Wednesday, December 14, 2011

New Presentation on HCC University

There's a new presentation and quiz on!  Check out Documentation for Ophthalmology coding.  This presentation should help Ophthalmologists and Optometrists understand ICD-9 coding requirements.  Go Here and scroll down to the first downloadable presentation!

Friday, December 9, 2011

New Tools on HCC University!

We sometimes receive diagnosis codes that are unlikely, based on the place of service.  These codes represent conditions that are of such severity that they usually require hospitalization.  We've prepared several short handouts to help physicians and other clinicians understand the correct use of these codes.  Most of them can be printed on a half sheet of paper (we recommend an eye catching color like yellow or bright blue for impact) to share with your clinicians. 

Choose from:

Sepsis Fact Sheet
Acute MI Fact Sheet
Unstable Angina/Acute Coronary Syndrome Fact Sheet
Acute Respiratory Failure Fact Sheet
Acute CVA Fact Sheet

Download them now on the Tools Page.  Scroll down to "Downloadable Tools".

Wednesday, December 7, 2011

2012 ICD-10 CM Codes Published

The National Center for Health Statistics has published the 2012 ICD-10 codes.  You can view and download the files HERE.

Monday, December 5, 2011

A Very Frequently Asked Question

We frequently are asked about "where CMS says" one thing or another.  First, you have to remember that CMS can't and won't address every possible situation.  By applying common rules and logic, you can usually know what CMS would do in a given situation.  One question we get a lot is:

Our doctors want to know why they can’t just write “250.40 –diabetes with renal manifestations” in the record and code 250.40—and where CMS says they can’t do this.

Our answer to this question is as follows:

CMS doesn’t write the rules for ICD-9 by themselves—and it would be impossible to write a rule for each and every possible situation that can occur.  The Official Coding Guidelines make it clear that a diagnosis must be supported by the medical record, and must affect the care of the patient.

The rules for ICD-9 are written by the four cooperating parties – the American Health Information Management Association, the National Center for Health Statistics, the American Hospital Association, as well as CMS.  All official interpretations not found in the coding guidelines are the responsibility of the American Hospital Association, via Coding Clinic.

A short diagnosis code description (like diabetes with renal manifestations) is just that—a description.  The word “manifestations” is not a diagnosis, it’s a category of conditions, and the physician is required to describe what disease in that category exists.  A physician can no more support an ICD-9 code by writing the description than they can support an E/M code by writing its description. 

Writing “Office or other outpatient visit for the evaluation and management of an established patient, which requires at least 2 of these 3 key components: A detailed history; A detailed examination; Medical decision making of moderate complexity. Counseling and/or coordination of care with other providers or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the presenting problem(s) are of moderate to high severity. Physicians typically spend 25 minutes face-to-face with the patient and/or family” does not support a 99214, it’s a description of a 99214. Similarly, in order to support a diagnosis, the physician must document what’s wrong with the patient.

So, with diagnosis coding, the physician must document in the medical record what is actually wrong with the patient--not a category of what's wrong with the patient.

Wednesday, November 9, 2011

Do You Need Free CEUs?

Who doesn't need free CEUs?  Well, there are 12 CEUs available on the CMS website for AAPC members.  You can check them out here at the Medicare Learning Network.

The Medicare Learning Network offers courses on everything from the CMS 1500 form to PQRI and E-Prescribing.

Wednesday, November 2, 2011

New CMS ICD-10 Implementation Handbooks

CMS has developed  Implementation Handbooks and related templates to help providers and payers in transitioning from ICD-9 to ICD-10.  We'll be posting the handbooks and templates on HCC University, but in the meantime, you can download them from the CMS website at:

ICD-10 Implementation Handbooks

Tuesday, November 1, 2011

ICD-10 Presentation on HCC University

We've posted our second provider ICD-10 presentation on HCC University--Diabetes in ICD-10.  This presentation should help you understand the documentation requirements for Diabetes under ICD-10.  Keep watching this space for more presentations on ICD-10.  Next up--Cardiovascular disease.

Monday, October 10, 2011

Thursday, September 29, 2011

Full Text of the 2012 ICD-9 Now Available!

The full text of the 2012 ICD-9 Code book, effective October 1, 2012 is now available on our website.  You can download the book, including the official guidelines here: 2012 ICD-9 .

When CMS posts the update to the CMS-HCC model, we'll post them on HCC University.

