Peer To Peer Coding

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  • Peer To Peer Coding

    1. 1. Welcome
    2. 2. Bridging the ICD9 Communication Gap Physician members RPO
    3. 3. Glossary <ul><li>CMS – Center for Medicare/Medicaid Services </li></ul><ul><li>MA - Medicare Advantage = capitated Medicare product (ex: Texas Health Springs) </li></ul>
    4. 4. Glossary <ul><li>ICD9 coding – International Classification of Diseases, 9 th Revision </li></ul><ul><li>E & M coding – Evaluation and Management </li></ul><ul><li>HCC – Hierarchical Condition Category </li></ul>
    5. 5. Communication Foundation Block of Our Profession
    6. 8. <ul><li>Ancillary Services </li></ul><ul><li>Consult with specialists </li></ul><ul><li>Review medical literature </li></ul>
    7. 10. Problem / Diagnoses List Defines Disease Complexity
    8. 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
    9. 12. Proper Flow of Information Medicare Advantage Good coding
    10. 13. Proper Flow of Revenue Medicare Advantage
    11. 14. Gap in Communication Poor coding
    12. 15. Gap in Flow of Revenue
    13. 16. Bridging the Gap in ICD9Communication Poor coding
    14. 17. Proper Allocation of Resources
    15. 22. Pitfalls ! <ul><li>‘ Up-scoring ’ = using an ICD9 code without proper documentation </li></ul><ul><li>Up-scoring ICD9 equivalent to Up-coding E&M code </li></ul><ul><ul><li>Same penalties – Same risks </li></ul></ul>
    16. 23. Schutzhund Pic/analogy
    17. 24. HMR <ul><li>You are verifying condition has been documented and treated in the current fiscal year in a face to face visit </li></ul><ul><li>CMS will periodically audit </li></ul>
    18. 25. ICD9 Coding Simple, but Not Easy <ul><li>Simple – attach a number to a diagnosis / condition </li></ul><ul><li>Not Easy = thousands of diagnoses / conditions </li></ul>
    19. 26. Barrier to Proper ICD9 Coding “Information Overload” <ul><li>Over 12,000 ICD9 codes </li></ul><ul><li>Only 3000 have HCC value </li></ul><ul><li>3000 remains overwhelming </li></ul>
    20. 27. Solution <ul><li>Concentrate on important conditions in the ICD9 communication ‘gap’ </li></ul><ul><ul><li>Major clinical conditions </li></ul></ul><ul><ul><ul><li>Leading causes of premature death/disability </li></ul></ul></ul><ul><ul><li>High prevalence </li></ul></ul><ul><ul><ul><li>Frequently under-coded/under-diagnosed </li></ul></ul></ul>
    21. 28. Presentation HCC Conditions <ul><li>Diabetes complications </li></ul><ul><ul><li>Renal </li></ul></ul><ul><ul><li>Peripheral circulatory </li></ul></ul><ul><ul><li>Neurological </li></ul></ul><ul><ul><li>Ophthalmological </li></ul></ul>
    22. 29. Presentation HCC Conditions <ul><li>Hypertension complications </li></ul><ul><ul><li>Hypertensive Heart Disease </li></ul></ul><ul><ul><li>Hypertensive Kidney Disease </li></ul></ul><ul><ul><li>Combination HDD & HKD </li></ul></ul>
    23. 30. Presentation HCC Conditions <ul><li>COPD </li></ul><ul><li>Old MI / CABG / CAD </li></ul>
    24. 31. Presentation HCC Conditions Characteristics <ul><li>Leading causes of death & disability </li></ul><ul><li>Under-diagnosed </li></ul><ul><li>Outcome improvement possible </li></ul>
