Peer To Peer Coding
- 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
- 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
- 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
- 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