CMS Launches Get Ready 5010 Website

CMS has launched a new website, GetReady5010.org, to support providers in implementing the ANSI 837 5010 Claims transaction.

Starting January 11-13, CMS will begin a webinar series to support the transition. The webinars will feature speakers from CMS, provider and payer organizations, and will discuss:

1.  The current level of readiness and plans for testing
2.  How to prepare for testing
3.  Version 5010 basics for newcomers

HCCUniversity.com has a new webpage dedicated to the transitions to 5010 (full encounter data) and  ICD-10 transitions--Full Encounter Data and ICD-10 .

Medicare Wellness Exam

UPDATE:  CMS has published a revision to the requirements of the Annual Wellness Visit.  On January 10, 2011, CMS removed the provision for voluntary advance care planning.  No other changes to the requirements were made.  Note that this does not prevent a physician from discussing this with a patient, it only deletes it as a requirement for the Annual Wellness Visit.


There are a number of interesting provisions of the Affordable Care Act being implemented via the Physician Fee Schedule (PFS)final rule. The implementation date of most of the provisions is January 1, 2011. Although the PFS is a fee for service (FFS) or Original Medicare rule, most of these have an impact on our network, either for their FFS patients, or their MA members. For MA members, you should contact your contracted health plan for information regarding the Annual Wellness Visit. 






Over the next few weeks, we'll be posting some of these provisions in the PFS. 


Original Medicare excludes screening and preventative services.  Over the past few years, laws have been passed allowing a number of these screening services as exceptions to Medicare law--for example, screenings for colon cancer, screening mammography, a "Welcome to Medicare" physical, etc. 


The Affordable Care Act (ACA) § 4403 has added another set of preventative services to Medicare-- an Annual Wellness Visit (AWV), including Personalized Prevention Plan Services (PPPS) for Medicare beneficiaries as of January 1, 2011. Based on this revision,  CMS amended sections 411.15(a)(1) and 411.15 (k)(15) of 42 CFR (list of examples of routine physical examinations excluded from coverage)  This amendment’s expanded coverage now allows payment for an AWV, including PPPS, for an individual who is no longer within 12 months of the beneficiary's  Medicare Part B coverage date and has not received either an initial preventive physical examination (IPPE-the "Welcome to Medicare physical") or an AWV within the past 12 months. No Medicare coinsurance or Part B deductibles apply to the AWV. 

 Who Can Provide the Annual Wellness Visit  with PPPS?

1. A physician who is a doctor of medicine or osteopathy (as defined in section 1861(r)(1) of the Social Security Act (the Act); or,
2. A physician assistant, nurse practitioner, or clinical nurse specialist (as defined in section 1861(aa)(5) of the Act); or,
3. A medical professional (including a health educator, registered dietitian, or nutrition professional or other licensed practitioner) or a of such medical professionals, working under the direct supervision (as defined in 42 CFR 410.32(b)(3)(ii)) of a physician (a doctor of medicine or osteopathy) 

The services required for an AWP with PPPS are slightly different depending on whether this is the first AWP with PPPS, or a subsequent AWP with PPS.  Note that these requirements may be changed (enhanced) at the direction of the Secretary, or through the National Coverage Determination process.

What is Included in an Initial AWV with PPPS?

• Establishment of an individual’s medical/family history.
• Establishment of a list of current providers and suppliers that are regularly involved in providing medical care to the individual.
• Measurement of an individual’s height, weight, BMI (or waist circumference, if appropriate), BP, and other routine measurements as deemed appropriate, based on the beneficiary’s medical/family history.
• Detection of any cognitive impairment that the individual may have as defined in this section. Review of the individual’s potential (risk factors) for depression, including current or past experiences with depression or other mood disorders, based on the use of an appropriate screening instrument for persons without a current diagnosis of depression, which the health professional may select from various available standardized screening tests designed for this purpose and recognized by national medical professional organizations.