    25. 32. Our Experience <ul><li>Have a system in place to process complex data </li></ul><ul><ul><li>History </li></ul></ul><ul><ul><li>Physical findings </li></ul></ul><ul><ul><li>Labs/tests/specialty consultation </li></ul></ul>
    26. 33. Our Experience <ul><li>Goal is to use every encounter as an opportunity </li></ul><ul><li>Not practical in a ‘typical’ PCP office </li></ul>
    27. 34. Our System Demonstration purposes only – not RPO sanctioned <ul><li>Annual Health Review </li></ul><ul><ul><li>No co-pay </li></ul></ul><ul><ul><li>Checklist customized to age, gender, known history </li></ul></ul>
    28. 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
    29. 36. Our System <ul><li>Annual Health Review </li></ul><ul><ul><li>Checklist components </li></ul></ul><ul><ul><ul><li>Tied or ‘linked’ to correct ICD9 codes </li></ul></ul></ul><ul><ul><ul><li>EMR / paper (demonstrations to follow) </li></ul></ul></ul>
    30. 37. Our System <ul><li>Annual Health Review </li></ul><ul><ul><li>Augment with interactive DVD </li></ul></ul><ul><ul><ul><li>www.crosbyclinic.com </li></ul></ul></ul>
    31. 38. Diabetes as Prototype <ul><li>Uncomplicated DM – 250.0x </li></ul><ul><li>(x = 0-3) </li></ul><ul><ul><ul><li>250.00 – Type 2, controlled or unk. </li></ul></ul></ul><ul><ul><ul><li>250.01 - Type 1, controlled or unk. </li></ul></ul></ul><ul><ul><ul><li>250.02 - Type 2, uncontrolled </li></ul></ul></ul><ul><ul><ul><li>250.03 – Type 1, uncontrolled </li></ul></ul></ul>
    32. 39. Diabetes as Prototype <ul><li>Uncomplicated – 250.0x </li></ul><ul><li>Renal – 250.4x + manifestation code </li></ul><ul><li>Ophthalmic – 250.5x + manifestation code </li></ul><ul><li>Neuropathy – 250.6x + manifestation code </li></ul><ul><li>PVD – 250.7x + manifestation code </li></ul>
    33. 40. Diabetes Renal Complications <ul><li>History – ask - checklist </li></ul><ul><li>Physical exam </li></ul><ul><ul><li>Limited value </li></ul></ul>
    34. 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
    35. 42. Diabetes Renal Complications <ul><li>History – ask - checklist </li></ul><ul><li>Physical exam </li></ul><ul><ul><li>Limited value </li></ul></ul>
    36. 43. Diabetes Renal Complications <ul><li>Proteinuria detection </li></ul><ul><ul><li>Microalbumin-to-creatinine ratio </li></ul></ul><ul><ul><ul><li>Spot collection = less collection error </li></ul></ul></ul><ul><ul><ul><li>May be transient – MUST be confirmed </li></ul></ul></ul><ul><ul><ul><ul><li>ADA: + 2 of 3 over 3-6 months </li></ul></ul></ul></ul>
    37. 44. Diabetes Renal Complications <ul><li>Proteinuria detection </li></ul><ul><ul><li>Timed collection – 24 hr/ 10 hr overnight </li></ul></ul><ul><ul><ul><li>Prone to collection error </li></ul></ul></ul><ul><ul><ul><li>Cumbersome for patient and staff </li></ul></ul></ul>
    38. 45. Diabetes Renal Complications <ul><li>Estimated glomerular filtration rate (eGFR) </li></ul><ul><li>(Definition CKD from the National Kidney Foundation’s </li></ul><ul><li>Kidney Disease Outcomes Quality Initiative) </li></ul><ul><ul><li>GFR below 60 mL. per minute per 1.73 m 2 for three or more months (Stage 3 or greater) </li></ul></ul>
