Welcome
Bridging the ICD9 Communication Gap
Physician members RPO
Glossary
• CMS – Center for Medicare/Medicaid Services
• MA - Medicare Advantage = capitated Medicare product (ex: Texas Health Springs)
Glossary
• ICD9 coding – International Classification of Diseases, 9th Revision
• E & M coding – Evaluation and Management
• HCC – Hierarchical Condition Category
Communication
Foundation Block of Our Profession
• Ancillary Services• Consult with specialists• Review medical literature
Problem / Diagnoses List
Defines Disease Complexity
Disease Complexity(aka Burden of Disease)
Translate
IntoE & M codes
Non-capitated third party payers
Translate
IntoICD9
codes
Medicare Advantage
Communication to Third Party Payers
Proper Flow of InformationMedicare Advantage
Good coding
Proper Flow of RevenueMedicare Advantage
Gap in Communication
Poor coding
Gap in Flow of Revenue
Bridging the Gap in ICD9Communication
Poor coding
Proper Allocation of Resources
Pitfalls !
• ‘Up-scoring’ = using an ICD9 code without proper documentation
• Up-scoring ICD9 equivalent to Up-coding E&M code– Same penalties – Same risks
Schutzhund Pic/analogy
HMR
• You are verifying condition has been documented and treated in the current fiscal year in a face to face visit
• CMS will periodically audit
ICD9 CodingSimple, but Not Easy
• Simple – attach a number to a diagnosis / condition
• Not Easy = thousands of diagnoses / conditions
Barrier to Proper ICD9 Coding “Information Overload”
• Over 12,000 ICD9 codes
• Only 3000 have HCC value
• 3000 remains overwhelming
Solution
• Concentrate on important conditions in the ICD9 communication ‘gap’
–Major clinical conditions• Leading causes of premature death/disability
–High prevalence• Frequently under-coded/under-diagnosed
Presentation HCC Conditions
• Diabetes complications–Renal–Peripheral circulatory–Neurological–Ophthalmological
Presentation HCC Conditions
• Hypertension complications–Hypertensive Heart Disease–Hypertensive Kidney Disease–Combination HDD & HKD
Presentation HCC Conditions
• COPD
• Old MI / CABG / CAD
Presentation HCC ConditionsCharacteristics
• Leading causes of death & disability
• Under-diagnosed
• Outcome improvement possible
Our Experience
• Have a system in place to process complex data
– History
– Physical findings
– Labs/tests/specialty consultation
Our Experience
• Goal is to use every encounter as an opportunity
• Not practical in a ‘typical’ PCP office
Our SystemDemonstration purposes only – not RPO sanctioned
• Annual Health Review
–No co-pay
–Checklist customized to age, gender, known history
Past Medical Information
Yes No
Have you ever been told your diabetes has damaged your nerves? 6
Have you ever been told your diabetes has damaged your kidneys? 4
Current Symptoms
Do you have a numbness, burning, or tingling in your feet or legs? 6
…………………………
DO NOT WRITE BELOW THIS LINE
Yes No
Patient has loss of sensation with monofilament test or tuning fork 6
Pt has abn urine microalbumin confirmed - 2 specimens over 3 mo’s 4
Pt has decreased eGFR confirmed – 2 measurements over 3 mo’s 4
Our System
• Annual Health Review
–Checklist components• Tied or ‘linked’ to correct ICD9 codes
• EMR / paper (demonstrations to follow)
Our System
• Annual Health Review
–Augment with interactive DVD
• www.crosbyclinic.com
Diabetes as Prototype
• Uncomplicated DM – 250.0x (x = 0-3)
• 250.00 – Type 2, controlled or unk.• 250.01 - Type 1, controlled or unk.• 250.02 - Type 2, uncontrolled• 250.03 – Type 1, uncontrolled
Diabetes as Prototype
• Uncomplicated – 250.0x
• Renal – 250.4x + manifestation code
• Ophthalmic – 250.5x + manifestation code
• Neuropathy – 250.6x + manifestation code
• PVD – 250.7x + manifestation code
Diabetes Renal Complications
