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QRA Coaching

Consists of a provider specifically trained in Risk Adjustment documentation and coding

Mining medical records for Risk Adjustment diagnoses

Available for one on one coaching on risk adjustment, coding, quality, etc

Program is designed to help you achieve better coding, documentation, and quality for your patients and your business

Coordination will take place with your office staff, managers, PBMs, and market medical directors

More details to come …

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Financial Disclosure

Dr. Robin Eickhoff has no relevant financial interests to disclose.

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Objectives

By the end of this presentation, you will be able to apply best practices to improve risk adjustment processing system (RAPS) documentation in your clinic.

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Introduction

During this presentation, we’ll look at the following:

The language barriers between coding and clinical language

When documentation will and won’t support a diagnosis

WellMed Medical Management - Do not copy or distribute without written permission.

The impact of documentation that does not validate on a Centers for Medicare and Medicaid Services (CMS) Risk Adjustment Data Validation (RADV) audit

5

Coding Language vs. Clinical Language

Avoid “history of” statements

“Unspecified” vs. “Other Specified” in coding language

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History of …

In clinical language, “Patient presents with History of DM, HTN, Hyperlipidemia” means patient has these diagnoses …

HOWEVER …

In coding language, this means the diagnoses:

Are in the “history” and no longer active.

Would be coded as a “Z” code: “Personal History of…” and not billable codes.

This is particularly a problem if “history of” is used in the Assessment section.

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Unspecified vs. Other Specified

Unspecified

There is not enough detail in the documentation to use a more specific diagnosis/code.

“Lazy man’s code”

Other Specified

The specific diagnosis is known, however there is no specific ICD-10 code to match it.

You must also identify what the “OTHER” is in the documentation.

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Unspecified

Sometimes there is no other choice:

e.g. PVD is unspecified, but usually a more specific code exists.

Using a less specific diagnosis can result in decreased reimbursement:

Major Depressive Disorder, single episode (with no severity specified), does NOT risk adjust!

Ex: Major Depressive Disorder, single episode, mild (or moderate, severe, in remission) all risk adjust.

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Unspecified

Example:

Major Depression Documentation

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Unspecified

WellMed Medical Management - Do not copy or distribute without written permission.

8. Single major depressive episode on zyprexa at 2.5 mg a day, patient takes ½ tab po qdaily uses diazepam at night time and occasionally during day, understands risks of using zyprexa and diazepam F32.9: Major depressive disorder, single episode, unspecified

15.Single major depressive episode – declines medical rx at present. She again declines medical treatment. F32.9 Major depressive disorder, single episode, unspecified

WALK THE PLANK!!

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Unspecified

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8. Single major depressive episode on zyprexa at 2.5 mg a day, patient takes ½ tab po qdaily uses diazepam at night time and occasionally during day, understands risks of using zyprexa and diazepam F32.9: Major depressive disorder, single episode, unspecified

15.Single major depressive episode – declines medical rx at present. She again declines medical treatment. F32.9 Major depressive disorder, single episode, unspecified

mild

mild

AVAST, MATEY! PASS THE RUM!

12

Other Specified

You MUST document what “OTHER” is!!

If there is no specific documentation identifying “other,” the documentation will not validate for a CMS audit.

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Example – ”Other specified”

Current Medications

Taking • Diazepam 5 MG Tablet 1 tablet as needed

Twice daily • Micardis HCT 80-12.5 MG Tablet 1 tablet

Once per day • Levothyroxine Sodium 75 MCG Tablet 1

tablet Once per day • Atorvastatin Calcium 20 MG Tablet 1 tablet

Once per day • Alendronate Sodium 70 MG Tablet 1 tablet

Q weekly for Osteoporosis • Aspir-8181 MG Tablet Delayed Release 1

tablet Once per day • Vitamin D3 1000 UNIT Capsule 1 capsule

Once per day • Vitamin B-6 MG Tablet 1 tablet Once per day • Flonase 50 MCG/ACT Suspension 1 spray in

each nostril Once per day Not Taking/PRN • Zantac 150 Maximum Strength 150 MG

Tablet 1 tablet q day prn reflux sxs

Reason for Appointment

1. 6 month f/u 2. Pt unaccompanied at today’s visit 3. Pt brought in a list of current medications but not the bottles History of Present Illness

General: The patient is an 80-year-old female with history of hypertensions, major depression, sinus bradycardia, coronary artery disease, pulmonary hypertension, and CK D3. The patient presents to clinic for routine follow-up and reports she’s been doing very well. The patient informs me she continues to perform all of her activities of daily living and walks for exercise. She states she likes to stay active and she tries to follow a low-fat low-cholesterol diet. The patient denies depression SI/HI, shortness of breath, external chest pain, palpitations, black/red stools, fever/chills, malaise or acute change in vision/speech/memory/extremity function. The patient does admit to experiencing nocturnal leg and foot pain and is requesting medication for her neuropathy.

