The document discusses strategies for improving ICD-9 coding accuracy and completeness, with a focus on common chronic conditions like diabetes, hypertension, heart disease, and kidney disease. It provides diagnostic criteria and recommended ICD-9 codes for documenting complications from these conditions, such as neuropathy, retinopathy, kidney damage, and congestive heart failure. Checklists and electronic medical record tools are presented as ways to systematically capture this clinical information and apply the proper ICD-9 codes.

1. Welcome

2. Bridging the ICD9 Communication Gap Physician members RPO

3. Glossary CMS – Center for Medicare/Medicaid Services MA - Medicare Advantage = capitated Medicare product (ex: Texas Health Springs)

4. Glossary ICD9 coding – International Classification of Diseases, 9 th Revision E & M coding – Evaluation and Management HCC – Hierarchical Condition Category

5. Communication Foundation Block of Our Profession

8. Ancillary Services Consult with specialists Review medical literature

10. Problem / Diagnoses List Defines Disease Complexity

11. Communication to Third Party Payers Disease Complexity (aka Burden of Disease) Translate Into E & M codes Non-capitated third party payers Translate Into ICD9 codes Medicare Advantage

12. Proper Flow of Information Medicare Advantage Good coding

13. Proper Flow of Revenue Medicare Advantage

14. Gap in Communication Poor coding

15. Gap in Flow of Revenue

16. Bridging the Gap in ICD9Communication Poor coding

17. Proper Allocation of Resources

22. Pitfalls ! ‘ Up-scoring ’ = using an ICD9 code without proper documentation Up-scoring ICD9 equivalent to Up-coding E&M code Same penalties – Same risks

23. Schutzhund Pic/analogy

24. 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

25. ICD9 Coding Simple, but Not Easy Simple – attach a number to a diagnosis / condition Not Easy = thousands of diagnoses / conditions

26. Barrier to Proper ICD9 Coding “Information Overload” Over 12,000 ICD9 codes Only 3000 have HCC value 3000 remains overwhelming

27. 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

28. Presentation HCC Conditions Diabetes complications Renal Peripheral circulatory Neurological Ophthalmological

29. Presentation HCC Conditions Hypertension complications Hypertensive Heart Disease Hypertensive Kidney Disease Combination HDD & HKD

30. Presentation HCC Conditions COPD Old MI / CABG / CAD

31. Presentation HCC Conditions Characteristics Leading causes of death & disability Under-diagnosed Outcome improvement possible

32. Our Experience Have a system in place to process complex data History Physical findings Labs/tests/specialty consultation

33. Our Experience Goal is to use every encounter as an opportunity Not practical in a ‘typical’ PCP office

34. Our System Demonstration purposes only – not RPO sanctioned Annual Health Review No co-pay Checklist customized to age, gender, known history

35. 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

36. Our System Annual Health Review Checklist components Tied or ‘linked’ to correct ICD9 codes EMR / paper (demonstrations to follow)

37. Our System Annual Health Review Augment with interactive DVD www.crosbyclinic.com

38. 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

39. 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

40. Diabetes Renal Complications History – ask - checklist Physical exam Limited value

41. 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

42. Diabetes Renal Complications History – ask - checklist Physical exam Limited value

43. 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

44. Diabetes Renal Complications Proteinuria detection Timed collection – 24 hr/ 10 hr overnight Prone to collection error Cumbersome for patient and staff

45. Diabetes Renal Complications Estimated glomerular filtration rate (eGFR) (Definition CKD from the National Kidney Foundation’s Kidney Disease Outcomes Quality Initiative) GFR below 60 mL. per minute per 1.73 m 2 for three or more months (Stage 3 or greater)

46. Diabetes Renal Complications Estimated glomerular filtration rate (eGFR) Labs routinely providing eGFRs http://nkdep.nih.gov/professionals/gfr_calculators/

47. Diabetes Renal Complications Once DM with renal complication verified: 250.4x …… PLUS Manifestation Code Most common = CKD 585.1-9

48. Diabetes Renal Complications Type 2 DM - (eGFR 52 - A1c 8.3) 250. 4 2 4 = renal 2 = Type 2/uncontrolled

49. Diabetes Renal Complications Type 2 DM - (eGFR 52 - A1c 8.3) 250. 4 2 PLUS - 585. 3 3 = Stage 3 CKD

50. 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

51. Diabetes Renal Complications What if THS is under-funded Patient suffers THS vulnerable You are undercompensated

52. Pitfall Reminder Goal is accurate ICD9 coding Up-scoring ICD9 equivalent to Up-coding E&M code Same penalties – Same risks

