AAPC Richardson, TX Chapter Monthly Meeting 4/17/2017 @ 6pm Location: Methodist Richardson/Renner Medical Center-Physician Pavilion I 2821 E President George-Physician Services Building, 2nd floor Conference Room #200 Bush Highway at Renner Rd/ Richardson, TX 75082 Speaker: Diana J. Adams RHIT, RRA, Inc. Topic: ICD10 Quick Review for 2017 Coordinating Coding Guidelines to Clinical Documentation Learn to read between the lines from guidance that is given
AAPC April 2017 Richardson Chapter Diana Adams, RHIA
Coordinating Coding Guidelines to Clinical Documentation Learn to read between the lines from guidance that is given
Codes titled unspecified are for use when the information in the medical record is insufficient to assign a more specific code. For those categories for which an unspecified code is not provided, the other specified code may represent both other and unspecified.
If a definitive diagnosis has not been established by the end of the encounter, it is appropriate to report codes for sign(s) and/or symptom(s) in lieu of a definitive diagnosis. When sufficient clinical information is not known or available about a particular health condition to assign a more specific code, it is acceptable to report the appropriate unspecified code (for example, a diagnosis of pneumonia has been determined but the specific type has not been determined). In fact, you should report unspecified codes when such codes most accurately reflect what is known about the patient s condition at the time of that particular encounter. It is inappropriate to select a specific code that is not supported by the medical record documentation or to conduct medically unnecessary diagnostic testing to determine a more specific code. Reference: www.cms.gov/medicare/coding/icd10/downloads/icd- 10mythsandfacts.pdf
Will the ICD-10 flexibilities be extended beyond October 1, 2016? CMS will not extend ICD-10 flexibilities beyond October 1, 2016. There will be no additional flexibility guidance. Many major insurers did not choose to offer coding flexibility, so many providers are already using specific codes. Please refer to the appropriate coding guidelines. www.cms.gov/medicare/coding/ic D10/Clarifying-Questions-and- Answers-Related-to-the-July-6-2015-CMS-AMA-Joint- Announcement.pdf Is Medicare going to phase in the requirement to code to the highest level of specificity? No, providers should already be coding to the highest level of specificity. ICD-10 flexibilities were solely for the purpose of contractors performing medical review so that they would not deny claims solely for the specificity of the ICD-10 code as long as there is no evidence of fraud. These ICD-10 medical review flexibilities will end on October 1, 2016. As of October 1, 2016, providers will be required to code to accurately reflect the clinical documentation in as much specificity as possible, as per the required coding guidelines.
The assignment of a diagnosis code is based on the provider s diagnostic statement that the condition exists. The provider s statement that the patient has a particular condition is sufficient. Code assignment is not based on clinical criteria used by the provider to establish the diagnosis
So how does this change support improving quality of care, reducing cost or improving documentation and the accuracy required to create accurate data? Today, when sepsis is coded, auditors search the clinical documentation to find lab (etc.) results to support the code assignment especially since the criteria is specific. With the new Guideline, how are auditors to determine whether the assigned diagnosis is accurate? Take pneumonia for example a positive chest x-ray, sputum culture, high white blood cell count, and certain findings on physical examination supports the diagnosis.
.always expected coders and auditors to examine the entire record just to be sure: The entire record should be reviewed to determine the specific reason for the encounter and the conditions treated.
The assignment of a diagnosis code is based on the provider s diagnostic statement that the condition exists. The provider s statement that the patient has a particular condition is sufficient, if adequate supporting clinical criteria are present. Code assignment by the coder should never be based solely on clinical criteria.