Have questions about risk adjustment or ICD-9-CM coding?  Contact us at

Tuesday, September 20, 2011

CMS Updates on Full Encounter Data

Last Week, CMS posted an updated CMS Encounter Data Participant Guide. Also published was a presentation from the training sessions held by CMS in August and September.  It does not appear that the presentation was updated, although we do not know for sure. It still contains references to benchmarks for 60% submission within 60 days and 90% within 90 days.  We are still hoping that CMS will not hold us to these benchmarks.  However, Medical Groups and Hospital providers must be prepared for the possiblity that this may occur.

We will be posting these new documents on HCC University on the Full Encounter Data/ICD-10 page within the next 48 hours.

Thursday, September 8, 2011

New Presentation Posted on HCC University

We've just posted a new presentation on HCC University--ICD-10 and GEMs 101.  This presentation will give you an overview of the ICD-10 coding system, and the General Equivalent Mappings, a dictionary which maps the current ICD-9 system to ICD-10.   Go to Presentations to review.

We'll be posting more ICD-10 related presentations and materials over the next few months.

What else would you like to see on HCC U?  Leave us a comment, or send an email to

Monday, August 22, 2011

Full Encounter Data Update

The rules for Full Encounter Data are ever evolving.  Today, CMS released the new Encounter Data Quarterly Newsletter.  It seems the rules for Full Encounter Data are ever evolving.  Initially, CMS told Health Plans that they would not be submitting Interim hospital bills.  In this newsletter, CMS has indicated that Interim bills will be submitted. 

In the category of good news, CMS has indicated that if Health Plans don't have the full 9 digit ZIP code, they can use 9999 for the last 4 digits.  Medical groups should submit the correct ZIP code whenever possible, but if it's unavailable, 9999 will pass the CMS edits.

Finally, sometime this month, CMS will release the Encounter Data Companion Guides. 

We'll post the newsletter on HCC University on the Full Encounter Data/ICD-10 page in the next few days.

Thursday, August 18, 2011

2012 ICD-9-CM Guidelines Posted

The Official ICD-9-CM coding guidelines, effective 10-1-2011, were posted on the National Center For Health Statistics website.  A copy of the new guidelines will be posted on the Tools page at shortly.

Few changes are included, but there are some of note.  There are new sections added to describe:
  • Appropriate coding of post-procedural infection and post-procedural septic shock (I.C.1.b.10.c.)
  • Appropriate coding of types and stages of glaucoma (I.C.6.b.) and
  • Guidelines for complications of care (I.C.17.f.1.)

Tuesday, August 16, 2011

Coding Symptoms Inherent in a Disease

In the first quarter of 2010, the following question was submitted to Coding Clinic:

What is the correct code assignment for a diagnosis of “compensated respiratory acidosis” in a patient with chronic obstructive pulmonary disease (COPD)?

Coding Clinic advised that only one code should be assigned--496 for the COPD.  This answer illustrates a coding principle that sometimes is problematic--symptoms of a disease are not coded when they are inherent to the disease.  Often, physicians will list these symptoms or signs when they are causing a specific problem for the patient.  For example, tremor is a hallmark of Parkinson's disease, and a physician may note that the tremor exists, is increasing or is decreasing.  Coders may be tempted to code the tremor because the physician has evaluated it--but it's a part of the disease. In that case, only the Parkinson's disease should be coded.

Sometimes, it's not so clear that a problem is a usual part of the disease.  For example, in the second quarter of 2010, a patient presented with gross hematuria due to a prostate malignancy.  While the prostate malignancy caused the hematuria, it isn't a usual part of the disease, and the questioner was instructed to code the hematuria, and the prostate cancer as a secondary diagnosis. In that case, the hematuria was a complication, and complications are coded separately.

When in doubt, coders should query the physician as to whether a listed symptom or sign is a usual part of the disease process, or a complication.  This affords coders a great opportunity to work collaboratively with the physician--it allows the coder the opportunity to both gain information from the physician, and provide the physician with information regarding coding rules. 

Thursday, July 21, 2011

CMS Full Encounter Updates

CMS is currently holding technical assistance meetings for health plans across the country.  SCAN representatives attended the July session in San Diego the week of July 11.

A lot of issues remain up in the air, but we do know a few things.