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Example – ”Other specified”

Assessments

1. Need for pneumococcal vaccine – Z233 (Primary) 2. Polyneuropathy in other diseases classified elsewhere – 357.4 3. General medical examination – Z00.00 4. Hypothyroidism, unspecified – E03.9 5. Vitamin D deficiency, unspecified – E 55.9 6. Pure hypercholesterolemia – E78.0 7. Bradycardia, unspecified – R00.1 8. Anemia in chronic kidney disease – D63.1 9. Atherosclerosis of aorta – I70.0 10.Essential (primary) hypertension – I10 11. Gastro-esophageal reflux disease without esophagitis – K21.9 12.Atherosclerotic heart disease of native coronary artery without angina pectoris – I25.10 13.Major depressive disorder, recurrent, in partial remission – F33.41 14.Other secondary pulmonary hypertension – I27.2 15.Chronic kidney disease, stage 3 (moderate) – N18.3 16.Diverticulosis of large intestine without perforation or abscess without bleeding – K57.30 17.Age-related osteoporosis without current pathological fracture – M81.0 18.Allergic rhinitis, unspecified – J30.9 19.Polyneuropathy in diseases classified elsewhere – G63 20.Other abnormal glucose – R73.09 21.Aortic ectasia, unspecified site – I77.819

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Example – ”Other specified”

4. Hypothyroidism, unspecified Notes: The patient is currently on levothyroxine 50 g 1 tablet daily. Her thyroid levels are within normal limits. We’ll continue to monitor patients thyroid levels.

5. Vitamin D deficiency, unspecified Notes: patient remains on vitamin D3 1000 unit capsules 1 by mouth daily, vitamin D level is on target and she was instructed to continue with the supplement.

19. Polyneuropathy in diseases classified elsewhere Notes: The patient complains of nighttime leg pain with give patient trial of Neurontin 100 mg 1 by mouth daily at bedtime. Reviewed medication profile and precautions. Reviewed fall precautions the patient. Patient will monitor symptoms and return to clinic in 3-4 weeks if symptoms persist.

20. Other abnormal glucose Notes: The patient’s recent hemoglobin A1c was 5-9. Discussed dietary modifications c low card diet and benefits of daily exercise. We’ll continue to monitor patient’s hemoglobin A1c and make med changes as needed.

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WALK THE PLANK!!

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Example – ”Other specified”

Assessments

1. Epigastric pain – 789.06 (Primary) 2. Diabetes with neurological manifestations, type II or unspecified type, not stated as uncontrolled –

250.60 3. Diabetes with other specified manifestations, type II or unspecified type, not stated as uncontrolled –

250.80 4. Other and unspecified hyperlipidemia – 272.4 5. Polyneuropathy in diabetes – 357.2 6. General medical examination – V70.9

3. Diabetes with other specified manifestations, type II or unspecified type, not stated as uncontrolled Notes: See DM with neuro. 4. Other and unspecified hyperlipidemia Notes: 2/12/1012 trig 162 HDL 38. Secondary to DM. We discussed the importance of regular exercise and dietary modifications to control lipids. Recheck lipids as noted, monitor hepatic function with LFTs.

2. Diabetes with neurological manifestations, type II or unspecified type, not stated as uncontrolled – 250.60

3. Diabetes with other specified manifestations, type II or unspecified type, not stated as uncontrolled – 250.80

5. Polyneuropathy in diabetes – 357.2

AVAST, MATEY! PASS THE RUM!

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Cancer Documentation … Arrr!

Largest area of frustration with documentation for both providers and coders

Assume the person doing the audit does NOT have clinical background

Most coders do NOT have clinical background, not required for certificate

WellMed hires RNs that are also coders, but this is unique

When CMS does audits, they are looking documentation stating specifically the cancer is active. Not enough to just choose the “Malignant Neoplasm of …” code.

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Cancer Documentation … Arrr!

Documenting ACTIVE treatment (chemo, adjunctive therapy, radiation) will confirm the diagnosis.

Documenting abnormal lab values (CEA, CA27-29, PSA) will NOT confirm the diagnosis. You must tie the labs and diagnosis together.

Medications Lists can be used to confirm a diagnosis, but with new medications, a coder may not recognize what that medicine is being used to treat, so document it!