    39. 46. Diabetes Renal Complications <ul><li>Estimated glomerular filtration rate (eGFR) </li></ul><ul><ul><li>Labs routinely providing eGFRs </li></ul></ul><ul><ul><li>http://nkdep.nih.gov/professionals/gfr_calculators/ </li></ul></ul>
    40. 47. Diabetes Renal Complications <ul><li>Once DM with renal complication verified: </li></ul><ul><ul><li>250.4x …… PLUS </li></ul></ul><ul><ul><li>Manifestation Code </li></ul></ul><ul><ul><ul><li>Most common = CKD 585.1-9 </li></ul></ul></ul>
    41. 48. Diabetes Renal Complications <ul><li>Type 2 DM - (eGFR 52 - A1c 8.3) </li></ul><ul><li>250. 4 2 </li></ul><ul><ul><ul><li>4 = renal </li></ul></ul></ul><ul><ul><ul><li>2 = Type 2/uncontrolled </li></ul></ul></ul>
    42. 49. Diabetes Renal Complications <ul><li>Type 2 DM - (eGFR 52 - A1c 8.3) </li></ul><ul><ul><li>250. 4 2 </li></ul></ul><ul><ul><li>PLUS - 585. 3 </li></ul></ul><ul><ul><ul><li>3 = Stage 3 CKD </li></ul></ul></ul>
    43. 50. Diabetes Renal Complications <ul><li>What IF? </li></ul><ul><li>Type 2 DM - (eGFR 52 - A1c 8.3) </li></ul><ul><ul><li>250.00 vs. 250.42 + 585.3 </li></ul></ul><ul><ul><ul><li>RPO/THS Under-funded by CMS </li></ul></ul></ul>
    44. 51. Diabetes Renal Complications <ul><li>What if THS is under-funded </li></ul><ul><ul><ul><li>Patient suffers </li></ul></ul></ul><ul><ul><ul><li>THS vulnerable </li></ul></ul></ul><ul><ul><ul><li>You are undercompensated </li></ul></ul></ul>
    45. 52. Pitfall Reminder <ul><li>Goal is accurate ICD9 coding </li></ul><ul><li>Up-scoring ICD9 equivalent to Up-coding E&M code </li></ul><ul><ul><li>Same penalties – Same risks </li></ul></ul>
    46. 53. Coding Memorization <ul><li>Impossible to recall all variations </li></ul><ul><ul><li>ICD9 ‘text’ – gold standard </li></ul></ul><ul><ul><li>Laminates / linked checklists </li></ul></ul><ul><ul><li>EMR </li></ul></ul>
    47. 54. <ul><li>EMR demonstration </li></ul>
    48. 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
    49. 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
    50. 57. Diabetes Peripheral Vascular Complications <ul><li>History </li></ul><ul><ul><li>Symptoms </li></ul></ul><ul><ul><ul><li>Claudication </li></ul></ul></ul><ul><ul><ul><li>Pallor, skin changes </li></ul></ul></ul>
    51. 58. Diabetes Peripheral Vascular Complications <ul><li>Physical Exam: </li></ul><ul><ul><li>Pedal pulses </li></ul></ul><ul><ul><li>Skin / color / hair </li></ul></ul><ul><li>Ankle-brachial index (ABI) </li></ul><ul><ul><li><0.9 </li></ul></ul><ul><ul><li>***Dr. Sid King – Living Well </li></ul></ul>
    52. 59. Diabetes Peripheral Vascular Complications <ul><li>Once DM with PVD verified: </li></ul><ul><ul><li>250.7x …… PLUS </li></ul></ul><ul><ul><li>Manifestation Code </li></ul></ul><ul><ul><ul><li>Most common = Peripheral angiopathy 443.81 </li></ul></ul></ul>
    53. 60. Diabetes Neurological Complications <ul><li>History </li></ul><ul><ul><li>Symptoms </li></ul></ul><ul><ul><ul><li>Burning, numbness </li></ul></ul></ul><ul><ul><ul><li>Diabetic Neuropathy Score </li></ul></ul></ul>
    54. 61. Diabetes Neurological Complications <ul><li>Physical exam </li></ul><ul><ul><li>Monofilament test </li></ul></ul>
    55. 63. Diabetes Neurological Complications <ul><li>Physical exam </li></ul><ul><ul><li>Tuning fork 128 Hz </li></ul></ul>