  • CMS is holding fast on the subject of the 13 month timely filing.  Plans are given an additional month over the 12 month FFS timely filing to account for the submission from provider to plan to CMS.   There is discussion of filing benchmarks and we hope to know more about this after the final session ending the first week of August.
  • Plans cannot make material corrections to claims/encounters, this must be done by the provider of service.  For example, diagnosis codes, procedure codes and other fields involved in pricing the claim (e.g., addresses, modifiers) must be corrected by the provider.
  • Full 9 digit ZIP codes will be required on claims/encounters.
  • CMS has clarified that the only dental claims that will be required are those that are covered by fee-for-service Medicare.  This includes jaw reconstruction after an accident, and examinations (no treatment) prior to kidney transplants and some heart valve implants.  If the services are performed by a hospital based dentist (rare) then the submission must be on the 837 I, and if performed by a dentist in private practice, on the 837P.  No 837D (dental) claims will be accepted by CMS.
  • \CMS has no projected date for a draft of the CMS-HCC model with ICD-10 codes.  There was also no update about a move to the new 87 disease CMS-HCC model.
As we learn more from CMS about full encounter data requirements, we'll post it here.

Please let us know if there are any specific issues you'd like to see in this space.  You can leave us a comment, or email us at

Monday, July 18, 2011

CMS Physician Conference Call for ICD-10 Implementation

Date:  08/03/2011

Time:  1:00 - 3:00 PM  EASTERN TIME

Subject:  ICD-10 Implementation Strategies for Physicians National Provider Call

Target Audience: Medical coders, physician office staff, provider billing staff, health records staff, vendors, educators, system maintainers, laboratories, and all Medicare fee-for-service (FFS) providers


The Centers for Medicare & Medicaid Services (CMS) will host a national provider call on "ICD-10 Implementation Strategies for Physicians." Is your office preparing for a smooth transition to ICD-10 on October 1, 2013? CMS subject matter experts will discuss ways that physician offices can prepare for the change to ICD-10 for medical diagnosis and inpatient procedure coding. A question and answer session will follow the presentations.

  • The following topics will be discussed:
  • ICD-10 requirements and resources overview
  • Implementation strategies for physician offices
  • Update on coverage conversion activities
  • National ICD-10 implementation issues
  • Update on bill processing, including claims that span the implementation date
  • Update on Home Health Agency Home Health Resource Grouper

How to Register:

In order to receive the call-in information, you must register for the call. It is important to note that if you are planning to sit in with a group, only one person needs to register to receive the call-in data. This registration is solely to reserve a phone line, NOT to allow participation.

Please note: If you plan to request continuing education credit from your professional organization and if this organization requires proof of registration, you will personally need to register so that you receive a confirmation e-mail.

Registration will close at 1:00 p.m. ET on August2, 2011, or when available space has been filled. No exceptions will be made, so please be sure to register prior to this time.

To register for the call participants need to go to:

Fill in all required data.

Verify that your time zone is displayed correctly in the drop down box.

Click "Register".

You will be taken to the "Thank you for registering" page and will receive a confirmation e-mail shortly thereafter. Note: Please print and save this page, in the event that your server blocks the confirmation e-mails. If you do not receive the confirmation e-mail, please check your spam/junk mail filter as it may have been directed there.

If assistance for hearing impaired services is needed the request must be sent to no later than 3 business days before the event.

On the day of the call, please dial in at least 15 minutes before call start time.

Presentation Materials:

Presentation materials for the August 3 call will be available on in the "Downloads" section no later than 24 hours before the conference call. Remember to download the presentation materials from the CMS site prior to the teleconference.

Continuing Education Credits

 Continuing education credits may be awarded by the American Academy of Professional Coders (AAPC) or the American Health Information Management Association (AHIMA) for participation in CMS National Provider Conference Calls.

Continuing Education Information for American Academy of Professional Coders (AAPC)

If you have attended or are planning to attend a CMS National Provider Conference Call, you should be aware that CMS does not provide certificates of attendance for these calls. Instead, the AAPC will accept your e-mailed confirmation and call description as proof of participation. Please retain a copy of your e-mailed confirmation for these calls as the AAPC will request them for any conference call you entered into your CEU Tracker if you are chosen for CEU verification. Members are awarded one (1) CEU per hour of participation.

Continuing Education Information for American Health Information Management Association (AHIMA)

AHIMA credential-holders may claim 1 CEU per 60 minutes of attendance at an educational program. Maintain documentation about the program for verification purposes in the event of an audit. A program does not need to be pre-approved by AHIMA, nor does a CEU certificate need to be provided, in order to claim AHIMA CEU credit. For detailed information about AHIMA's CEU requirements, see the Recertification Guide on AHIMA's web site.


Please note: The statements above are standard language provided to CMS by the AAPC and the AHIMA. If you have any questions concerning either statement, please contact the respective organization, not CMS.

Monday, June 27, 2011

Retention of Medical Records

We’ve received questions about the length of time a provider has to keep medical records.  Usually the question includes a statement of how long the person asking believes they have to keep them.  Most often, we hear 7 years—although 5 years and 3 years come up.  It’s no wonder there’s confusion. 