53. Coding Memorization Impossible to recall all variations ICD9 ‘text’ – gold standard Laminates / linked checklists EMR

54. EMR demonstration

55. 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

56. ( 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) = 357.2 Peripheral autonomic neuropathy = 337.1

57. Diabetes Peripheral Vascular Complications History Symptoms Claudication Pallor, skin changes

58. Diabetes Peripheral Vascular Complications Physical Exam: Pedal pulses Skin / color / hair Ankle-brachial index (ABI) <0.9 ***Dr. Sid King – Living Well

59. Diabetes Peripheral Vascular Complications Once DM with PVD verified: 250.7x …… PLUS Manifestation Code Most common = Peripheral angiopathy 443.81

60. Diabetes Neurological Complications History Symptoms Burning, numbness Diabetic Neuropathy Score

61. Diabetes Neurological Complications Physical exam Monofilament test

63. Diabetes Neurological Complications Physical exam Tuning fork 128 Hz

64. Diabetes Neurological Complications Once DM with neuropathy verified: 250.6x …… PLUS Manifestation Code Most common = Polyneuropathy 357.2

65. Diabetes Ophthalmic Complications History – ask checklist Physical exam If skilled with ophthalmoscope Ophthalmology consult

66. Diabetes Ophthalmic Complications Retinopathy Cataract Glaucoma

67. Diabetes Ophthalmic Complications Blindness Macular / retinal edema

68. Diabetes Ophthalmic Complications Once DM with ophthalmic pathology verified: 250.5x …… PLUS Manifestation Code Most common = Peripheral retinopathy 362.01-362.07

69. Hypertension Complications Hypertensive Heart Disease Hypertensive Kidney Disease Hypertensive Heart & Kidney Disease

70. Hypertension Essential – 401.x Hypertensive heart disease – 402.xx Hypertensive kidney disease – 403.xx Hypertensive heart & kidney disease – 404.xx

71. Hypertension Complications Major factors Duration of hypertension Level of control of HTN

72. Hypertension Complications Hypertensive Heart Disease without CHF Left ventricular hypertrophy LVH present in 30% adult hypertensives 90% with severe uncontrolled HTN

73. ECG criteria ECHO

74. Hypertension Complications Hypertensive Heart Disease without CHF ??? AAA PE: pulsation below umbilicus U/S all smokers/former smokers > age 65

75. Hypertension Complications Hypertensive Heart Disease with CHF CHF may, of course, present without HTN CHF coding is used with or without HTN

76. CHF History Risk factors Hypertension, CAD, valvular disease, etc. Symptoms Dyspnea Edema Fatigue

77. CHF Physical Exam Edema Lungs Neck veins

78. CHF Testing: BNP ECHO Cardiology consult

79. CHF Isolated diastolic CHF: Symptoms of CHF with normal ejection fraction ICD9 = 428.3x

80. Hypertension Complications Hypertensive Heart Disease with CHF Use appropriate 402.xx HDD code Use additional CHF code – 428.x

81. Hypertension Complications Hypertensive Kidney Disease Same diagnostic tools as DM Microalbumin-to-creatinine ration eGFR Imaging

82. Hypertension Complications Hypertensive Kidney Disease Code Hypertension by stage – 403.xx Stage I-IV Stage V-ESRD Use additional CKD code – 585.x

83. Hypertension Complications Hypertensive Heart & Kidney Disease Use appropriate HDD 404.xx code Use additional CV code (CHF, etc.) Use additional CKD code

84. COPD History Ask: checklist Risk factors: Smoker Asthma Toxic exposure Alpha1 antitrypsin

85. COPD History Chronic bronchitis – most common Chronic sputum production (3 mo/2yrs)

86. COPD Physical Exam Increased AP diameter Blue bloater Pink puffer

87. COPD Pulmonary Function Testing Test all with strong historical risk factor or symptoms 20 pack year history Toxic exposures Asthma

88. COPD Acute exacerbation of chronic bronchitis Increasing sputum production Increasing sputum color (white>yellow, etc) Increasing dyspnea

89. CAD/Old MI Old MI - 412 CABG – 414.04 CAD – 414.01

90. Tools Use symmetry report to identify high risk candidates “ no encounter list” Legg VA my experience

91. Tools Use EVERY encounter to search for short list codes Build on knowledge of short list

93. 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