BC ADVANTAGE AUDIO SERIES MEDICARE RISK ADJUSTMENT CODING

BC ADVANTAGE AUDIO SERIES: MEDICARE RISK ADJUSTMENT CODING 101 1 Presented by: Darlene Boschert, RHIA, CPC-H, CPC-I Providing LOW-COST educational resources for Medical office Professionals

RISK ADJUSTMENT 101 Prior to 2003 Payments to the health plan were based on demographics – male, female, age, zip code. 2003 MRA payment methodology was started in 2003 Mandated by the Balance Budget Act of 1997 2003 – 2007 Between 2003 and 2007 the project was phased in Since 2007, payment is based on formulaic calculation: CMS approved base rate x factors associated with HCCs x factors associated with member’s demographics 2

RISK ADJUSTMENT 101 Risk Adjustment Payment methodology used by Medicare Advantage health plan to adjust health plan payments Based on the enrollee health status and demographic characteristics Hierarchical Condition Category (HCC) Model What is Hierarchical Condition Category? • CATEGORY OF MEDICAL CONDITIONS THAT MAP TO A CORRESPONDING GROUP OF ICD-9 DIAGNOSIS CODES • 10, 000 ICD-9 codes map to 1 of 188 HCCs 3

EXAMPLE OF HCC AND ICD-9 CODE MAPPING ICD-9 -CM Codes, CMS-HCC and Rx. HCC Models DIAGNOSIS CODE 272. 0 272. 1 272. 2 272. 3 272. 4 272. 5 272. 7 272. 8 272. 9 273. 2 273. 3 273. 4 275. 01 275. 03 275. 09 275. 1 275. 3 277. 00 SHORT DESCRIPTION Pure hypercholesterolemia Pure hyperglyceridemia Mixed hyperlipidemia Hyperchylomicronemia Hyperlipidemia NEC/NOS Lipoprotein deficiencies Lipidoses Lipoid metabolic dis NEC Lipoid metabolic dis NOS Paraproteinemia NEC Macroglobulinemia Alpha-1 -antitrypsin def Heredity hemochromatosis Hemochromatosis NEC Disorder iron metablsm NEC Dis copper metabolism Dis phosphorus metabolic Cystic fibrosis w/o ileus 2013 CMS-HCC Model Category 107 CMS-HCC PACE/ESRD Model Category 23 23 23 110 Rx. HCC Model Category 23 23 23 18 19 19 19 103 4

RISK ADJUSTMENT 101 CMS MODELS In addition to the CMS-HCC Model, there are two other risk adjustment model of payments. Two of the models include sub-models or categories. CMS-HCC model for Medical Part A and B New Enrollee Sub-Model Community Sub-Model Long-Term Institutional Sub-Model ESRD Model for ESRD Beneficiaries New Enrollee Sub-Model Dialysis Sub-Model Transplant Sub-Model Post Transplant Sub-Model Part D drug Model 5

RISK ADJUSTMENT 101 CHARACTERISTICS OF CMS-HCC MODEL HCCs/Multiple Chronic Diseases Base payment for each member based on HCCs and influenced by Medicare Costs for Chronic Diseases Diagnostic Sources CMS will consider Diagnoses from IP & OP, Hospital & Physician Disease interactions Additional factors applied when hierarchy of more severe and less severe conditions exist Characteristics of CMS-HCC Model Prospective in Nature Diagnosis from base year used to predict payment for next year: Enrollee vs Existing Enrollee Demographics Final adjustment due to: age, sex, original Medicare entitlement, disability & Medicaid status 6

MEAT ? ? ? Just what is this? These are the guidelines you must follow to make sure that the documentation you are auditing has everything that you need. Documentation must support the code selected in accordance with the established ICD-9 -CM and Coding Clinic coding guidelines Code all documented co-existing conditions which impact patient care (i. e. management and/or treatment) 7

MEAT? ? Do not code conditions that no longer exist (e. g. stated “history of” conditions with no evidence of current active treatment or “resolved”, etc. ) Do not code rule out, suspected, or probable conditions 8