• History – ask - checklist
• Physical exam– Limited value
Past Medical Information
Yes No
Have you ever been told your diabetes has damaged your nerves? 6
Have you ever been told your diabetes has damaged your kidneys? 4
Current Symptoms
Do you have a numbness, burning, or tingling in your feet or legs? 6
…………………………
DO NOT WRITE BELOW THIS LINE
Yes No
Patient has loss of sensation with monofilament test or tuning fork 6
Pt has abn urine microalbumin confirmed - 2 specimens over 3 mo’s 4
Pt has decreased eGFR confirmed – 2 measurements over 3 mo’s 4
Diabetes Renal Complications
• History – ask - checklist
• Physical exam– Limited value
Diabetes Renal Complications
• Proteinuria detection
–Microalbumin-to-creatinine ratio• Spot collection = less collection error• May be transient – MUST be confirmed– ADA: + 2 of 3 over 3-6 months
Diabetes Renal Complications
• Proteinuria detection
– Timed collection – 24 hr/ 10 hr overnight• Prone to collection error• Cumbersome for patient and staff
Diabetes Renal Complications
• Estimated glomerular filtration rate (eGFR)
(Definition CKD from the National Kidney Foundation’sKidney Disease Outcomes Quality Initiative)
– GFR below 60 mL. per minute per 1.73 m2 for three
or more months (Stage 3 or greater)
Diabetes Renal Complications
• Estimated glomerular filtration rate (eGFR) – Labs routinely providing eGFRs
– http://nkdep.nih.gov/professionals/gfr_calculators/
Diabetes Renal Complications
• Once DM with renal complication verified:
–250.4x …… PLUS
– Manifestation Code• Most common = CKD 585.1-9
Diabetes Renal Complications
• Type 2 DM - (eGFR 52 - A1c 8.3)
250. 42 • 4 = renal• 2 = Type 2/uncontrolled
Diabetes Renal Complications
• Type 2 DM - (eGFR 52 - A1c 8.3) –250.42
–PLUS - 585.3 • 3 = Stage 3 CKD
Diabetes Renal Complications
What IF?
• Type 2 DM - (eGFR 52 - A1c 8.3)
250.00 vs. 250.42 + 585.3
RPO/THS Under-funded by CMS
Diabetes Renal ComplicationsWhat if THS is under-funded
• Patient suffers
• THS vulnerable
• You are undercompensated
Pitfall Reminder
• Goal is accurate ICD9 coding
• Up-scoring ICD9 equivalent to Up-coding E&M code– Same penalties – Same risks
Coding Memorization
• Impossible to recall all variations
– ICD9 ‘text’ – gold standard
– Laminates / linked checklists
– EMR
• EMR demonstration
Past Medical Information
Yes No
Have you ever been told your diabetes has damaged your nerves? 6
Have you ever been told your diabetes has damaged your kidneys? X 4
Current Symptoms
Do you have a numbness, burning, or tingling in your feet or legs? 6
…………………………
DO NOT WRITE BELOW THIS LINE
Yes No
Patient has loss of sensation with monofilament test or tuning fork 6
Pt has abn urine microalbumin confirmed - 2 specimens over 3 mo’s 4
Pt has decreased eGFR confirmed – 2 measurements over 3 mo’s X 4
(4) Diabetes – Renal Manifestations
Diabetes Renal Code
Type 2 – controlled/ukn
Type 1 – controlled/ukn
Type 2 – Uncontrolled
Type 1 – Uncontrolled
250.40 250.41 250.42 250.43
Manifestation Code
I GFR > 90 II – 60-89 III – 30-59 IV – 15-29 V- <15 Elevated microalbumin
585.1 585.2 585.3 585.4 585.5 585.9
(6) Diabetes – Neurologic Manifestations
Diabetes Neuro -
Code
Type 2 – controlled/ukn
Type 1 – controlled/ukn
Type 2 – Uncontrolled
Type 1 – Uncontrolled
250.60 250.61 250.62 250.63
Manifestation Codes
Polyneuropathy (most common) = 357.2Peripheral autonomic neuropathy = 337.1
Diabetes Peripheral Vascular Complications
• History – Symptoms• Claudication• Pallor, skin changes
Diabetes Peripheral Vascular Complications
• Physical Exam:– Pedal pulses – Skin / color / hair
• Ankle-brachial index (ABI)– <0.9
– ***Dr. Sid King – Living Well
Diabetes Peripheral Vascular Complications
• Once DM with PVD verified: – 250.7x …… PLUS