There are likely multiple record-keeping requirements that apply to your organization, each of which your organization must comply.

For example, if your organization is a downstream contractor of a Medicare Advantage Plan, Centers for Medicare & Medicaid Services (CMS) specifically requires that your organization agree that:
·         Department of Health and Human Services, the Comptroller General, or their designees have the right to inspect, evaluate, and audit any pertinent contracts, books, documents, papers, and records involving transactions related to the Medicare Advantage contract; and
·         Department of Health and Human Services', the Comptroller General's, or their designee's right to inspect, evaluate, and audit any pertinent information for any particular contract period will exist through 10 years from the final date of the contract period [meaning the contract between CMS and the Medicare Advantage plan] or from the date of completion of any audit, whichever is later.
Source: 42 CFR 422.504 (e) (4) and Medicare Managed Care Manual, Chapter 11 - Medicare Advantage Application Procedures and Contract Requirements, section 110.1.

Ultimately, the determination of which legal requirements apply to your organization is a complicated issue that depends on a variety of factors. As always, readers should consult qualified counsel for assistance. This article does not constitute legal advice.

Friday, June 17, 2011

More Updates from Coding Clinic

On June 3 we posted several new Coding Clinic rulings.  Today, we're posting several more updates.  Keep your eyes on this space for more posts on recent Coding Clinic rulings.

Volume:  2011

Issue:  First 

Title:  Systemic Inflammatory Response Syndrome (SIRS) due to Pancreatitis

The questioner asked for clarification of the advice published in First Quarter 2010. In that issue, coders were instructed to assign code 995.93, Systemic inflammatory response syndrome due to noninfectious process without acute organ dysfunction for SIRS due to a noninfectious condition, such as pancreatitis. Because the etiology of pancreatitis can either be infectious or noninfectious, the questioner asked if the provider be queried.  

Coding Clinic acknowledged that pancreatitis can have various etiologies; however, the majority of cases of pancreatitis are non-infectious. In many cases, the cause is unknown.  If the provider documents specifically that the SIRS is due to infectious pancreatitis, use the infectious SIRS code rather than the noninfectious one.  The provider should be queried if the medical record documentation is not clear.

Volume:  2011

Issue:  First 

Title:  Borderline Diabetes Mellitus

The question of coding a diagnosis of borderline diabetes was posed.

Coding Clinic answered that code assignment should be based on physician documentation, and sometimes might require querying the physician.

If not, a diagnosis of “borderline diabetes” without further confirmation of the disease should be assigned the appropriate code from subcategory 790.2, Abnormal glucose.

Volume: 2011

Issue:  First 

Title:  Chronic Venous Embolism and Thrombosis

The questioner noted that there were codes for chronic venous embolism and thrombosis, and asked when  DVT becomes chronic.

Coding Clinic noted that there were no specific timelines for when DVT or any other condition becomes chronic. The assignment of chronic DVT is based on provider documentation.

 Volume:  s2011

Issue:  First 

Title:  Broken Catheter Tip Retrieved via Thrombectomy

The questioner noted that a patient was admitted for thrombosed arteriovenous graft. An aspiration of thrombus was performed. During the procedure, the catheter tip separated at the entry site of the sheath after access through scar tissue. Open thrombectomy was performed with retrieval of the catheter tip. What is the code assignment for the broken catheter tip?


Coding Clinic advised the questioner to assign code 996.1, Mechanical complication of other vascular device, implant, and graft, for the broken catheter tip.

If the catheter tip had not been retrieved, codes 996.1, Mechanical complication of other vascular device, implant, and graft, and 998.4, Foreign body accidentally left during a procedure, would be assigned.

Note there is a previous Coding Clinic, First Quarter 1995, with  an example of a catheter tip that broke off during chemotherapy infusion.


Issue:  First 

Title:  Broken Needle Left during Surgery

The questioner asked about a needle placed along the right lateral aspect of the sewing ring of the aortic valve and passed through tissue to try to cinch the valve down. The suture broke from the needle and the needle was lost within this tissue.  An x-ray was done which did not reveal the needle. The chest was closed and a second x-ray showed that the needle was to the right of the aortic valve. The chest was reopened but the needle still could not be located or palpated.

 The surgeon decided that continuing to look for the needle was likely to cause the patient more harm than good. Therefore, the chest was closed again, and the patient was transferred to ICU in stable condition.
The questioner asked what the correct diagnosis code assignment is when a provider intentionally leaves a foreign body in the patient and the documentation clearly states that removing the foreign body will cause more harm than good? Would code 998.4, Foreign body accidentally left during procedure, be appropriate?