ACCEPTABLE SOURCE DOCUMENTS • • • Progress Notes Consult Notes Procedure Notes Hospital Notes Pathology Reports Each page of the source document must contain a patient name and date of service or shows continuity from page to page Enter the ARC note stating “Patient name or DOS is not on subsequent page” in cases where either the patient name or DOS is missing or only shows continuity Example of Continuity for notes without patient name and DOS on each page of the note (Note: The following example is not all-inclusive, there are other forms of acceptable continuity; consult a manager/lead when in doubt): “Page (1 of 3), (2 of 3), (3 of 3)” on each page of the note 9

UNACCEPTABLE SOURCE DOCUMENTS § Skilled Nursing Facility (SNF) (SNF visits are acceptable IF the provider is not employed by the SNF, consult a manager/lead when in doubt) § Diagnostic Radiology § Freestanding Ambulatory Surgery Center (ASC) § Alternative data sources (e. g. , pharmacy) § Unacceptable physician extenders (e. g. , nutritionist) § Durable Medical Equipment (DME) 10

CONSULTATION NOTES – DATE OF SERVICE Before abstracting diagnostic data from a consult note you must first verify that the visit was a face-to-face encounter and that the date of service is clearly documented. Ascertaining the date of service can sometimes be difficult on consult notes because of letter formatting. Acceptable vs. Not Acceptable – Examples Not Acceptable Date: 02/04/08 Dear Dr. Smith: Mary is seen in consultation. I have been following your patient for peripheral neuropathy. Patient is doing well and will be returning to you for follow up care. Bob Green, MD Mary is seen today in consultation. I have been following your patient for peripheral neuropathy. Patient is doing well and will be returning to you for follow up care. Bob Green, MD 11

HOSPITAL NOTES WITHIN AN OUTPATIENT RECORD • Following are acceptable record sources in the hospital setting: o Admit History & Physical o Hospital progress notes o Operative reports o Discharge/Transfer Summary • The Discharge/Transfer Summary is the preferred hospital note • Hospital records are to be abstracted in accordance with ICD-9 Coding Guidelines for Outpatient Services o Exception: Special inpatient projects – Always consult your manager/lead before coding according to Inpatient Guidelines 12

PATHOLOGY REPORTS • Pathology reports are acceptable, as a last resort, if the record is from an approved facility/provider type • Pathology reports are reviewed in accordance with the established ICD-9 Coding Guidelines for Outpatient Services • The “collection date” is always assigned as the date of service for diagnosis codes abstracted from a pathology note • Conditions listed as probable, suspected, consistent with, rule out, etc. are not confirmed diagnoses, therefore, should not be captured in accordance with the established ICD-9 Coding Guidelines for Outpatient Services 13

ACCEPTABLE DOCUMENTATION HPI & ROS – Conditions may be captured from one of these sections when its documentation indicates that a condition was monitored, evaluated, addressed, assessed and/or treated PMH – Status codes (e. g. , old M. I. , amputations, etc. ) may be captured from this section. This section should also be used to confirm specificity (e. g. , surgical procedures may serve to confirm “active” vs. “history of” conditions) Exam – Exam findings constitute evaluation (e. g. , actinic keratosis, arthritis, etc. ) Assessment/Plan – Coded conditions must be substantiated either by evaluative statements or evidence that conditions were monitored/addressed/assessed or treated 14

M. E. A. T. M Monitor: Order/reference labs/other tests E Evaluate: Examine (as in the Physical Exam) A Address/Assess: Address: Acknowledge that the condition exists and is being managed / Assess: Give Status or Level of a condition T Treat: Prescribe medication, surgical/otherapeutic intervention, referral to other specialists for treatment/consult, any plan for management of a condition 15

M. E. A. T. • Documentation of a descriptive diagnosis only is insufficient for entitled HCC code capture • Documentation of each condition must also be accompanied by evidence of at least one of the following: § § § Monitoring Evaluating Addressing Assessing Treating (Note: Some conditions carry specific M. E. A. T. requirements, i. e. cancer, acute care setting conditions such as CVA, TIA, etc. ) 16