    56. 64. Diabetes Neurological Complications <ul><li>Once DM with neuropathy verified: </li></ul><ul><ul><li>250.6x …… PLUS </li></ul></ul><ul><ul><li>Manifestation Code </li></ul></ul><ul><ul><ul><li>Most common = Polyneuropathy 357.2 </li></ul></ul></ul>
    57. 65. Diabetes Ophthalmic Complications <ul><li>History – ask checklist </li></ul><ul><li>Physical exam </li></ul><ul><ul><li>If skilled with ophthalmoscope </li></ul></ul><ul><li>Ophthalmology consult </li></ul>
    58. 66. Diabetes Ophthalmic Complications <ul><li>Retinopathy </li></ul><ul><li>Cataract </li></ul><ul><li>Glaucoma </li></ul>
    59. 67. Diabetes Ophthalmic Complications <ul><li>Blindness </li></ul><ul><li>Macular / retinal edema </li></ul>
    60. 68. Diabetes Ophthalmic Complications <ul><li>Once DM with ophthalmic pathology verified: </li></ul><ul><ul><li>250.5x …… PLUS </li></ul></ul><ul><ul><li>Manifestation Code </li></ul></ul><ul><ul><ul><li>Most common = Peripheral retinopathy </li></ul></ul></ul><ul><ul><ul><li>362.01-362.07 </li></ul></ul></ul>
    61. 69. Hypertension Complications <ul><li>Hypertensive Heart Disease </li></ul><ul><li>Hypertensive Kidney Disease </li></ul><ul><li>Hypertensive Heart & Kidney Disease </li></ul>
    62. 70. Hypertension <ul><li>Essential – 401.x </li></ul><ul><li>Hypertensive heart disease – 402.xx </li></ul><ul><li>Hypertensive kidney disease – 403.xx </li></ul><ul><li>Hypertensive heart & kidney disease – 404.xx </li></ul>
    63. 71. Hypertension Complications <ul><li>Major factors </li></ul><ul><ul><li>Duration of hypertension </li></ul></ul><ul><ul><li>Level of control of HTN </li></ul></ul>
    64. 72. Hypertension Complications <ul><li>Hypertensive Heart Disease without CHF </li></ul><ul><ul><li>Left ventricular hypertrophy </li></ul></ul><ul><ul><ul><li>LVH present in 30% adult hypertensives </li></ul></ul></ul><ul><ul><ul><li>90% with severe uncontrolled HTN </li></ul></ul></ul>
    65. 73. <ul><li>ECG criteria </li></ul><ul><li>ECHO </li></ul>
    66. 74. Hypertension Complications <ul><li>Hypertensive Heart Disease without CHF </li></ul><ul><ul><li>??? AAA </li></ul></ul><ul><ul><ul><li>PE: pulsation below umbilicus </li></ul></ul></ul><ul><ul><ul><li>U/S all smokers/former smokers > age 65 </li></ul></ul></ul>
    67. 75. Hypertension Complications <ul><li>Hypertensive Heart Disease with CHF </li></ul><ul><ul><li>CHF may, of course, present without HTN </li></ul></ul><ul><ul><li>CHF coding is used with or without HTN </li></ul></ul>
    68. 76. CHF <ul><li>History </li></ul><ul><ul><li>Risk factors </li></ul></ul><ul><ul><ul><li>Hypertension, CAD, valvular disease, etc. </li></ul></ul></ul><ul><ul><li>Symptoms </li></ul></ul><ul><ul><ul><li>Dyspnea </li></ul></ul></ul><ul><ul><ul><li>Edema </li></ul></ul></ul><ul><ul><ul><li>Fatigue </li></ul></ul></ul>
    69. 77. CHF <ul><li>Physical Exam </li></ul><ul><ul><li>Edema </li></ul></ul><ul><ul><li>Lungs </li></ul></ul><ul><ul><li>Neck veins </li></ul></ul>
    70. 78. CHF <ul><li>Testing: </li></ul><ul><ul><li>BNP </li></ul></ul><ul><ul><li>ECHO </li></ul></ul><ul><ul><li>Cardiology consult </li></ul></ul>
    71. 79. CHF <ul><li>Isolated diastolic CHF: </li></ul><ul><ul><li>Symptoms of CHF with normal ejection fraction </li></ul></ul><ul><ul><li>ICD9 = 428.3x </li></ul></ul>
