Download CCHP Coding Guidelines

CCHP Coding Guidelines
(2013)
CCHP
•
Purpose
– Reimburse MA organizations accurately and fairly by adjusting payment for
enrollees based on health status.
•
Background
– Prior to 2000 MA payments were based on demographics
– 2003 CMS HCC Risk Adjustment Model phased in
• 90/10 (90% old demographic model and 10% Risk Adjustment model)
– 2007, CMS revenue to the MA organizations is based solely on the Risk
Adjustment model
– 2012, CMS Revenue has been split between Star Ratings and Risk Adjustment.
2
•
Hierarchical Condition Categories (HCC)
– Categorized ICD-9 codes of separate groups of clinically related codes or HCCs,
(e.g. diabetes, cancer, ischemic heart disease, chronic kidney disease, etc.)
– 2011-2012 76 HCC Categories comprised of over 3525 Diagnoses
– Risk Adjustment Factor (RAF) score is assigned to each HCC category
– Possible talk of increasing the HCC Categories with the implementation of ICD-10
in 2014
•
Additive Model
– The risk adjustment factors (RAF) for each member’s qualifying chronic conditions
are added together to determine the member’s health status
3
•
Lagged Model
– CMS uses diagnostic information from the prior (DOS) year reporting period as the
predictor of health care costs and revenue for the upcoming year.
•
Demographics Variable
–
–
–
–
•
Age
Sex
Medicaid eligibility
Disability status
Disease Interactions and Hierarchies
– Certain Disease Interactions allow for additional risk adjustment factors to be added
to the enrollee’s total risk adjustment factor score.
4
Valid Data Sources
•
Professional Providers - this does not limit to primary care physician (PCP).
 Other acceptable physician specialties:
Oncology
Allergy/Immunology
Anesthesiology
Dermatology
Gastro Enterology
Obstetrics/Gynecology
Opthalmology
Psychiatry
Pulmonary Disease
General Surgery
Otolaryngology
Cardiology
Colorectal Surgery
Internal Medicine
Neurology/Neuro Surgery
Othropedic Surgery
Plastic & Reconstructive Surgery
Urology etc…
REFERENCE: COMPLETE LIST OF 2013 ACCEPTABLE PHYSICAN SPECIALTY TYPE:
http://www.csscoperations.com/internet/cssc3.nsf/docsCat/CSSC~CSSC%20Operations~Risk%20Adjustment%20Pr
ocessing%20System~References?open&expand=1&navmenu=Risk%5eAdjustment%5eProcessing%5eSystem||
 Acceptable non-physician providers:
Oral Surgery (Dentist)
Nurse Practitioner (NP)
Optometry
Physician Assistant (PA)
5
Acceptable Physician Specialty Types for
2014 Payment Year (2013 Dates of Service)
Risk Adjustment Data Submission
CODE
SPECIALTY
CODE
1
General Practice
25
2
3
General Surgery
Allergy/Immunology
26
27
SPECIALTY
Physical Medicine And
Rehabilitation
Psychiatry
Geriatric Psychiatry
CODE
SPECIALTY
4
Otolaryngology
28
Colorectal Surgery
76*
5
6
7
Anesthesiology
Cardiology
Dermatology
29
33*
34
Pulmonary Disease
Thoracic Surgery
Urology
77
78
79
8
Family Practice
35
Chiropractic
80
Vascular Surgery
Cardiac Surgery
Addiction Medicine
Licensed Clinical Social Worker
36
Nuclear Medicine
81
Critical care (intensivists)
37
38
Pediatric Medicine
Geriatric Medicine
82
83
Hematology
Hematology/Oncology
67
Occupational Therapist
68
72*
Clinical Psychologist
Pain Management
Peripheral Vascular Disease
12
Interventional Pain Management
(IPM)
Gastroenterology
Internal Medicine
Osteopathic Manipulative Medicine
39
Nephrology
84
Preventive Medicine
13
14
Neurology
Neurosurgery
40
41
Hand Surgery
Optometry
85
86
Maxillofacial Surgery
Neuropsychiatry
15
Speech Language Pathologist
42
Certified Nurse Midwife
89*
Certified Clinical Nurse Specialist
16
Obstetrics/Gynecology
43
Certified Registered Nurse
Anesthetist
90
Medical Oncology
17
Hospice And Palliative Care
44
Infectious Disease
91
Surgical Oncology
18
19
20
46*
48*
50*
Endocrinology
Podiatry
Nurse Practitioner
92
93
94
Radiation Oncology
Emergency Medicine
Interventional Radiology
21
Ophthalmology
Oral Surgery
Orthopedic Surgery
Cardiac Electrophysiology
62*
Psychologist
97*
Physician Assistant
22
Pathology
64*
Audiologist
98
23
Sports Medicine
65
Physical Therapist
99
Gynecologist/Oncologist
Unknown Physician Specialty
24
Plastic And Reconstructive Surgery
66
Rheumatology
C0
Sleep Medicine
9
10
11
6
Valid Data Sources (cont..)
•
Hospital Inpatient - must be an acceptable inpatient facility
 Acceptable Inpatient Facility
Short term hospital
Long term hospitals
Rehabilitation hospitals
Children’s hospitals
Psychiatric hospitals