• Review of the individual’s functional ability and level of safety based on direct observation, or the use of appropriate screening questions or a screening questionnaire, which the health professional may select from various available screening questions or standardized questionnaires designed for this purpose and recognized by national professional medical organizations.
• Establishment of a written screening schedule for the individual, such as a checklist for the next 5 to 10 years, as appropriate, based on recommendations of the United States Preventive Services Task Force (USPSTF) and the Advisory Committee on Immunization Practices (ACIP), as well as the individual’s health status, screening history, and age-appropriate preventive services covered by Medicare.
• Establishment of a list of risk factors and conditions for which primary, secondary, or tertiary interventions are recommended or are underway for the individual, including any mental health conditions or any such risk factors or conditions that have been identified through an IPPE, and a list of treatment options and their associated risks and benefits.
• Furnishing of personalized health advice to the individual and a referral, as appropriate, to health education or preventive counseling services or programs aimed at reducing identified risk factors and improving self-management, or community-based lifestyle interventions to reduce health risks and promote self-management and wellness, including weight loss, physical activity, smoking cessation, fall prevention, and nutrition.
• Any other element(s) determined appropriate by the Secretary of Health and Human Services through the National Coverage Determination (NCD) process.

What is Included in a Subsequent AWV/PPPS?

• An update of the individual’s medical/family history.
• An update of the list of current providers and suppliers that are regularly involved in providing medical care to the individual, as that list was developed for the first AWV providing PPPS.
• Measurement of an individual’s weight (or waist circumference), BP, and other routine measurements as deemed appropriate, based on the individual’s medical/family history.
• Detection of any cognitive impairment that the individual may have as defined in this section.
• An update to the written screening schedule for the individual as that schedule is defined in this section, that was developed at the first AWV providing PPPS.
• An update to the list of risk factors and conditions for which primary, secondary, or tertiary interventions are recommended or are under way for the individual, as that list was developed at the first AWV providing PPPS.
• Furnishing of personalized health advice to the individual and a referral, as appropriate, to health education or preventive counseling services or programs.
• Any other element(s) determined by the Secretary through the NCD process.

Note: Voluntary Advanced Care Planning refers to verbal or written information regarding an individual’s ability to prepare an advance directive in the case where an injury or illness causes the individual to be unable to make health care decisions and whether or not the physician is willing to follow the individual’s wishes as expressed in an advance directive.

Codes for AWV/PPPS

Two new HCPCS codes have been developed for these services:

• G0438 - Annual wellness visit, includes a personalized prevention plan of service (PPPS), first visit, (Short descriptor – Annual wellness first)
• G0439 - Annual wellness visit, includes a personalized prevention plan of service (PPPS), subsequent visit, (Short descriptor – Annual wellness subseq) will be implemented
• Effective for services on or after January 1, 2011, FFS Medicare contractors (Medicare Adminstrative Contractors, Medicare Intermediaries and Medicare Carriers) will pay claims containing these codes provided the requirements for coverage and eligibility are met.

Edited 1/20/2011

Medicare Web Based Training Modules

Did you know that Medicare offers Web Based Training (WBT) modules for coders, physician and hospital staff? 

There are currently 15  Web-Based Training Courses available.  You can learn about topics ranging from Medicare covered preventative services to the Inpatient Prospective Payment System (IPPS).  The following WBTs are currently available:

1. Acute Hospital Inpatient Prospective Payment System (IPPS) (July 2008)  (30 minutes)

2.  Certificate of Medical Necessity (June 2009)  (60 minutes)

3. CMS Form 1500 (08/05) (July 2008)  (60 minutes)

4.  Diagnosis Coding: Using the ICD-9-CM (December 2009)  (75 minutes)

5.  HIPAA EDI Standards (March 2009)  (60 minutes)

6.  Medicare Fraud and Abuse (February 2010)  (60 minutes)

7.  Medicare Preventive Services Series Part 3 (October 2009)  (90 minutes)

8.  Medicare Preventive Services Series: Part 1 Adult Immunizations (September 2007)  (60 minutes)

 9.  Medicare Preventive Services Series: Part 2 (November 2009)  (82 minutes)

10.   PQRI and E-Prescribing (September 2009)  (60 minutes)

11.   Skilled Nursing Facility Consolidated Billing (October 2009)  (60 minutes)

12.   Understanding the Remittance Advice for Professional Providers (March 2009)  (60 minutes)

13.  Uniform Billing (UB)-04 - (July 2008)  (114 minutes)

14.  World of Medicare (January 2010)  (60 minutes)

15. Your Office in the World Of Medicare (May 2010)  (120 minutes)

Do you like the idea of Web Based Training?  What Risk Adjustment WBTs would be of interest to you?  Let us know in the comments section. 

What's New In Coding Clinic?

As you know, Coding Clinic is the official interpreter of ICD-9 coding guidelines.  So, when coding guidelines are unclear, Coding Clinic makes an official ruling.  There are a number of new Coding Clinic rulings, some of which may come up in Risk Adjustment.

Some recent Coding Clinic postings:

Coding Clinic, 2010 Q3, Acute on Chronic Kidney Failure. –The questioner asked what the correct coding was if a patient with documented acute kidney failure and End Stage Renal Disease (ESRD).  In addition, they wanted to know if the acute kidney failure was an exacerbation of the chronic kidney failure.

Coding Clinic replied that these are two separate diseases, and if both were documented, both should be coded.

Coding Clinic, 2010 Q4, Hypertensive Urgency—The questioner asked what the correct coding assignment was for hypertensive urgency.

Coding Clinic replied that the physician should be queried to determine what the specific type of hypertension was.  If still not further specified, the correct code was 401.9, Essential Hypertension, unspecified.  The alphabetic index now (as of the 2011 ICD-9) indicates that hypertensive urgency is coded 401.9.

NOTE: Hypertensive Urgency is described as systolic blood pressure over 180 mm Hg or diastolic blood pressure above 120 mm Hg.   Like Hypertensive Emergency (hypertensive crisis), Hypertensive Urgency generally requires hospitalization.

Coding Clinic 2010, Q2 – Infection due to Dialysis Catheter – The questioner asked what the correct code for infection due to a dialysis catheter. 

Coding Clinic replied that coding would be dependent on where the catheter was placed, i.e., if the infection is due to a centrally placed catheter, then the correct code is  999.31, Infection due to central venous catheter. If the infection is due to a peripherally placed catheter, then 996.62, Infection and inflammatory reaction, Due to vascular device, implant and graft is the correct code.

What Diagnoses are not appropriate in a Physician Office Setting?

There are a number of diagnoses not likely to be treated in a doctor’s office.  Often, these are documented in the medical record and submitted to us.  These conditions are things like CVA (stroke), Acute Respiratory Failure, Sepsis, and Acute coronary syndrome and Acute MI that are normally treated in a hospital setting.

In almost all cases, these conditions are submitted based on a misunderstanding of ICD-9 rules.   Usually, the physician documents something like  “CVA” in the medical record, and then chooses the diagnosis code for CVA for submission to the health plan. 

The problem is that most patients who are having a stroke are not seen in a doctor’s office. It’s true that on rare occasions, the patient does appear in a doctor’s office with a life threatening condition, but usually the physician is trying to convey that this is a problem that occurred in the past.

Physicians generally document as a way of capturing what’s wrong with the patient.  But there is another reason—it can serve as a reminder for the physician what they thought about at the last visit.  So, if they see “CVA” or “acute respiratory failure” listed on the last note, they know that this is a patient who had a CVA or acute respiratory failure in the past.  

Acute MI is a little different, and coding for Acute MI is appropriate for 8 weeks after the event.  Because there’s a lot of confusion about acute MI coding, we’ll be doing a separate blog posting on this in the future.

Physicians need to be educated that there are codes for the history of many illnesses, most of them are in the “V” section of the ICD-9.  History of MI is an exception—it’s ICD-9 412.  History of something like pneumonia or septicemia can be coded to V12.09 (personal history of other infectious disease) if the physician documents the history of and considers it a significant diagnosis.

