disabled since he had
back surgery that lead to spinal cord injury and led him to have
paraplegia with neurogenic bladder and made him wheel chair
dependent. On further questioning, Mr. Brown admitted to have
history of cocaine dependence until 20 years ago. He was actually
admitted to detox unit to stop cocaine abuse. Patient has not used
cocaine since. Mr. Brown also developed a residual speech
impediment since he had a subdural hematoma 4 years after he fell out of the wheel chair
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Physical exam VS BP 130/70 pulse 60 resp 20
HEENT- NC/AT
Neck- no adenopathy
Lungs—clear
Card– RRR
Abdomen—soft and nontender no HSM
Ext 2+ bilat d pedis no leg swelling
Neuro—pt not able to move legs
CN 2-12 intact pt noted to speak very slow and at
times speech is slight slurred. This is unchanged for long
time per patient
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HCC-Assessment Cocaine dependence, in remission 0.250 52
Paraplegia 0.907 68
Neurogenic bladder (0.509) 69
Late effect of Spinal cord injury (0.509) 69
Late effect of intracranial injury 0.097 155
Major depressive disorder, recurrent 0.322 55
Fracture of thoracic vertebra 0.404 157
HCC RAF total- 1.980
Status and plan needed for every assessment (diagnosis)
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