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Example – Cancer

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Assessments

1. Malignant neoplasm of prostate – C61 (Primary) 2. Gastrostomy status – Z93.1 3. Alzheimers disease, unspecified – G30.9 4. Secondary hyperaldosteronism – E26.1 5. Polyneuropathy in disease classified elsewhere – G63 6. Hypertensive heart and chronic kidney disease with heart failure and stage 1 through stage 4 chronic kidney disease, or

unspecified chronic kidney disease – I13.0 7. Paroxysmal atrial fibrillation – I48.0 8. Unspecified diastolic (congestive) heart failure – I50.30 9. Atherosclerosis of aorta – I70.0 10. Peripheral vascular disease, unspecified – I73.9 11. Hyperlipemia – E78.5 12. CKD (chronic kidney disease) stage 2, GFR 60-89 ml/min – N18.2 13. Actinic keratoses – L57.0 14. Prediabetes – R73.09 Treatment

1. Malignant neoplasm of prostate Notes: Has been on Lupron in the past and followed with urology, not interested in pursuing further treatments or f/u at this time.

WALK THE PLANK!!

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Example – Cancer

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Assessments

1. Malignant neoplasm of prostate – C61 (Primary) 2. Gastrostomy status – Z93.1 3. Alzheimers disease, unspecified – G30.9 4. Secondary hyperaldosteronism – E26.1 5. Polyneuropathy in disease classified elsewhere – G63 6. Hypertensive heart and chronic kidney disease with heart failure and stage 1 through stage 4 chronic kidney disease, or

unspecified chronic kidney disease – I13.0 7. Paroxysmal atrial fibrillation – I48.0 8. Unspecified diastolic (congestive) heart failure – I50.30 9. Atherosclerosis of aorta – I70.0 10. Peripheral vascular disease, unspecified – I73.9 11. Hyperlipemia – E78.5 12. CKD (chronic kidney disease) stage 2, GFR 60-89 ml/min – N18.2 13. Actinic keratoses – L57.0 14. Prediabetes – R73.09 Treatment

1. Malignant neoplasm of prostate Notes: Has been on Lupron in the past and followed with urology, not interested in pursuing further treatments or f/u at this time. We will continue to monitor this active cancer for progression.

AVAST, MATEY! PASS THE RUM!

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Example – Cancer

Current Medications

Taking • Simvastatin 40 mg Tablet 1 tablet in the

evening Once a day • Benazepril HCI 20 MG Tablet 1 tablet Once a

day • Aspirin 81 MG Tablet 1 tablet Once a day • Calcium 600 MG Tablet 1 tablet with meals

twice a day • Vitamin D 5000 IU 1 tablet as needed Once a

day • Tamoxifen Citrate 20 MG Tablet 1 tablet

Once a day • Levothyroxine 25 MCG Tablet 1 tablet Once

a day • Vitamin D 5000 unit Capsule as directed

Reason for Appointment

1. 5 month f/u 2. pt accompanied by husband 3. pt brought in a list of current medications but not the bottles verbally went over to the best

of the patients ability History of Present Illness

General: The pt is an 82 y/o F who presents for routine f/u on her Mult Med Problems. She continues to be followed by Oncology for her Breast Cancer. She has a hx of venous stasis ulcers and c/o new lesion on her Lt Leg which she states started about 5 wks ago. She denies SOB, CP, Palp, Wt loss, F/c, pain, N/v or acute change to her visions/speech/memory or extremity functions.

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She continues to be followed by Oncology for her Breast Cancer.

22

Example – Cancer

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Assessments

1. Venous stasis ulcer of left lower extremity – 454.0 (Primary) 2. Chronic kidney disease, Stage I – 585.1 3. Breast CA – 174.9 4. Pure hypercholesterolemia – 272.0 5. Benign essential hypertensions – 401.1 6. General medical examination – V70.9 Treatment

3. Breast CA Notes: The patient continues to be followed by oncology for this and is currently taking tamoxifen 20 mg 1 tablet daily.

AVAST, MATEY! PASS THE RUM!

23

Cancer Documentation … Ugh!

If “active surveillance” is taking place (patient has ACTIVE cancer) you need say that specifically.

Active surveillance is when patient has active cancer and you are just monitoring it.

It is not active surveillance if the patient has undetectable or normal tumor markers and you are just watching for recurrence. Even if the oncologist documents active cancer!

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Cancer Documentation … Ugh!

Resolve active cancer once patient is considered treated and “in remission.”

Exception: Leukemia and multiple myeloma “in remission” are still considered active cancers.

Don’t forget to document metastatic cancer location. Example: Secondary Malignant Neoplasm of lymph nodes.

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When Your Coder Reviews Your Notes …

Don’t make them look like this …

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… 26

When Your Coder Reviews Your Notes …

Or this …

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… Or this!

Or this …

27

When Your Coder Reviews Your Notes …

Make them look like THIS!!

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When Your Coder Reviews Your Notes …

… and say …

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Summary

You are now able to apply best practices to improve RAPS documentation in your clinic.

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Questions?

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