Coding clinic advised to assign code 998.4, Foreign body accidentally left during a procedure. Although the surgeon made the decision to leave the needle because continuing to search for it might cause harm to the patient, it was not the intent of the original procedure to leave a foreign body behind.

Year:   2011

Issue:  First 

Title:  Coding for Home Health Care

The questioner asked if symptoms codes should be assigned along with the aftercare codes. As an example, they asked if it was appropriate to assign a code for gait abnormality when a patient is receiving home health aftercare following joint replacement? Does the advice change depending on whether this is an outpatient encounter versus an inpatient admission?

Coding Clinic answered that  symptom codes may be assigned in conjunction with V codes when they provide additional information about the specific problem being addressed. In the given example, code 781.2, Abnormality of gait, may be assigned in conjunction with code V54.81, Aftercare following joint replacement.

Year: 2011

Issue:  First 

Title:  Code Assignment Based on Up and Down Arrows

The questioner asked if it was appropriate to assign a diagnosis code for a condition listed with up and down arrows?  Examples were provided:  ↑ cholesterol, or ↑lipids, or ↓hemoglobin and hematocrit, and they wondered if a code should be assigned for hypercholesterolemia, or hyperlipidemia, or low H&H, etc.? They also wondered if the  advice changed depending on whether this is an outpatient encounter versus an inpatient admission?

Coding Clinic advised that it is not appropriate for the coder to report a diagnosis based on up and down arrows, and that diagnosing a patient’s condition is solely the responsibility of the provider.

The use of up and down arrows can have variable interpretations and do not necessarily mean “abnormal.” They could simply be indicating change (including improvement) over past results. Therefore the provider should be queried regarding the meaning of the arrows and request that the appropriate documentation of a condition or diagnosis be provided.

Coding Clinic advised that this response was consistent with the coding guideline on abnormal findings which states: “abnormal findings (laboratory, x-ray, pathologic, and other diagnostic results) are not coded and reported unless the provider indicates their clinical significance. If the findings are outside the normal range and the attending provider has ordered other tests to evaluate the condition or prescribed treatment, it is appropriate to ask the provider whether the abnormal finding should be added.” The same advice applies for both inpatient and outpatient admissions.

Friday, June 10, 2011

New Full Encounter Data Web-Page

In addition to the ICD-10/Full Encounter Data page on HCC University, a new web page for only Full Encounter Data Information has been launched!

Visit our new Full Encounter Data page here .

Friday, June 3, 2011

Recent Coding Clinic Decisions

The last quarter  2010 and the first quarter 2011 Coding Clinic rulings were recently released. Because there are so many decisions, we'll post them over the next week in small batches so that the posts aren't too long  We hope that this information is helpful to you!

Volume: 2011

Issue:  First 

Title:  Postoperative Aspiration Pneumonia

The question of the  correct code assignment for a diagnosis of postoperative aspiration pneumonia was made, noting that  ICD-9-CM’s Tabular List under code 997.39 provides the following inclusion terms: “Pneumonia (aspiration) resulting from a procedure.” The questioner went on to note that the instructional note under category 997 states, “Use additional code to identify complication.” Should code 997.39, Respiratory complications, Other respiratory complications, be assigned along with code 507.0, Pneumonitis due to solids and liquids, Due to inhalation of food or vomitus, to describe postsurgical aspiration pneumonia?

Coding Clinic answered that it was appropriate to assign both codes together. The questioner was instructed to assign code 997.39, Respiratory complications, Other respiratory complications, and code 507.0, Pneumonitis due to solids and liquids, due to inhalation of food or vomitus, for postsurgical aspiration pneumonia. Coding Clinic went on to indicate that the title of code 997.39 is broad  and that the  assignment of code 507.0 provides additional information about the specific respiratory complication.

Volume:  2011

Issue:  First 

Title:  Pancytopenia due to Drug

The questioner indicated confusion about coding drug-induced pancytopenia. Coding Clinic had previously advised how to code chemotherapy induced aplastic anemia but did not address pancytopenia secondary to drugs. The ICD-9-CM indexes pancytopenia to code 284.1, Pancytopenia. However, code 284.1 is excluded from pancytopenia due to or with aplastic anemia (284.9) as well as that which is drug induced (284.89). If the provider documents “pancytopenia due to chemotherapy” and there is no documentation of “aplastic anemia,” how is this coded?

Coding clinic answered that based on the instructional note under code 284.1, the correct code would be Other specified aplastic anemias 284.89, along with the appropriate E-code to identify the drug. Although there is no medical record documentation of aplastic anemia, the instructional note indicates that drug-induced pancytopenia is classified to code 284.89.