Documentation of these historical conditions should make it clear that it is a disease that occurred in the past. Any condition that is no longer being treated should be noted to be a history of the condition.  Where a code for the history of the disease exists, it should be submitted using that code, not a code for the acute condition.

Coders need to be aware that even when a physician documents one of these conditions, they should not code them. It’s important to educate the physician and explain that these acute conditions should be documented and submitted as a “history of” code.

Do you have a have a confusing coding issue that you're dealing with? Drop us a line at coding@scanhealthplan.com, or leave us a comment and we'll do what we can to help!

CMS Announces Partial Freeze of ICD-9/ICD-10 Codes

Today, CMS released a notice regarding a partial freeze of ICD-9-CM/ICD-10 Code sets prior to the ICD-10-CM implementation on October 1, 2013.

According to the ICD-10-CM notice, the freeze will be implemented as follows:

The partial freeze will be implemented as follows:

                        • The last regular annual update to both ICD-9 and ICD-10 code sets will be made on October 1, 2011.

                        • On October 1, 2012 there will be only limited code updates to both ICD-9- CM and ICD- 10 code sets to capture new technology and new  diseases.

                        • There will be no updates to ICD-9 -CM on October 1, 2013 as the system will no longer be a HIPAA standard.

Transcripts of the ICD-9-CM Coordination and Maintenance Committee meeting can be found at: http://www.cms.gov/ICD9ProviderDiagnosticCodes/03_meetings.asp.

Although we expect that CMS will provide a ICD-9 to ICD-10 crosswalk of the CMS-HCC model at some point, we don’t know when that will happen. 

You can read the CMS notice here, on the Tools Page at HCCUniversity.com.

Changes to the CMS-HCC Model for 2011

As noted in our last post, the updated CMS-HCC Model codes were posted to our website on 9-29-2010.  You can view the file on our Tools Page.  But, what are the changes to the model for 2011?

In short, CMS has:

• Deleted two codes from the model --279.4 and 453.8.  Both of these codes are truncated codes, i.e., not at the highest level of specificity
• Deleted three codes from HCC 80--404.03, 404.93 and 404.13.  Note that these codes all still map to HCC 131
• Added 8 new codes to the model. All of these codes are new ICD-9 codes.  While the codes are effective 10-1-2010, they do not count in the CMS-HCC model until 1-1-2011.

See below for details.

ICD-9-CM Code	ICD9_Description	CMS-HCC Model Category	CMS HCC Model 2011	Action Taken	Comments
40413	Ben Hyp Ht/Kid W Hf/Kid	80	No	Deleted from this HCC	Although this diagnosis remains in the model under HCC 131, it no longer maps to HCC 80.
2794	Autoimmune Disease Nec	45	No	Deleted from the model	This diagnosis code was removed from the model. It is not at the highest level of specificity, and more specific codes in this section remain in the model.
4538	Venous Thrombosis Nec	105	No	Deleted from the model	This diagnosis code was removed from the model. It is not at the highest level of specificity, and more specific codes in this section remain in the model.
40493	Hyp Hrt/Kid Nos W Hf/Kid	80	No	Deleted from this HCC	Although this diagnosis remains in the model under HCC 131, it no longer maps to HCC 80.
40403	Mal Hyp Hrt/Kid W Hf/Kid	80	No	Deleted from this HCC	Although this diagnosis remains in the model under HCC 131, it no longer maps to HCC 80.
44770	Aortic ectasia, site NOS	105	Yes	Added	This is a new diagnosis code for 2011. The code is effective 10-1-2010, but not included in the model until 1-1-2011.
56032	Fecal impaction	31	Yes	Added	This is a new diagnosis code for 2011. The code is effective 10-1-2010, but not included in the model until 1-1-2011.
23773	Schwannomatosis	10	Yes	Added	This is a new diagnosis code for 2011. The code is effective 10-1-2010, but not included in the model until 1-1-2011.
23779	Neurofibromatosis NEC	10	Yes	Added	This is a new diagnosis code for 2011. The code is effective 10-1-2010, but not included in the model until 1-1-2011.
78033	Post traumatic seizures	74	Yes	Added	This is a new diagnosis code for 2011. The code is effective 10-1-2010, but not included in the model until 1-1-2011.
44773	Thoracoabd aortc ectasia	105	Yes	Added	This is a new diagnosis code for 2011. The code is effective 10-1-2010, but not included in the model until 1-1-2011.
44772	Abdominal aortic ectasia	105	Yes	Added	This is a new diagnosis code for 2011. The code is effective 10-1-2010, but not included in the model until 1-1-2011.
44771	Thoracic aortic ectasia	105	Yes	Added	This is a new diagnosis code for 2011. The code is effective 10-1-2010, but not included in the model until 1-1-2011.

