Transcript CARDIOLOGY

MEDICARE RISK ADJUSTMENT
HCC CARDIOLOGY
Presented by Susan Wyatt CPC, CPC-I, CPMA
Director of Risk Adjustment Audit and Education
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7/16/2015
WHAT IS MEDICARE RISK ADJUSTMENT?
(MRA)
Before 2003
Payment to Health Plan
(Managed Care)
• Not influenced by Health
Status
• Based on Demographics
• “Capitated”
Flat rate/member/year
After 2003
Payment to Health Plan
(CMS HCC Managed Care)
• Risk Adjusted for Health Status
• Based partially on
Demographics
MRA payment methodology was mandated by the
Balanced Budget Act of 1997
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WHAT IS AN HCC?
(Hierarchical Condition Category)
14,400 ICD-9
Diagnosis
Codes
• All Codes in the ICD-9
3,000
Reimbursable
ICD-9 Codes
• Map to 1 of 79 Categories
• Each Code AKA an “HCC”
79 Categories
of Codes
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
Clinically Related Conditions

Additive and Hierarchical

Chronic and Acute Conditions
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WHY IS MRA IMPORTANT?
Specific diagnostic documentation and coding of conditions is
necessary for accurate reimbursement
Disease
Interactions
Documentation
HCC DX
Codes
RAF
Score
HCC
Categories
Documentation is
the Core
RAF Score reflects disease
burden of the patient
Demographics
Current Year Reporting Predicts Revenue for Upcoming Year
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DOCUMENTATION GUIDELINES
Encounter must
be a face-toface visit
Legible Signature
and Provider
Credentials
•
•
•
•
•
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Patient Name;
DOB; DOS on
every page
(backside too!)
Manage,
Evaluate, Assess,
Treat – MEAT!
All Chronic Conditions must be documented
at least once every year!
Document Acute Conditions when
applicable!
Think about diagnostic documentation as a
form of nomenclature!
Thorough documentation promotes
Continuity of Care!
We cannot code from a problem list or from
past medical history!
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CARDIOLOGY
HCC
85
.368
HCC
85
.368
HCC
85 & 55
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•
•
•
•
CHF (compensated or decompensated)
Heart Failure
Systolic and/or Diastolic
Acute and/or Chronic
428.0
428.9
• Cardiomyopathy
• Metabolic Cardiomyopathy
• Cardiomyopathy in Other Diseases
• Secondary Cardiomyopathy
425.4
425.7
425.8
425.9
• Alcoholic Cardiomyopathy
• Also – Alcohol Dependent
• or Alcohol Dependence in Remission
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425.5 .368
303.90
303.93 .420
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CARDIOLOGY
HCC
87 & 88
.258 & .141
HCC
96
.295
•
•
•
•
Unstable Angina
Angina
Acute Coronary Occlusion w/o MI
Acute Ischemic Heart Disease
411.1
413.9
411.81
411.89
•
•
•
•
Atrial Fibrillation
Atrial Flutter
Paroxysmal Tachycardia NOS
(Atrial (PAT) 427.0 or Ventricular 427.1 also)
427.31
427.32
427.2
• Complete or 3rd degree block
• SSS/-Chronic Sinus Bradycardia/Tachy-Brady Syndrome
HCC
96
.295
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426.0
427.81
• (If patient has a pacemaker for the SSS or Complete or 3rd degree
block then you only code the pacemaker V45.01.You cannot code
426.0 or 427.81)
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CARDIOLOGY
HCC
86
.275
HCC
87
.258
HCC
86
.275
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•
•
•
•
Acute MI Initial NOS
410.91
NSTEMI Initial
410.71
STEMI Initial
410.51
Can be coded as acute MI up to 8 wks after initial MI if documentation supports
the 8 week time frame. Example: “PT had MI 6 weeks ago”
• Acute MI Subsequent (admitted back to hospital)
• Acute MI Unspecified
• Old MI ( Exists in old model only but still counts for 67%)
410.92
410.90
412
• Chordae Tendinae Rupture
• Papillary Muscle Rupture
429.5
429.6
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CARDIOLOGY
HCC
84
.329
HCC
84
.329
HCC
186
.891
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• Cardiogenic Shock
• Postop Cardiogenic Shock
• Cardiac Arrest
785.51
998.01
427.5
• Ventricular Fibrillation
• Ventricular Flutter
427.41
427.42
• Heart Transplant
• Complication of Heart Transplant
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V42.1
996.83
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CARDIOLOGY
HCC
136
.224
HCC
85
.368
HCC
85
.368
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• Hypertensive CKD Stages 5 or ESRD
• (This is an assumed relationship)
• Assign code for CKD as well
403.91
• Hypertensive Heart Ds w/Heart Failure
• (This is not an assumed relationship-it must be stated)
• Assign code for Heart Failure as well
402.91
• Hypertensive Heart Ds & CKD Stg 5 or ESRD
• Assign code for Heart Failure and CKD as well
404.91
428.X
585.X
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585.X
428.X
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CARDIOLOGY
HCC
85
.368
HCC
85
.368
HCC
85
.368
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•
•
•
•
•
Rheumatic Heart Failure
Acute Cor Pulmonale
Primary Pulmonary Hypertension
Pulmonary Hypertension
Chronic Pulmonary Heart Disease (Cor Pulmonale)
398.91
415.0
416.0
416.8
416.9
• Endomyocardial Fibrosis
• Hypertrophic Obstructive Cardiomyopathy
425.0
425.11
• Myocarditis NOS
• Myocardial Degeneration
429.0
429.1
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CARDIOLOGY
HCC
176
.566
HCC in old model
only
67%
HCC in the old
model only
67%
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• Reaction to cardiac device, implant or graft
996.61
• Malfunction cardiac device, implant or graft NOS
• Malfunction of cardiac pacemaker
• Malfunction of cardiac prosthetic heart valve
996.00
996.01
996.02
• Malfunction of coronary bypass graft
• Mechanical complication automatic implantable defibrillator
996.03
996.04
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HISTORY OF
Coders
interpretation
of “H/O”
Providers meaning
of “H/O”
Coders use ICD9 interpretation of history which is resolved,
gone and typically not coming back.
Clinicians use H/O typically meaning the patient’s history,
not that the condition is history.
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CARDIOLOGY NON-HCC CONDITIONS
Sinus
Bradycardia
427.89
Acute
Myocarditis
422.90
Ischemic
Cardiomyopathy
414.8
CAD
414.01 & 414.00
Ischemic
Heart Disease
414.9
Tachycardia
785.0
Cardiac
Dysrhythmia
427.9
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CARDIOLOGY NON-HCC CONDITONS
Cardiomegaly
429.3
Cardiac
Tamponade
423.3
ASCVD
429.2
Pericarditis
423.9
Aortic/Mitral
Valve
Disorders
424.X
Takotsubo
Syndrome
429.83
BBB
426.5X
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CARDIOLOGY- NON HCC
(It is a Part D)
Hypertension,
Unspecified
401.9
Hypertension,
Malignant
401.0
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Hypertension,
Benign
401.1
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CONTACT INFORMATION
 Susan Wyatt
CPC, CPCI, CPMA
 12900 Park Plaza Dr.
 Cerritos, Ca. 90703
 562-622-2850
 Fax 562-622-2849
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7/16/2015