Med assistance facilities/Critical access hospitals
Religious non-medical institution (formerly Christian Science sanatoria)
 Non-acceptable Facility- these facilities submits directly to CMS
Skilled Nursing Facilities (SNF) Hospital inpatient swing bed
Intermediate care facilities
Respite care
Hospice
•
Hospital Outpatient - please see list of acceptable providers under professional
providers
7
Documentation Requirements
A.
Legibility - the medical record must be legible
B.
Patient Identification
-
every page must contain the following patients
information:
a) Patient first & last name
b) Patient’s date of birth
C.
Visit Date - all encounters must have a date of service otherwise, it becomes an
invalid record
*** Consult notes MUST include the date of service and not just the date of when the
letter was created.
D.
Abbreviations - Only standard and commonly used abbreviations & symbols are
acceptable in risk adjustment documentation
Example of unacceptable symbols: ↑↓
Note: Interpreting (↑↓) symbols is prohibited for coding
ICD-9 Coding Clinic, Vol 28 No 1, 1st Qtr 2011
8
Documentation Requirements (cont..)
E. Medical Record Documentation
Well documented medical records promote effective communication,
coordination, continuity and quality of care thereby overall efficiency of a
patient’s health management.
F.
Coding
▪
Accurate coding is the key to prompt and entitled reimbursement, practice
profiling and contract negotiations. It is critical for both legal and financial
reasons.
▪
While in the past reimbursement was driven by CPT (service) codes
reported, under the Risk Adjustment model the combined assigned risk
value of ICD-9 (diagnosis) codes drives payment from CMS.
▪
For this reason, the completeness of clinical documentation has reached
an
all new level of importance. It is now more important than ever for
providers and coders alike to thoroughly document and code to ensure
complete and accurate reporting of all relevant health conditions.
9
Documentation Requirements (cont..)
G. Face-to-Face
a)
b)
The medical record must clearly demonstrate a face-to-face visit for risk adjustment
purposes.
Hospital discharge note must also demonstrate that it was a face-to-face visit otherwise,
it is an unacceptable document.
What to look for: I spoke with the patient today….
c)
When reviewing a consult note please verify that the visit was a face-to-face encounter
and that the date of service is clearly documented.
Note: The dictation of the consult note cannot be assumed as the DOS. The key word
“today” identifies the dictation date as the DOS.
c)
d)
e)
Surgical notes are all acceptable.
Telephone messages as an addendum to a valid face-to-face visit is acceptable otherwise, it is
an unacceptable document.
Other unacceptable notes:
•
Super bills
•
Encounter forms
•
Referrals
H. Format of the medical record -
SOAP (Subjective, Objective, Assessment & Plan) or
free form are acceptable formats.
10
Documentation Requirements (cont..)
I.
Provider name, credentials, signature and signature date
•
•
•
•
•
•
All medical record should include the full name and credentials of the valid provider and the
date it was signed.
Signatures must include credentials and must be legible
Date when the note was signed should also be included
Preprinted forms with the providers complete information is acceptable only if it is signed.
Signature stamps are no longer acceptable effective January 1, 2009.
CR 5971 (Transmittal #248) was issued prohibiting stamped signatures.
This mandate applies to all providers and suppliers
Electronic signature are acceptable. The document must specifically state that it was reviewed
and signed by the provider
Example of valid electronic signature:
[Electronically} Signed by, Authenticated by, Approved by, Completed by,
Finalized by, Validated by, Verified by, Signed:, Confirmed by,
Example of invalid electronic signature:
Created by, Received by/for, Administratively signed, Digitally signed (unless
there is a digital signature on the document)
•
Ambiguous credentials such as PhD is required to specify the specialty such as Psychologist to
qualify for Risk Adjustment purposes.
*** Records with unacceptable signatures should still be coded. An attestation for the note
however, should be submitted to qualify for Risk Adjustment purposes.
11
Risk Adjustment – Coding Rule & Practices

