In fee-for-service medicine, physician services are paid based on the fee associated with that CPT code, HCPCS code and modifiers. The diagnosis coding establishes the medical necessity for this service. With new payment models, diagnosis coding for physician services takes on added importance. Accurate and complete diagnosis coding will affect incentive payments and negative payment adjustments along with utilization, quality measures and patient satisfaction. Medical practices joining accountable care organizations, Medicare shared savings programs or entering into diagnosis risk-adjusted contracts with private payers need to review their diagnosis coding and many will need to make changes.
It is important for physician practices to understand the concepts of risk-adjusted diagnosis coding. Hierarchical Coding Conditions (HCCs) is a common nonproprietary system already in use by Medicare for Medicare advantage and comprehensive primary care + programs. Medical practices need to follow ICD-10 rules when selecting diagnosis codes for an encounter, and know whether to use all current and past conditions. Medical practices should take special care with selecting specific diagnosis codes for chronic conditions and know what types of unspecified codes don’t carry a risk-adjusted factor. Practices often neglect to report status codes and failure to do that has negative consequences in risk-adjusted diagnosis coding.
This presentation provides an overview for medical practices in the important concepts related to risk-adjusted diagnosis coding. As our healthcare system moves from value to volume, accurately reporting the severity of illness for individual patience becomes imperative.
At the end of the session participants will be able to:
- Demonstrate knowledge of two key concepts of risk-adjusted diagnosis coding
- Evaluate their own ICD 10 coding use of unspecified codes and use of status codes
- Develop a plan to increase specificity in both primary care and specialty claims
There are opportunities for you to capture a more appropriate HCC code. Consider this list of the top 10 coding errors for risk adjustment:
- The record does not contain a legible signature with credential.
- The electronic health record (EHR) was unauthenticated (not electronically signed).
- The highest degree of specificity was not assigned the most precise ICD-9-CM code to fully explain the narrativedescription of the symptom or diagnosis in the medical chart.
- A discrepancy was found between the diagnosis codes being billed versus the actual written description in the medical record. If the record indicates depression, NOS (311 Depressive disorder, not elsewhere classified), but the diagnosis code written on the encounter document is major depression (296.20 Major depressive affective disorder, single episode, unspecified), these codes do not match; they map to a different HCC category. The diagnosis code and the description should mirror each other.
- Documentation does not indicate the diagnoses are being monitored, evaluated, assessed/addressed, or treated (MEAT).
- Status of cancer is unclear. Treatment is not documented.
- Chronic conditions, such as hepatitis or renal insufficiency, are not documented as chronic.
- Lack of specificity (e.g., an unspecified arrhythmia is coded rather than the specific type of arrhythmia).
- Chronic conditions or status codes aren’t documented in the medical record at least once per year.
- A link or cause relationship is missing for a diabetic complication, or there is a failure to report a mandatory manifestation code.
Regardless of where you find shortcomings in your facility, you should consider ways to improve clinical documentation. Develop a compliance plan and implement prospective and retrospective, internal and external chart reviews with ongoing monitoring and feedback. Be sure to review records based on official coding guidelines.