peer to peer coding
DESCRIPTION
TRANSCRIPT
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Welcome
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Bridging the ICD9 Communication Gap
Physician members RPO
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Glossary
• CMS – Center for Medicare/Medicaid Services
• MA - Medicare Advantage = capitated Medicare product (ex: Texas Health Springs)
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Glossary
• ICD9 coding – International Classification of Diseases, 9th Revision
• E & M coding – Evaluation and Management
• HCC – Hierarchical Condition Category
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Communication
Foundation Block of Our Profession
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• Ancillary Services• Consult with specialists• Review medical literature
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Problem / Diagnoses List
Defines Disease Complexity
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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
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Proper Flow of InformationMedicare Advantage
Good coding
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Proper Flow of RevenueMedicare Advantage
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Gap in Communication
Poor coding
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Gap in Flow of Revenue
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Bridging the Gap in ICD9Communication
Poor coding
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Proper Allocation of Resources
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Pitfalls !
• ‘Up-scoring’ = using an ICD9 code without proper documentation
• Up-scoring ICD9 equivalent to Up-coding E&M code– Same penalties – Same risks
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Schutzhund Pic/analogy
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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
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ICD9 CodingSimple, but Not Easy
• Simple – attach a number to a diagnosis / condition
• Not Easy = thousands of diagnoses / conditions
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Barrier to Proper ICD9 Coding “Information Overload”
• Over 12,000 ICD9 codes
• Only 3000 have HCC value
• 3000 remains overwhelming
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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
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Presentation HCC Conditions
• Diabetes complications–Renal–Peripheral circulatory–Neurological–Ophthalmological
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Presentation HCC Conditions
• Hypertension complications–Hypertensive Heart Disease–Hypertensive Kidney Disease–Combination HDD & HKD
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Presentation HCC Conditions
• COPD
• Old MI / CABG / CAD
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Presentation HCC ConditionsCharacteristics
• Leading causes of death & disability
• Under-diagnosed
• Outcome improvement possible
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Our Experience
• Have a system in place to process complex data
– History
– Physical findings
– Labs/tests/specialty consultation
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Our Experience
• Goal is to use every encounter as an opportunity
• Not practical in a ‘typical’ PCP office
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Our SystemDemonstration purposes only – not RPO sanctioned
• Annual Health Review
–No co-pay
–Checklist customized to age, gender, known history
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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
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Our System
• Annual Health Review
–Checklist components• Tied or ‘linked’ to correct ICD9 codes
• EMR / paper (demonstrations to follow)
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Our System
• Annual Health Review
–Augment with interactive DVD
• www.crosbyclinic.com
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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
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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
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Diabetes Renal Complications
• History – ask - checklist
• Physical exam– Limited value
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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
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Diabetes Renal Complications
• History – ask - checklist
• Physical exam– Limited value
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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
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Diabetes Renal Complications
• Proteinuria detection
– Timed collection – 24 hr/ 10 hr overnight• Prone to collection error• Cumbersome for patient and staff
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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)
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Diabetes Renal Complications
• Estimated glomerular filtration rate (eGFR) – Labs routinely providing eGFRs
– http://nkdep.nih.gov/professionals/gfr_calculators/
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Diabetes Renal Complications
• Once DM with renal complication verified:
–250.4x …… PLUS
– Manifestation Code• Most common = CKD 585.1-9
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Diabetes Renal Complications
• Type 2 DM - (eGFR 52 - A1c 8.3)
250. 42 • 4 = renal• 2 = Type 2/uncontrolled
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Diabetes Renal Complications
• Type 2 DM - (eGFR 52 - A1c 8.3) –250.42
–PLUS - 585.3 • 3 = Stage 3 CKD
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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
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Diabetes Renal ComplicationsWhat if THS is under-funded
• Patient suffers
• THS vulnerable
• You are undercompensated
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Pitfall Reminder
• Goal is accurate ICD9 coding