Volume: 2011

Issue:  First 

Title:  Transbronchial Biopsy of Lung  (inpatient procedure coding)

The questioner noted that a procedurewas listed as bronchoscopy due to nodular infiltrates and atelectasis and airway examination. In addition, washings, brushing and biopsy were taken from the left lower lobe and washings from the right lower lobe. Additionally, the provider has clarified that a transbronchial biopsy of the left lower lobe was performed. No lung tissue was identified on the pathology report. How should this be reported?

Coding clinic indicated that based on the provider’s documentation, they should assign procedure code 33.27, Closed endoscopic biopsy of lung, for the transbronchial biopsy. Although there was an absence of lung tissue in the pathology report, it did not preclude the assignment of the code when the procedure is performed by the provider. Tissue samples may be inadequate or inconclusive, leading to the lack of lung tissue in the path report.

Volume:  2011

Issue:  First 

Title:  Trichilemmal (Pilar) Cyst

The questioner indicated that a  patient presented for outpatient surgery for removal of a scalp lesion. The provider documented “skin lesion, scalp––excised.” The pathology report indicates “trichilemmal cyst (pilar cyst).” ICD-9-CM classifies a cyst of the scalp as a sebaceous cyst. There is confusion as to whether this should be coded as a trichilemmal or sebaceous cyst. What is the correct diagnosis code for this encounter?


The questioner was told to assign code 704.8, Other specified diseases of hair and hair follicles, for the trichilemmal (pilar) cyst.

Volume:  2011

Issue:  First 

Title:  Postoperative Hemorrhage and Postoperative Hematoma

The questioner was concerned about  inconsistency in hospital coding of postoperative hemorrhage vs. postoperative hematoma.  They noted that when a surgical wound is slightly oozing blood and is treated with pressure, it is being coded as a postoperative hemorrhage. By the same token, if a small hematoma is noted after surgery, but not treated, it is still being coded as postoperative hematoma. Could you provide us with guidance so that we can consistently code these conditions?

Coding Clinic answered quite strongly, reiterating the Official Coding Guidelines on complications of  care:  “As with all procedural or postprocedural complications, code assignment is based on the provider’s documentation of the relationship between the condition and the procedure” (Section I.C.17.f.1.a) Further, the Guidelines specify that “for reporting purposes, the definition for “other diagnoses” is interpreted as additional conditions that affect patient care in terms of requiring clinical evaluation; or therapeutic treatment; or diagnostic procedures; or increased nursing care and/or monitoring.” Coding Clinic reminded the questioner that  not all conditions that occur during or following surgery are classified as complications. First, there must be more than a routinely expected condition or occurrence. In addition, there must be a cause-and-effect relationship between the care provided and the condition, and an indication in the documentation that it is a complication. The coder cannot make the determination whether something that occurred during surgery is a complication or an expected outcome. Finally, they stated (emphasis added) Only a physician can diagnose a condition, and the physician must explicitly document whether the condition is a complication. If it is not clearly documented, the coder should query the physician for clarification.

Volume:  2011

Issue:  First 

Title:  Superior Semicircular Canal Dehiscence Syndrome

The question was regarding a 53-year-old male who presented  with “left superior semicircular canal dehiscence syndrome (SSCDS).” What is the correct code assignment for this syndrome?

Coding Clinic answered to assign code 386.8, Other disorders of labyrinth, along with code 733.99, Other disorders of bone and cartilage, for SSCDS. In addition, codes for any other manifestations of the syndrome that are present should be coded.  Coding Clinic noted that treatment can involve reparative surgery, resurfacing the dehiscence of the semicircular canal, and that the etiology of the syndrome is unknown.

We'll post more rulings on Monday.  Have a great weekend.

OIG Posts Slides and Video from Provider Compliance Training


The OIG has made the HEAT Provider Compliance Training Webcast Video available in 16 short modules instead of the original long video.  The content has not been changed, merely broken up for ease of viewing.
This will allow users to select a topic area to view without having to watch the entire 3 hour and 45 minute video. There is a new URL:

Today, the OIG  posted a video recording of the HEAT Provider Compliance Training session held on May 18, 2011 in Washington, DC. The session recording is quite long at 3 hours and 45 minutes. It is available at
While not specifically related to Medicare Advantage, this training session is pertinent for any practice which sees Medicare and/or Medi-Cal/Medicaid patients.
If you can't commit to that length of time (we know you're busy!) you can find the training session's related briefing material posted at 
There are 13 files including the PowerPoint slide presentation, a number of background papers, and a link to a video recording of Inspector General Levinson's keynote speech at the HCCA 15th Annual Compliance Institute.