    72. 80. Hypertension Complications <ul><li>Hypertensive Heart Disease with CHF </li></ul><ul><ul><li>Use appropriate 402.xx HDD code </li></ul></ul><ul><ul><li>Use additional CHF code – 428.x </li></ul></ul>
    73. 81. Hypertension Complications <ul><li>Hypertensive Kidney Disease </li></ul><ul><ul><li>Same diagnostic tools as DM </li></ul></ul><ul><ul><ul><li>Microalbumin-to-creatinine ration </li></ul></ul></ul><ul><ul><ul><li>eGFR </li></ul></ul></ul><ul><ul><ul><li>Imaging </li></ul></ul></ul>
    74. 82. Hypertension Complications <ul><li>Hypertensive Kidney Disease </li></ul><ul><ul><li>Code Hypertension by stage – 403.xx </li></ul></ul><ul><ul><ul><li>Stage I-IV </li></ul></ul></ul><ul><ul><ul><li>Stage V-ESRD </li></ul></ul></ul><ul><ul><li>Use additional CKD code – 585.x </li></ul></ul>
    75. 83. Hypertension Complications <ul><li>Hypertensive Heart & Kidney Disease </li></ul><ul><ul><li>Use appropriate HDD 404.xx code </li></ul></ul><ul><ul><li>Use additional CV code (CHF, etc.) </li></ul></ul><ul><ul><li>Use additional CKD code </li></ul></ul>
    76. 84. COPD <ul><li>History </li></ul><ul><ul><li>Ask: checklist </li></ul></ul><ul><ul><li>Risk factors: </li></ul></ul><ul><ul><ul><li>Smoker </li></ul></ul></ul><ul><ul><ul><li>Asthma </li></ul></ul></ul><ul><ul><ul><li>Toxic exposure </li></ul></ul></ul><ul><ul><ul><li>Alpha1 antitrypsin </li></ul></ul></ul>
    77. 85. COPD <ul><li>History </li></ul><ul><ul><li>Chronic bronchitis – most common </li></ul></ul><ul><ul><ul><li>Chronic sputum production (3 mo/2yrs) </li></ul></ul></ul>
    78. 86. COPD <ul><li>Physical Exam </li></ul><ul><ul><li>Increased AP diameter </li></ul></ul><ul><ul><li>Blue bloater </li></ul></ul><ul><ul><li>Pink puffer </li></ul></ul>
    79. 87. COPD <ul><li>Pulmonary Function Testing </li></ul><ul><ul><li>Test all with strong historical risk factor or symptoms </li></ul></ul><ul><ul><ul><li>20 pack year history </li></ul></ul></ul><ul><ul><ul><li>Toxic exposures </li></ul></ul></ul><ul><ul><ul><li>Asthma </li></ul></ul></ul>
    80. 88. COPD <ul><li>Acute exacerbation of chronic bronchitis </li></ul><ul><ul><li>Increasing sputum production </li></ul></ul><ul><ul><li>Increasing sputum color (white>yellow, etc) </li></ul></ul><ul><ul><li>Increasing dyspnea </li></ul></ul>
    81. 89. CAD/Old MI <ul><li>Old MI - 412 </li></ul><ul><li>CABG – 414.04 </li></ul><ul><li>CAD – 414.01 </li></ul>
    82. 90. Tools <ul><li>Use symmetry report to identify high risk candidates </li></ul><ul><li>“ no encounter list” Legg VA my experience </li></ul>
    83. 91. Tools <ul><li>Use EVERY encounter to search for short list codes </li></ul><ul><li>Build on knowledge of short list </li></ul>
    84. 93. <ul><li>Codes Secondary </li></ul><ul><ul><li>Dialysis ?DM </li></ul></ul><ul><ul><li>Decubitus </li></ul></ul><ul><ul><li>Paralysis ?? 67 VS hemiplegia 100 </li></ul></ul><ul><ul><li>Amputation ?DM </li></ul></ul><ul><ul><li>Rheumatology 38 </li></ul></ul><ul><ul><li>Chronic hepatitis 27 </li></ul></ul><ul><ul><li>Seizures 74 </li></ul></ul><ul><ul><li>Cancer 10 </li></ul></ul><ul><ul><li>Drug abuse 52 **alcohol </li></ul></ul>

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