• Up-scoring ICD9 equivalent to Up-coding E&M code– Same penalties – Same risks
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Coding Memorization
• Impossible to recall all variations
– ICD9 ‘text’ – gold standard
– Laminates / linked checklists
– EMR
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• EMR demonstration
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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
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(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
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Diabetes Peripheral Vascular Complications
• History – Symptoms• Claudication• Pallor, skin changes
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Diabetes Peripheral Vascular Complications
• Physical Exam:– Pedal pulses – Skin / color / hair
• Ankle-brachial index (ABI)– <0.9
– ***Dr. Sid King – Living Well
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Diabetes Peripheral Vascular Complications
• Once DM with PVD verified: – 250.7x …… PLUS
– Manifestation Code• Most common = Peripheral angiopathy 443.81
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Diabetes Neurological Complications
• History – Symptoms• Burning, numbness• Diabetic Neuropathy Score
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Diabetes Neurological Complications
• Physical exam
–Monofilament test
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Diabetes Neurological Complications
• Physical exam
– Tuning fork 128 Hz
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Diabetes Neurological Complications
• Once DM with neuropathy verified: – 250.6x …… PLUS
– Manifestation Code• Most common = Polyneuropathy 357.2
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Diabetes Ophthalmic Complications
• History – ask checklist
• Physical exam– If skilled with ophthalmoscope
• Ophthalmology consult
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Diabetes Ophthalmic Complications
• Retinopathy
• Cataract
• Glaucoma
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Diabetes Ophthalmic Complications
• Blindness
• Macular / retinal edema
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Diabetes Ophthalmic Complications
• Once DM with ophthalmic pathology verified: – 250.5x …… PLUS
– Manifestation Code• Most common = Peripheral retinopathy• 362.01-362.07
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Hypertension Complications
• Hypertensive Heart Disease
• Hypertensive Kidney Disease
• Hypertensive Heart & Kidney Disease
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Hypertension
• Essential – 401.x
• Hypertensive heart disease – 402.xx
• Hypertensive kidney disease – 403.xx
• Hypertensive heart & kidney disease – 404.xx
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Hypertension Complications
• Major factors
–Duration of hypertension
– Level of control of HTN
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Hypertension Complications
• Hypertensive Heart Disease without CHF
– Left ventricular hypertrophy
• LVH present in 30% adult hypertensives
• 90% with severe uncontrolled HTN
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• ECG criteria
• ECHO
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Hypertension Complications
• Hypertensive Heart Disease without CHF
– ??? AAA
• PE: pulsation below umbilicus
• U/S all smokers/former smokers > age 65
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Hypertension Complications
• Hypertensive Heart Disease with CHF
– CHF may, of course, present without HTN
– CHF coding is used with or without HTN
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CHF
• History– Risk factors • Hypertension, CAD, valvular disease, etc.
– Symptoms• Dyspnea• Edema• Fatigue
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CHF
• Physical Exam – Edema
– Lungs
– Neck veins
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CHF
• Testing:
– BNP
– ECHO
– Cardiology consult
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CHF
• Isolated diastolic CHF:
– Symptoms of CHF with normal ejection fraction
– ICD9 = 428.3x
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Hypertension Complications
• Hypertensive Heart Disease with CHF
–Use appropriate 402.xx HDD code
–Use additional CHF code – 428.x
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Hypertension Complications
• Hypertensive Kidney Disease
– Same diagnostic tools as DM• Microalbumin-to-creatinine ration• eGFR• Imaging
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Hypertension Complications
• Hypertensive Kidney Disease
– Code Hypertension by stage – 403.xx• Stage I-IV• Stage V-ESRD
– Use additional CKD code – 585.x
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Hypertension Complications
• Hypertensive Heart & Kidney Disease
– Use appropriate HDD 404.xx code
– Use additional CV code (CHF, etc.)
– Use additional CKD code
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COPD
• History –Ask: checklist
–Risk factors:• Smoker• Asthma• Toxic exposure• Alpha1 antitrypsin
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COPD
• History
–Chronic bronchitis – most common• Chronic sputum production (3 mo/2yrs)
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COPD
• Physical Exam
– Increased AP diameter
– Blue bloater
– Pink puffer
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COPD
• Pulmonary Function Testing
– Test all with strong historical risk factor or symptoms• 20 pack year history• Toxic exposures• Asthma
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COPD
• Acute exacerbation of chronic bronchitis – Increasing sputum production
– Increasing sputum color (white>yellow, etc)
– Increasing dyspnea
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CAD/Old MI
• Old MI - 412
• CABG – 414.04
• CAD – 414.01
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Tools
• Use symmetry report to identify high risk candidates
• “no encounter list” Legg VA my experience
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Tools
• Use EVERY encounter to search for short list codes
• Build on knowledge of short list
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• 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