DO: Follow standard ICD-9-CM and Coding Clinic coding guidelines to properly
substantiate the reporting of diagnostic codes.

DO: Report codes only from documentation meeting the established guidelines set
forth by ICD-9-CM, Coding Clinic, in addition to any other governing authoritative
entities.

DO: Continually review coding practices through self-auditing to ensure that all
diagnostic data has been reported correctly so that accurate reimbursement is received.
Always seek guidance from a coding manager when in doubt.

DON’T: Code a diagnosis to obtain higher reimbursement without proper supporting
documentation. Coding without proper supporting documentation (a.k.a. “upcoding”)
is considered fraudulent and is punishable by law.
12
Risk Adjustment – Coding Rule & Practices (Cont.)
■
Use the corresponding ICD-9-CM book to the date of service
■
Use the upcoming year’s ICD-9-CM book effective October 1st of the current
year to assign the updated diagnosis codes
 Example:
Date of Service:
ICD-9-CM Book:
10/1/2012
2013
■
Code to the highest degree of specificity by assigning the most precise ICD - 9 code to
describe the symptom or condition
■
Do not code signs/symptoms integral to a more definitive diagnosis
Do not code from memory; index to the tabular all diagnosis codes
13
ICD-9 Coding Guidelines
1.
2.
3.
4.
5.
6.
Use both alphabetical index & tabular list when assigning codes.
Code all diagnoses to the highest specificity.
Symptoms should never be coded unless a definitive diagnosis was not established at
the end of the visit or admission.
Include multiple codes when correct coding of a condition or combination of
conditions warrants usage.
– Example:
• Hypertensive Heart Disease with Chronic Kidney Disease Stage III and CHF:
404.91 + 428.0 + 585.3
Diagnoses described as acute/sub-acute and chronic, Use a code that describes acute
on chronic. If such code is not available, code both acute & chronic.
Late effects usually have two codes. The condition of the late effect, sequenced first
followed by the late effect code.
**** There are certain exclusions, e.g. late effect of stroke/CVA)
14
HCC Coding Guidelines
A. Necessity of document - written documentation is the ONLY basis of coding
abstraction. If it was not written(DOCUMENTED), it does not exist.
B. All conditions captured must be supported by MEAT or the required
specific MEAT for certain conditions (e.g. cancer, MI, CVA, TIA, PE, etc.)
What does MEAT stand for?
M = Monitoring - Ordering/referencing labs/other tests
E = Evaluating - Examining (as in the Physical Exam)
A = Assessing and/or - Acknowledging/Giving Status/Level of a Condition
Addressing
T = Treating - Prescribing medication, surgical/other therapeutic intervention,
referral to other specialists for treatment/consult, any plan for
management of a condition
A minimum of one of the above MEAT components is required.
Note: Some conditions require specific MEAT to confirm new or active status (e.g. cancer, MI,
CVA, TIA, pulmonary embolism, fracture, etc.)
Key Point: Adhering to M.E.A.T. requirements is critical. Noncompliance with documentation
requirements poses serious legal and financial risk the health plan, to the company, and to the
coder!
15
HCC Coding Guidelines (cont.)
1. All diagnoses in the medical record must be addressed in any manner as indicated
above (MEAT). Status codes may sometimes be exempt from this.
Ask yourself- Was the condition Monitored, Evaluated, Assessed or Treated?
2. Conditions may be described and validated in certain parts of the medical chart:
History of Present Illness (HPI), Physical Exam (PE) and Assessment.
3. Medication List may only be used to validate a condition if the provider specifically
says that the medication list has been reviewed and for the patient to continue
present medication.
4. Blood pressure and glucose reading are adequate measures to support the condition
as the provider is Monitoring the condition.
5. Referrals to specialist , order of medication and other treatments may also be used in
supporting the written diagnoses
16
HCC Coding Guidelines (cont.)
C.
Combination Codes
1.
When a condition is appropriately described to be a manifestation of another code, and only
one condition has MEAT, the entire combination code should be coded.
Example: A patient with diabetic nephropathy was seen by the doctor and the treatment was
specifically for diabetes alone.
This should be coded as 250.40, 583.81
2.
When two conditions exist but were not appropriately linked, the conditions should be coded
separately.
Example: A patient came in with diabetes, taking insulin, complaining about peripheral
vascular disease being treated by trental. DX: DM, PVD
This should be coded as 250.00, 443.9
3.
These relationship should not be inferred except in specific cases where ICD-9 makes special
allowance.
Example:
Hypertension + CKD
DM + Gangrene
403.90+585.9
250.70+784.4