MONITORING Example Phrases indicating Monitored conditions include, but are not limited to: Patient with osteoporosis § § Dexa scan reveals osteoporosis Dexa scan ordered Patient with hyperlipidemia § Lipid profile ordered and/or results recorded Patient with GERD § EGD scheduled Patient with diabetes § HGBA 1 c and/or FBS, etc. ordered and/or results recorded 17

EVALUATING Example Phrases indicating Evaluated conditions include, but are not limited to: Diagnosis: Hypertension Patient’s blood pressure is slightly elevated (objective evaluation by M. D. ) § Blood Pressure/Vitals recorded (BP evaluated in physical exam) § Diagnosis: Asthma § Physical Exam – Chest: Decreased breath sounds, no rhonchi or wheezing (pertinent system evaluated in physical exam) Diagnosis: Generalized OA § Physical Exam – Extremities: Arthritic changes fingers both hands (Pertinent system evaluated in physical exam) 18

ADDRESSING VS. ASSESSING – WHICH IS WHICH? Example Terms/Phrases indicating Addressing and Assessing of conditions include, but are not limited to: § Addressing: Acknowledgment of a condition and its management § Assessing: Terms indicating status/level of a condition; such as stable, unstable, worsening, improved, mild, moderate, severe, controlled, uncontrolled, doing well, progressing, etc. § “Patient currently takes Xanax for anxiety” (Addressing) § “Patient currently takes Xanax for severe anxiety” (Addressing & Assessing) § “Patient’s depression is managed by Dr. Adams” (Addressing) § “Patient’s depression is managed by Dr. Adams, stable on Zoloft” (Addressing & Assessing) 19

ADDRESSING & ASSESSING - CONTINUED More example phrases indicating Addressing/Assessing of conditions include, but are not limited to: • • • “Patient has GERD which is followed by Dr. Smith” (Addressing) “Patient’s depression is improved with Prozac” (Assessing/Addressing) “Patient’s gout stable on Colchicine” (Assessing/Addressing) Blanket statements such as “Continue meds” or “Labs ordered” or “Continue Treatment” (without the specific medications and/or labs or treatment, as applicable, documented somewhere on the note to indicate which medications or labs are being referred to) are not specific enough. We must know which medication and/or lab test and/or treatment is being prescribed/filled or ordered. 20

TREATING • Treatment is typically documented in the Assessment/Plan section Examples indicating the Treating of conditions include, but are not limited to: § Medication prescribed/refilled § Referral of patient to a specialist for further evaluation and management § Surgical intervention (major and minor) § Counseling on diet, exercise, smoking cessation, lifestyle modification, etc. o Note: This type of counseling is not sufficient to support capturing all conditions categorically; consult a manager/lead for direction § “Continue current meds” (medication name or type must be on the note) § “Continue current treatment“ (treatment name or type must be on the note) 21

WHERE’S THE M. E. A. T. ? Scenario 1: Mrs. Clark comes in with her list of problems, she has been trying hard to follow her diet and has lost 2 lbs. Her lipids look good and I encouraged her to continue with her diet. Her hip is not as sore since starting the Celebrex. She said she is also walking and enjoys that. She states she is getting out more with friends now and it helps her forget how sad she is since her husband died. She continues to take the Prozac but not as often as before. Assessment: Depression (see underlined phrase for Addressing) Hyperlipidemia (see underlined phrases for Assessing / Treating) DJD (see underlined phrase for Addressing) Return to office in 2 months 22