Sunday, May 15, 2011

Recently Posted Tools and Documents on HCC University

We want to ensure that HCC University and the HCC University blog are your favorite risk adjustment related websites.  So, over the past few weeks, we’ve posted a large number of tools and documents on  Since none of us has time to check every day, we thought we’d give you an overview of what’s gone up on the site recently.

Full Encounter Data Information -  ICD 10/Full Encounter Data Page

Updates from the CMS Work Group Conference Calls have been posted:

Capitated and Staff Model Plans Summary Notes
Encounter Data Newsletter - Quarter 2
Encounter Data Work Group Summary Notes for Editing and Reporting: Key Findings and Recommendations #2
Third Party Submitters Work Group

Risk Adjustment Tools

2011 HCC List-Diagnosis Code Grouping - this file shows diagnosis codes grouped by HCC category.  Categories or codes with problematic guidelines have documentation and coding notes. - Excel file here.

Risk Adjustment Data Validation Tools

This checklist was used in the last National RADV to assist health plans in selecting the "One Best Medical Record" for submission.  Download here.

CMS Pilot RADV Findings—for services rendered July 1, 2001 through June 30, 2002, Published July 27, 2004.  Study findings here.

Annual Wellness Visit Tools

Annual Wellness Visit Presentation --Power Point Presentation.

Annual Wellness Visit form, instructions, and USPSTF Preventive services schedule - Zip File Here.

If you have questions, comments, or suggestions for new tools, leave us a comment here, or email us at

Tuesday, May 3, 2011

Creating Your Own Internal RADV Program

Today, we have a special guest posting by Debra Braden, CPC, CUC, HCC Coding Project Specialist:


Why would you want to create a RADV program?  Having an internal RADV program in place offers several benefits.  One benefit is that the program helps you prepare for the CMS RADV process.  Another benefit is that you gain an understanding of the current risk level.  Last but not least, you are able to evaluate physician’s documentation and offer feedback.  This benefit provides continuous improvement.

To help ensure a successful RADV audit, consider the following:

  • Set up a RADV team
  • Specify who will do which part of the RADV process
  • Plan the audit process
  • Set a timeline for achieving specific goals
  • Ensure that your data systems appropriately track claims and encounter data and that reporting is readily available.
  • Eliminate providers who don’t qualify to submit HCC’s
  • Ensure that your contact information for physicians, hospitals and other facilities is up to date
  • Contact providers with request for medical records
  • Follow up on requests based on a predetermined timeline
  • Create indexing and storage processes for image files for future RADV audits
  • Keep track of record receipt progress
  • Audit received records
  • Request attestations when necessary (note that in a CMS RADV, only CMS generated attestations are accepted)
  • Review data prepared for submission to CMS for accuracy
  • Track ways to improve the process for future audits all through the audit processes
  • Provide education for providers who need to improve their documentation and coding practices
  • Conduct ongoing mock or independent RADV’s

Internal RADV audits can help to reduce financial risk by alerting medical groups and plans about physicians who need training, alerting plans about codes that should be sent to CMS for deletion, and by streamlining and refining the process for future CMS RADV audits.

With proper planning and implementation, RADV audits can be completed on time and produce the best possible results for all parties within the healthcare delivery system.

For additional useful information please visit:

HCC Tools Page

Risk Adjustment Data Validation Study - Frequently Asked Questions

RAPS Participant Guide

For additional useful information please visit:

HCC Tools Page

Risk Adjustment Data Validation Study - Frequently Asked Questions

RAPS Participant Guide

Monday, April 25, 2011

Documentation--Why Bother?

Today, we have a guest posting from Debra Braden, CPC, CUC, HCC Coding Project Specialist in our Risk Adjustment Data Validation (RADV) department.


Since the advent of the HCC model, documentation has become more important than ever.  Because CMS reimburses for HCC’s they will also conduct audits to make sure the payments were justified.

There are other reasons that documentation is important.  Good documentation can help protect both the patient and the physician.  It is good patient care to clearly document why the patient is having the visit, the conditions they have and what the plan of treatment is.  This aids the current and any subsequent healthcare providers in knowing exactly what is going on with the patient and enables them to monitor and/or treat conditions.  Another important reason is in the case of a malpractice issue.  The court would be able to clearly see what is wrong with the patient and what the physician has done to care for the patient.