17
HCC Coding Guidelines (cont.)
D.
Highest Specificity -
Code to the highest specificity at all times. Signs and
symptoms should never be coded unless the doctor did not specify a definitive
diagnosis.
E.
Chronic Conditions - All chronic condition should be reassessed year after year
for risk adjustment purposes.
F.
Qualified Conditions
1. Outpatient setting- qualified conditions are never to be coded. These conditions
are usually indicated as: rule out, probable, suspect, questionable etc.
2. Inpatient setting- for risk adjustment purposes, qualified conditions may be coded
ONLY if it is still qualified at the day of discharge and not ruled out. Therefore,
qualified diagnoses should only be captured in the discharge report.
18
HCC Coding Guidelines (cont.)
G. Historical Conditions/ Status Codes
1.
2.
H.
Code all historical conditions that are relevant to the patient’s health status.
a) Status codes representing late status of a historical event such as:
amputation, - ostomy status, may be coded even if there was no MEAT
as they no longer need attention, unless an acute complication occurs.
b) Status codes representing a current medical regiment such as: renal
dialysis status, long term insulin use may also be coded without MEAT.
Some doctors often document “history off” a certain condition but is still
currently being treated. On these cases, although it is obviously an active
condition, it cannot be coded as current.
 Coder’s SHOULD NEVER assume
 Query the provider
Sequencing - In risk adjustment, sequencing is irrelevant.
19
Common Coding Errors
20
Neoplasm Coding
1.
Active Treatment
a)
b)
c)
d)
When validating neoplasms, the first few questions you need to ask yourself are; Is it
active or history? Is there treatment or on watchful waiting?
Surgery to remove cancer does not always indicate that the cancer is inactive.
Any form of treatment qualifies the cancer to be coded as active.
Common Treatments: Chemotherapy, Radiation, Anti-neoplastic drug therapy,
surgical exclusion, etc.
Note: Referral to another provider for follow-up (unless it is clearly documented that
the patient is newly diagnosed and being referred for evaluation of surgical/other cancer
treatment options) is not considered adequate supporting documentation to code active
cancer.
Also, simple monitoring of PSA for a patient with known prostate cancer is not
considered adequate supporting documentation to code active prostate cancer
2.
Specificity
Code all diagnoses to the highest specificity as described in the medical record.
a) Site
b) Morphology
21
Neoplasm (cont.)
3.
Primary & Secondary Site
a)
b)
4.
When the cancer is documented as “metastatic of/to”, code the neoplasm
as secondary.
When the cancer is documented as “metastatic from”, The site mentioned
is primary.
Unspecified Site
Use code 199.1 for unspecified site, primary or secondary.
EXAMPLE:
a) Patient status-post mastectomy for breast cancer, on Arimidex- 174.9,
breast cancer, unspecified
b) Secondary malignant neoplasm of the kidney, currently on chemo- 198.0,
199.1 (secondary kidney cancer, unknown primary site)
22
Cardiac Arrhythmias
Sick Sinus Syndrome/ Arrhythmia with pacemaker
a) If the implantation has been successfully done & the provider did not document any
complication, the arrhythmia becomes historical and should NOT be coded as
active.
b) Medications are clear document to support for conditions such as atrial flutter
and/or fibrillation. Code as active.
23
Coronary Artery Disease (CAD)
1.
CAD is coded as subcategory 414.0? The fifth digit specifies the particular type of
blood vessel in which the disease was found
•
Native- naturally occurring to the patient 414.01
•
Graft- vessel is placed by a surgical procedure 414.00
2.
Unspecified type of vessel with history of Coronary Artery Bypass Graft (CABG),
select 414.00.
3.
If the only documentation is CAD and no documentation of CABG was done, select
code 414.01.
24
Diabetes Mellitus
1.
Supporting Documents:
a)
b)
c)
d)
e)
2.
Medications
Insulin status - Code separately
Referrals
Lab Orders
Glucose monitoring
Types of Diabetes
a)
b)
Type I - Usually juvenile onset and insulin dependent.
Type II - Often adult onset.
****The type must be documented by the provider. Unspecified diabetes
defaults to diabetes type II regardless if the patient is on insulin.
25
Diabetes (cont.)
3. Diabetic Control
•
•
•
•
2 Types of Control:
 Controlled
 Uncontrolled
The term control in diabetes refers to the glucose levels. It is in the discretion of the
provider to qualify the control. Clear documentation is required to code uncontrolled
diabetes.
Terms to consider for uncontrolled diabetes:
 Out of control
 Without control
 Not controlled
 Uncontrolled
Unacceptable terms to code uncontrolled:
 Poorly controlled
 Not well controlled
 Not optimally controlled
 etc.
26
Diabetes (cont.)
4.
Diabetic Complications/Manifestations
■
■
▪