If you have questions or comments about this posting, or have ideas for future postings, please let us know by leaving a comment!

New ICD-9 Codes Added to CMS-HCC Model

CMS published the new codes for the CMS-HCC model today on their website.  The new codes are effective 1-1-2011, and include a number of the new 2011 ICD-9 codes.  *While the ICD-9 codes are effective 10-1-2010, they are not included in the model until 1-1-2011.*

You can find the file on HCC University on our Tools Page.

The following codes have been added to the CMS-HCC or the RxHCC model:

Please note that there may be new codes added in 2011 due to changes in the CMS-HCC model.  The first (proposed) announcement of this will occur in February, with the final announcement of changes in April.  These changes will be posted here as soon as they become available.

CMS Help for Providers

Did you know that CMS has email subscriptions for special topics?  You can sign up to receive email alerts for a number of specific or general topics at:  CMS Email Subscriptions.

Right now, two hot topics are the transition to the 5010 transaction for claims and encounters (required as of 1-1-2012) and ICD-10 Transition (required as of 10-1-2013).  CMS has published a number of informational articles for physicians, office staff, and vendors.  A few you might be interested in:

The ICD-10 Transition: An Introduction

Talking to Your Vendors About ICD-10 and Version 5010

Talking to Customers for Vendors

What topics would you like to see more about on HCC University?  Drop us a line at coding@scanhealthplan.com, or leave us a comment!

Full Text 2011 ICD-9-CM Codes Posted On HCC University

We've posted the full text of the 2011 ICD-9-CM on HCC University.  You can find the following files on the Tools page:

• 2011 ICD-9-CM Guidelines
• 2011 ICD-9-CM Preface
• 2011 ICD-9-CM Diagnosis Disease Index
• 2011 ICD-9-CM Diagnosis Tabular Listing
• 2011 ICD-9-CM Procedures Index
• 2011 ICD-9-CM Procedures Tabular Listing

All files are effective 10-1-2010.  You can download these files to your desktop, for easy searching. 

We hope you find these files useful. 

What tools would you like to see on HCC University?  Let us know in our comments section, and we'll do what we can to make it happen.

New ICD-9-CM Codes for 2011 (Effective Date 10-1-2010)

We’ve posted a copy of the new, revised and deleted ICD-9-CM codes for 2011 codes on our Tools page (Tools) As soon as the full text copies of ICD-9 have been posted, we’ll post them there too.

Note that CMS has not indicated which, if any, of these codes will be included in the CMS-HCC risk adjustment model.  As soon as new information becomes available, we’ll post it here.

Welcome!

Welcome to the new SCAN blog! We have added moderated comments to the new blog, so that you can join the conversation. Guidelines for posting are posted, and we hope that you’ll read them, and add to discussion. Because your comments need to be reviewed prior to posting, there may be a delay of up to a day before you see them.


We see this as a great opportunity for everyone to share their Medicare Advantage Risk Adjustment (RA) knowledge, ask questions, and further discussions on topics of interest to all of us involved in Risk Adjustment.

If you have ideas for future postings, have found a great resource, or want to know where to find information, let us know here.

Look for our next RA topic related posting in a few days…and please, join in!


The SCAN Risk Adjustment Team