– Manifestation Code• Most common = Peripheral angiopathy 443.81
Diabetes Neurological Complications
• History – Symptoms• Burning, numbness• Diabetic Neuropathy Score
Diabetes Neurological Complications
• Physical exam
–Monofilament test
Diabetes Neurological Complications
• Physical exam
– Tuning fork 128 Hz
Diabetes Neurological Complications
• Once DM with neuropathy verified: – 250.6x …… PLUS
– Manifestation Code• Most common = Polyneuropathy 357.2
Diabetes Ophthalmic Complications
• History – ask checklist
• Physical exam– If skilled with ophthalmoscope
• Ophthalmology consult
Diabetes Ophthalmic Complications
• Retinopathy
• Cataract
• Glaucoma
Diabetes Ophthalmic Complications
• Blindness
• Macular / retinal edema
Diabetes Ophthalmic Complications
• Once DM with ophthalmic pathology verified: – 250.5x …… PLUS
– Manifestation Code• Most common = Peripheral retinopathy• 362.01-362.07
Hypertension Complications
• Hypertensive Heart Disease
• Hypertensive Kidney Disease
• Hypertensive Heart & Kidney Disease
Hypertension
• Essential – 401.x
• Hypertensive heart disease – 402.xx
• Hypertensive kidney disease – 403.xx
• Hypertensive heart & kidney disease – 404.xx
Hypertension Complications
• Major factors
–Duration of hypertension
– Level of control of HTN
Hypertension Complications
• Hypertensive Heart Disease without CHF
– Left ventricular hypertrophy
• LVH present in 30% adult hypertensives
• 90% with severe uncontrolled HTN
• ECG criteria
• ECHO
Hypertension Complications
• Hypertensive Heart Disease without CHF
– ??? AAA
• PE: pulsation below umbilicus
• U/S all smokers/former smokers > age 65
Hypertension Complications
• Hypertensive Heart Disease with CHF
– CHF may, of course, present without HTN
– CHF coding is used with or without HTN
CHF
• History– Risk factors • Hypertension, CAD, valvular disease, etc.
– Symptoms• Dyspnea• Edema• Fatigue
CHF
• Physical Exam – Edema
– Lungs
– Neck veins
CHF
• Testing:
– BNP
– ECHO
– Cardiology consult
CHF
• Isolated diastolic CHF:
– Symptoms of CHF with normal ejection fraction
– ICD9 = 428.3x
Hypertension Complications
• Hypertensive Heart Disease with CHF
–Use appropriate 402.xx HDD code
–Use additional CHF code – 428.x
Hypertension Complications
• Hypertensive Kidney Disease
– Same diagnostic tools as DM• Microalbumin-to-creatinine ration• eGFR• Imaging
Hypertension Complications
• Hypertensive Kidney Disease
– Code Hypertension by stage – 403.xx• Stage I-IV• Stage V-ESRD
– Use additional CKD code – 585.x
Hypertension Complications
• Hypertensive Heart & Kidney Disease
– Use appropriate HDD 404.xx code
– Use additional CV code (CHF, etc.)
– Use additional CKD code
COPD
• History –Ask: checklist
–Risk factors:• Smoker• Asthma• Toxic exposure• Alpha1 antitrypsin
COPD
• History
–Chronic bronchitis – most common• Chronic sputum production (3 mo/2yrs)
COPD
• Physical Exam
– Increased AP diameter
– Blue bloater
– Pink puffer
COPD
• Pulmonary Function Testing
– Test all with strong historical risk factor or symptoms• 20 pack year history• Toxic exposures• Asthma
COPD
• Acute exacerbation of chronic bronchitis – Increasing sputum production
– Increasing sputum color (white>yellow, etc)
– Increasing dyspnea
CAD/Old MI
• Old MI - 412
• CABG – 414.04
• CAD – 414.01
Tools
• Use symmetry report to identify high risk candidates
• “no encounter list” Legg VA my experience
Tools
• Use EVERY encounter to search for short list codes
• Build on knowledge of short list
• Codes Secondary– Dialysis ?DM– Decubitus– Paralysis ?? 67 VS hemiplegia 100– Amputation ?DM– Rheumatology 38– Chronic hepatitis 27– Seizures 74– Cancer 10– Drug abuse 52 **alcohol
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