WHERE’S THE M. E. A. T. ? APHE M. E. A. T. ? Scenario 2: HISTORY: The patient recently had chest congestion. No fever, chest pain. Follow up for CHF, HTN, arthritis, coronary disease. Has no SOB, edema, chest pain. PFSH and meds reviewed – unchanged. ROS negative for skin rash, joint pain. PHYSICAL EXAMINATION: Nutrition good, BP 120/80, pulse 80, respirations 16, temp. 97. 0. PERRLA, conjunctiva clear, teeth, lips and gums normal, thyroid not enlarged, no neck mass, heart sounds are normal, no lift or thrill, lungs are clear, no rales, retraction, abdomen – no tenderness or mass, liver and spleen not enlarged, skin – no lesions, texture normal. Trace edema. IMPRESSION: Resolved bronchitis, stable CHF, hypertension, arthritis on medications. DISPOSITION: Continue medications. 23

WHERE’S THE M. E. A. T. ? HISTORY: Patient returns today with complaints of fatigue, congestion, headache for the past 6 days. Exam reveals boggy nasal turbinates, patient is very congested. No fever noted. Chest clear, no rales or wheezing. ASSESSMENT: Acute URI, amoxicillin 500 mg TID ANSWER: Exam – ENT and respiratory systems evaluated Treatment – Medication prescribed 24

WHERE’S THE M. E. A. T. ? HISTORY: Patient is seen for follow-up today of history of GERD, HTN, hypercholesterolemia, all stable on medication. Patient was counseled on diet and exercise and will return in 3 months for followup. ASSESSMENT: GERD, HTN, hypercholesterolemia ANSWER: Addressed/Assessed – “all stable on medication” Treatment – “patient was counseled on diet and exercise” 25

M. E. A. T. FAQ Question: "Continue current treatment documented on the same line as the diagnosis" is this considered documentation of MEAT? Answer: Yes, the main thing we do not want to see is just a listing of diagnoses in an EMR without documentation of monitoring, evaluation, assessing/addressing and treatment documented. Question: I'm a little unsure about when we can use medication lists when coding. When we have lists of medications within a note commonly titled as "CURRENT MEDICATIONS"- can we use these to match up with diagnoses listed in the assessment if they have no other MEAT? Answer: No. One exception would be if the medications are documented in the plan or they state continue all meds or continue meds in the plan. 26

M. E. A. T. FAQ Question: The provider states "patient currently taking…" either in the body of the note or in the Plan and lists a bunch of medications. Answer: This would be acceptable. The main thing we do not want to see is just a listing of diagnoses in an EMR without documentation of monitoring, evaluation, assessing/addressing and treatment documented. Question: The doctor lists diabetes in the PMH but does not mention it in the Assessment/Plan or provide any other MEAT for it. What should we do? Answer: Do not code, look for a better note. 27

M. E. A. T. FAQ Question: I see on the physical exam that the patient has some osteoarthritic changes in the hands. Is this codeable as 715. 34? Answer: No, the provider needs to make a definitive diagnostic statement of OA, ICD-9 -CM does not list a specific code for osteoarthritic changes Question: Chronic low back pain with a history of spinal stenosis. Note states continue Oxycontin 40 mg tid. Do we code the spinal stenosis instead of back pain? Answer: Code spinal stenosis 724. 00 RX-HCC category 45. Continue Oxycontin is considered treatment 28

M. E. A. T. FAQ Question: When a patient is described as 'anxious' or 'depressed' in the psychiatric exam portion of the note, is it acceptable to code 300. 00 or 311? Answer: No, the provider must make a clear assessment based on the DSMIV criteria. Question: When the physical exam portion of the note states “evidence of arthritis” or “arthritic changes noted” and the Assessment/Plan states “Arthritis”, is it okay to code arthritis if there is no other MEAT in the note? Answer: Yes. You can look within the body of the note for MEAT documentation. The diagnosis was documented in the Assessment/Plan; therefore, a notation on the exam supports the diagnosis definitively stated in the Assessment/Plan. 29

M. E. A. T. FAQ Question: I have a chart with a list of medications, do the medications have to be directly linked to the condition? For example, if Nexium is listed in the medication list And there is a Dx of GERD in the assessment, can we code it or does it have to specifically state Nexium for GERD? Answer: We cannot use a medication from the medication list only, unless there was other monitoring or evaluation noted. Such as GERD stable on Nexium for reflux worse in the evening, improvement with Nexium. Question: If the assessment states hyperlipidemia and HTN and the only plan is check bloods“, is this enough MEAT for hyperlipidemia? Answer: No. We need more specific information to indicate the blood tests referred 30 to monitor hyperlipidemia; such as, lipid profile, BMP, etc.