The classification presumes a causal relationship between the two conditions linked by these terms in the alphabetic Index or tabular List. These conditions should be coded as related even in the absence of provider documentation explicitly linking them, unless the documentation clearly states the conditions are unrelated. For conditions not specifically linked by these relational terms in the classification, provider documentation must link the conditions in order to code them as related. The classification presumes a causal relationship between hypertension and heart involvement and between hypertension and kidney involvement, as the two conditions are linked by the term with in the alphabetic Index
When a patient has a bilateral condition and each side is treated during separate encounters, assign the "bilateral" code (as the condition still exists on both sides), including for the encounter to treat the first side. For the second encounter for treatment (after one side has previously been treated and the condition no longer exists on that side), assign the appropriate unilateral code for the side where the condition still exists (e.g., cataract surgery performed on each eye in separate encounters). The bilateral code would not be assigned for the subsequent encounter, as the patient no longer has the condition in the previously-treated site. If the treatment on the first side did not completely resolve the condition, then the bilateral code would still be appropriate.
"Medically Necessary" services are procedures, treatments, supplies, devices, equipment, facilities or drugs (all services) that a medical practitioner, exercising prudent clinical judgment, would provide to a covered individual for the purpose of preventing, evaluating, diagnosing or treating an illness, injury or disease or its symptoms, and that are: in accordance with generally accepted standards of medical practice; and clinically appropriate in terms of type, frequency, extent, site and duration and considered effective for the covered individual's illness, injury or disease; and not primarily for the convenience of the covered individual, physician or other health care provider; and not more costly than an alternative service or sequence of services at least as likely to produce equivalent therapeutic or diagnostic results as to the diagnosis or treatment of that covered individual's illness, injury or disease.
For these purposes, "generally accepted standards of medical practice" means standards that are based on credible scientific evidence published in peerreviewed medical literature generally recognized by the relevant medical community, national physician specialty society recommendations and the views of medical practitioners practicing in relevant clinical areas and any other relevant factors.
G72.0 Drug-induced myopathy G72.1 Alcoholic myopathy G72.2 Myopathy due to other toxic agents G72.3 Periodic paralysis G72.4 Inflammatory and immune myopathies, not elsewhere classified G72.41 Inclusion body myositis [IBM] G72.49 Other inflammatory and immune myopathies, not elsewhere classified G72.8 Other specified myopathies G72.81 Critical illness myopathy G72.89 Other specified myopathies G72.9 Myopathy, unspecified
What is Critical Illness Myopathy? Critical illness myopathy is not well understood, but is becoming recognized as a clinical syndrome that typically occurs in the intensive care unit among patients who have been treated with multiple drugs. The most common clinical signs of the disease are diffuse weakness and a failure to wean from mechanical ventilation. Who gets Critical Illness Myopathy? Critical illness myopathy is a disease of limb and respiratory muscles, and it is observed during treatment in the intensive care unit. This sometimes may accompany critical illness polyneuropathy. In addition to the critical illness (severe trauma or infection), muscle relaxant drugs and corticosteroid medications may be contributing factors.
The Centers for Medicare & Medicaid Services (CMS) hierarchical condition categories (HCC) model, implemented in 2004, is a risk-adjustment model used to adjust Medicare payments to health care plans for the health expenditure risk of their enrollees. It s intended use is to pay insurance plans appropriately for their expected relative costs. For example, health plans that care for overwhelmingly healthy populations are paid less than those that care for much sicker populations.
Capturing demographic data is the easy part since this information is fixed and includes such parameters as patient age and address. Accurately aggregating diagnosis data is trickier since capture of this information relies on a face-to-face encounter and must be done annually. Data represented must be based on an active diagnosis. Providers can consider using the MEAT mnemonic: Being MONITORED (signs/symptoms, disease progression/regression) Being EVALUATED (test review, response to treatment) Being ASSESSED (tests ordered, record review, counseling, discussion) Being TREATED (meds, therapies, other modalities) Each year, providers must conduct a face-to-face encounter with their patients, and all diagnoses must be documented in the medical record. Only diagnoses meeting the above criteria count towards the final HCC score. For example, if a provider forgets to document a below the knee amputation diagnosis code for a patient, the encounter does not exist for the purposes of HCC calculations.
The bottom line is that clinical documentation matters.