60% of diabetics have systemic complications*
Appropriate linkage is required to establish the complication/manifestation.
Terms to consider:
Diabetic
Due to
Associated with
Secondary to
With
Related to
 Exception to this rule is the presence of gangrene and/ or hypoglycemia
diabetic patient. It is always assumed to have a casual relationship
27
Diabetes (cont.)
•
Fourth digit classifications depends on the system being affected.
–
–
–
–
–
–
–
–
–
–
•
•
250.0X
250.10
250.2X
250.3X
250.4X
250.5X
250.6X
250.7X
250.8X
250.9X
Diabetes with no complications
Diabetes with ketoacidosis
Diabetes with hypersmolarity
Diabetes with other coma
Diabetes with renal manifestations
Diabetes with ophthalmic manifestations
Diabetes with neurological manifestations
Diabetes with peripheral circulatory disorders
Diabetes with other specified manifestations
Diabetes with unspecified complications
Multiple manifestations, requires multiple codes.
The above codes should be followed by the specific manifestation code.
28
Chronic Kidney Disease/Failure
•
Staging of CKD

585.1 Chronic Kidney Disease, Stage 1

585.2 Chronic Kidney Disease, Stage II (mild)

585.3 Chronic Kidney Disease, Stage III (moderate)

585.4 Chronic Kidney Disease, State IV (severe)

585.5 Chronic Kidney Disease, Stage V

585.6 End Stage Renal Disease

585.9 Chronic Kidney Disease, unspecified
29
Chronic Kidney Disease (cont.)
Things to remember:
1.
2.
3.
4.
5.
6.
Glomerular filtration rate (GFR) is the best estimate of kidney function.
Persistent proteinuria means CKD.
High risk groups include those with DM, HTN and family history of kidney
disease.
HTN causes CKD and CKD causes HTN (always linked together).
Three simple tests can detect CKD: blood pressure, urine albumin and serum
creatinine.
V Codes:
•
V42.0 Kidney transplant, status
•
V45.11 Renal dialysis, status
Coder should never interpret lab results. When in doubt, query the doctor.
30
Chronic Kidney Disease (cont.)
Physicians sometimes use the terms renal insufficiency and renal failure
interchangeably.
Renal Insufficiency
– Renal insufficiency is considered an early stage of renal impairment:
• Acute – 593.9
• Chronic – 585.9
• Not specified as acute or chronic, but with stated cause or pathology - 583.0583.9
• Due to a procedure – 997.5
Renal Failure
•
•
Acute Renal Failure - 584.9
Renal Failure, Unspecified- 586
31
Myocardial Infarction & Angina
Myocardial Infarction
– It considered acute for a period of eight weeks after initial onset. This should be
coded from category 410.
– If the onset date is not given, code 412, Old MI.
– The fourth digit sub classification pertains to the location.
– The fifth digit sub classifications represents episode of care:
 410.X1 - Initial
 410.X2 - Subsequent
 410.X0 - Unspecified
32
Myocardial Infarction & Angina (cont.)
Angina
– It is a cardiac related chest pain.
– Although the pain is not always present, and it could be noted to be stable on
medication, angina should still be coded.
– After angina is treated surgically and completely resolved, it should then NO longer
be coded.
– Angina with no further specification should be coded as 413.9, Angina pectoris.
– Unstable angina(411.1), Equivalent to Intermediate Coronary Syndrome and
usually results to instant hospitalization.
33
Myocardial Infarction & Angina (cont.)
Acute myocardial infarction & unstable angina rarely happens in an outpatient
physician’s visit.
Things to Look for:
1.
2.
Patient was sent to the ER.
Ambulance was called for the patient to be transferred to the hospital.
34
Stroke
Simply Stated:
–
–
When did the event occur?
What deficits were left after the event that are evident today?
When did the event occur?
– Document Acute Stroke on first admission to hospital only - 434.91
– Document Residual Deficits of Stroke on office visits following the acute incident –
438.XX
– Document History of CVA if there are no residual deficits from a prior stroke code V12.54
– Code 436, Acute, but ill-defined, cerebrovascular disease is NOT a stroke code.
35
Stroke (cont.)
Late Effects of Stroke
– A late effect is the residual condition that remains after recovery of the acute phase.
– Document deficits after discharge from the initial acute episode.
Example:
Aphasia due to CVA 6 months ago
CVA two years ago with residual hemiplegia
– There is no time limit for the development of a residual.
– Code for CVA late effects should be selected from category 438.
– Dominant side vs. non-dominant side
 Dominant - 483.X1
 Non-Dominant - 483.X2
 Unspecified - 438.X0
36
Missed Opportunities
37
Protein-Calorie Malnutrition
•
Category 263 - Other and unspecified protein–calorie malnutrition is often underreported.
•
Factors that limit nutrient ingestion and absorption:
▪ Cancer
▪ ESRD
▪ Pancreatitis
▪ Alcoholic hepatitis
▪ Alcohol abuse and/or dependence
▪ Cirrhosis
▪ Liver disease
▪ Celiac disease
▪ Obesity (post-bariatric surgery)
▪ Cystic fibrosis
▪ Anemia
▪ Depression
38
Protein Calorie Malnutrition (cont.)
It’s worth a Second Look!
•
–
–
–
–
•
On the report:
Abnormal Weight Loss
Loss of Appetite
Underweight
Failure to Thrive
Query the provider:
– Malnutrition, Mild Degree
– Malnutrition, Moderate Degree
– Cachexia (Severe)
39
Traumatic vs. Pathologic Fractures
•
Unlike traumatic fractures, which are caused by an external injury, pathologic fractures
occur spontaneously in bones that are weakened by diseases such as:





•
Osteoporosis
Nutritional maladies
Paget’s Disease
Asceptic necrosis
Bone cancer
Spontaneous pathologic fractures are often associated with a fall; this could mistakenly
lead the coder to believe that it is a traumatic fracture.
40
Chronic Skin Ulcers
•
Words like "open wound” or “lesion” in documentation when “decubitus” or other forms
of non-healing ulcers are seen must be queried. Chronic ulcers usually are due to chronic
inflammation, ischemia or both.
Example:
 Diabetic ulcer, left foot
 Ulcer, sacrum
•
Foot ulcers may develop from conditions such as diabetic neuropathy or diabetic
peripheral vascular disease. Specific documentation will assure correct code selection.
41
Arthritis
•
The term “Arthritis” is unspecified.
•
Indicate type of arthritis for greater specificity:
– Osteoarthritis
– Rheumatoid
– Traumatic
•
Include complication if applicable:
– Traumatic arthritis due to ankle fracture sustained five years ago (Late effect)
42
COPD/Bronchitis
•
Correct coding depends on accurate documentation.
•
COPD(496) is assigned only when the medical record does not specify the type of COPD:
– Chronic obstructive bronchitis
– Chronic bronchitis with emphysema
– Obstructive chronic bronchitis, with acute exacerbation
Note: COPD is a nonspecific term that encompasses many different respiratory conditions;
review medical record and query physician for more specific documentation of emphysema,
bronchitis, asthma, etc.
43
Anemia
•
Often seen in the “generalized” term, “Patient is anemic.”
•
The use of precise terminology makes the difference:
–
–
–
–
–
–
Aplastic anemia
Drug induced anemia
Anemia in CKD
Anemia in neoplastic disease
Pancytopenia
Neutropenia
44
Depression vs. Major Depression
•
Category 311 (Depression) is reserved for depressive disorders not assigned a more
specific diagnosis.
•
Category 296.xx is reserved for patients having single or recurrent episodes of:
Depressive psychosis
Involutional melancholia
Psychotic depression
Psychosis or reaction
Endogenous depression
Monopolar depression
Manic-depressive
Autogenous depression
45
Documenting Complications of Care
•
Complications of surgical and medical care - categories 996-997
•
These categories include complications of surgical and medical care that occur when
the patient suffers additional pathology, injury or other complication during, or as a
result of, a procedure or medical treatment as documented by the physician.
46
Complications of Care
•
Mechanical problems of devices, implants,
grafts category 996
•
•
•
•
•
Breakdown (mechanical)
Obstruction, mechanical
Displacement
Perforation
Leakage
•
Protrusion
Such as:
• Cardiac device, implant and graft
• Vascular device, implant and graft
• Indwelling urinary catheter
• Internal joint prosthesis
• Peritoneal dialysis catheter
• Other internal orthopedic device,
implant and graft
• Other internal prosthetic device,
implant and graft
•
Other complications of internal (biological),
(synthetic) prosthetic device, implant, and graft category 996.7X
•
•
•
•
•
•
Occlusion due to the presence of any device,
implant or graft
Embolism due to the presence of any device,
implant or graft
Fibrosis due to the presence of any device,
implant, or graft
Hemorrhage due to presence of any device,
implant or graft
Pain due to the presence of any device,
implant or graft
Stenosis due to the presence of any device,
implant or graft
47
Complications of Care (cont.)
•
Infection and inflammatory reaction due to internal prosthetic device, implant
and graft 996.6x







Cardiac e.g. pacemaker
Vascular e.g. infusion pump
Nervous system e.g. spinal canal catheter
Indwelling urinary catheter (sepsis or cystitis?)
Genitourinary e.g. intrauterine contraceptive device
Internal joint prosthesis
Internal prosthetic e.g. breast or ocular lens
48
Complications of Care (cont.)
• Complications affecting specified body systems, not elsewhere classified category 997
This classification does not define a time limit for the development of a
complication. It may occur during the hospital episode in which the surgery
was performed, shortly thereafter, or years later.
The Coding Clinic, Second Quarter, 2002
49
HCC RISK ADJUSTMENT
&
PROCESS IMPROVEMENT
Contact Name
Telephone
Email Address
Lisa Williams, Director
Process Improvement
(323)-728-7232 ext. 2263
[email protected]
Nan Crawford, Senior
Project
Manager/Consultant on
behalf of CCHP
(714)-323-9723
[email protected]
Sandra Velando, CCS
Project Manager
(323)-728-7232 ext. 2159
[email protected]
50
- Fin -
51