M. E. A. T. FAQ Question: I have a note with a list of medications and a list of conditions and the end of the note states “continue meds”. is that enough meat, or does the note need to specify which meds are being used for a specific diagnosis? Answer: If there is only one diagnosis and the plan states continue meds that is acceptable. If there is more than 1 diagnosis and the plan states continue meds that is not acceptable because we cannot be certain which of those conditions is on medication. However, if there are 3 diagnoses and the medications are listed in the assessment and plan section with the diagnoses that would be acceptable. We want to stay away from coding only from a medication list. Question: Can we pickup late effects without there being evidence of treatment? Answer: Yes, these are residual conditions and can be coded. Often times there may be no treatment for the late effect (e. g. hemiparesis). 31

M. E. A. T. FAQ Question: If the physician documents hypertension in the assessment and they show the vitals of the BP in the exam is that enough MEAT? Answer: If the HTN was documented in the Assessment/Plan and the B/P was taken then it is acceptable enough. But IF the HTN was documented under the past medical history or stated as history of HTN this would not be acceptable unless there Is further MEAT. Such as, “patient here for f/u of HTN” only documented in the HPI and Assessment/Plan states only “continue current meds” or “advises low sodium diet…”, etc. 32

M. E. A. T. FAQ Question: I have had some doctors who are putting an "assessment" in the ROS. I know we are not to capture from this because it is normally the patient's words, but I am not sure about these "assessments" I am seeing. I have listed some examples: "hypothyroidism, doing well followed by Dr. Smith" or "DM under care of Dr. Jones" or "significant for coronary artery disease who sees Dr. Brown for”. Answer: This is more than a review of systems. The provider is documenting an assessment, even through the he has included this information in the ROS we should capture the diagnosis. Coder needs to read the entire note and assign codes based on MEAT. 33

M. E. A. T. FAQ Question: Do we need MEAT for both conditions to capture a combination code for the following conditions, HTN/CKD, COPD/Acute Bronchitis? Answer: No, one form of MEAT covers both conditions. You may use the combination code if the diagnoses are listed in the assessment or HPI. Be careful coding conditions from the past medical history that may no longer exist. Question: The patient presents for a scratchy throat and cough and under the assessment and plan the provider documents a diagnosis: Esophagitis Reflux, Course: “Progressing as expected". Under the plan there are no meds for the reflux. Can I code this with the statement of "progressing as expected? Answer: Yes, this would fall under evaluating and/or assessing in the M. E. A. T. elements. 34

M. E. A. T. FAQ Question: The note states "breast cancer, stable". Is this enough MEAT for a Cancer diagnosis? I know that each note stands alone but the other note for the same patient states "history of breast cancer". Should I enter the cancer note asking if the patient is currently receiving treatment? Answer: We cannot code cancer without documentation of active treatment such as; chemotherapy, radiation or antineoplastic treatment. Documentation that indicates a contraindication for treatment, or refused treatment would also be acceptable. 35

M. E. A. T. FAQ Question: The provider documents diabetic nephropathy, neuropathy and retinopathy but she’s only addressing the patients blood sugars and the nephropathy (labs done for creatinine and BUN). My question is, under the revised MEAT guidelines can I pickup the DM neuropathy and retinopathy since it is showing a relationship between the DM and the complications? There are no medications listed for these conditions. Answer: Yes, the provider documented the patient’s blood sugar. This would be evaluation or monitoring of their diabetes and their complication. It would be incorrect coding to only code the diabetes without the complication. 36

THANK YOU FOR LISTENING Darlene Boschert, RHIA, CPC-H, CPC-I darlenecpc@tampabay. rr. com 37