In order to pass CMS or Plan audits there is information that should be included in the medical record.  The patient’s name and one other identifier (date of birth, medical record or chart number) should be on every page.  The date of service, legible signature and credentials must be documented.  For a new condition the documentation should include the diagnosis, rationale, any related labs used for assigning the diagnosis and the plan of treatment.  For an established condition the documentation should include the diagnosis, status of the condition and the plan of treatment.

Based on findings from the Medicare Advantage Risk Adjustment Data Validation CMS-HCC Pilot Study several errors were found to be common.

·        Documentation to substantiate the diagnosis code was not in the medical record.
·        Chronic conditions coded but not documented in the report at the time of the visit.
·        Documentation was not in the medical record to support the specificity of conditions.
·        Truncated codes - Not using required 4th or 5th digits.
·        Physician unable to locate the medical record.
·        Coding for rule out, questionable or suspected conditions in the office.
·        Coding for acute conditions when the patient was status post or had a history of the condition.
·        Selecting codes incorrectly from superbills.
·        Not coding for documented conditions.

Keep in mind that just because an Electronic Medical Record is used doesn’t mean that it will automatically pass an audit.  Cloning notes from prior visits that a member had with a physician can cause inconsistencies within a note that would make it difficult for a certified medical coder to abstract a particular diagnosis even if it meets the criteria:  a) state the diagnosis, b) show logic or assessment and c) state plan.  Other problems can arise from use of an EMR including the use of an incorrect diagnosis selection lists.  The one thing that EMRs will solve is legibility, but unless intelligent notes are implemented, don’t expect an EMR to help you attain appropriate documentation.

Also keep in mind that good documentation doesn’t mean that the medical record has to be lengthy.  Good documentation simply means that specific information should be in the documentation that shows that a condition was evaluated and/or treated on the date of service.

Friday, April 8, 2011

CMS Releases Updated Acceptable Physician Specialty List

CMS posted an updated listing of acceptable physician types for risk adjustment purposes on the CSSC Operations Website.

Note that CMS has deleted specialty 70, Multi-Specialty Physician Group as an acceptable type, and added Interventional Pain Management (09), Speech Language Pathology (15), Hospice and Palliative Care (17), and Geriatric Psychiatry (27).

These changes were announced in the Announcement of Calendar Year (CY) 2012 Medicare Advantage Capitation Rates and Medicare Advantage and Part D Payment Policies and Final Call Letter released on April 4, 2011, effective January 1, 2010.

Both documents will be posted on the website in the near future.

Thursday, April 7, 2011

2012 CMS-HCC Model Diagnoses Posted

CMS has posted the diagnoses for the CMS-HCC, ESRD/PACE-HCC, and Rx-HCC models.  You can download the file from the CMS website here: 2012 Model Diagnoses (with FY2011 ICD-9-CM) (ZIP, 167 KB) .

Within the next couple of days you'll be able to download the file form our Tools Page on HCC University here.  Scroll down to "Downloadable Tools" and it will be the second file.

Watch this space for more information.

Monday, April 4, 2011

2012 Announcement Posted on the CMS Website

You can download the announcement here: 2012 Announcement.

As CMS indicated in the Advance Notice, there will not be a change to the CMS-HCC model for 2012, so that plans and providers can focus on other upcoming changes.

CMS also added several specialties to the acceptable physician specialties for risk adjustment, and deleted one tyep.

The additions are: Interventional Pain Management (IPM) (code 09), Speech Language Pathologist (code 15), Hospice and Palliative Care (code 17), and Geriatric Psychiatry (code 27). Note that Multispecialty Clinic or Group Practice (code 70) is not an Acceptable Physician Specialty Type.

More information will be posted as it becomes available.

Wednesday, March 23, 2011

Looking for Links to CMS 5010 Edits?

You can find them in the menu to the right of this post, titled: Full Encounter Data Links.  In addition to the front end edits, you will see a link to TARSC, where information regarding the ongoing CMS/Health Plan calls.

If you have questions, or comments, please post a comment or send them to us at

Monday, March 21, 2011

Do You Have Questions about CMS Full Encounter Data?

On Wednesday, we're having a Full Encounter Data webinar, to discuss the changes needed due to the CMS requirement that Health Plans begin submitted a full 837 v 5010 transaction for all encounter data, beginning 1/1/2012.

Do you have questions you'd like us to answer during the webinar?  If so, please send an email to with your question, or leave us a comment. We can't guarantee we'll have an answer, but we'll do everything we can to get the answers from CMS in the ongoing Health Plan/CMS meetings.

We have more information on our website at Full Encounter Data.

Tuesday, March 15, 2011

SCAN Hosts Full Encounter Data Webinar for our Provider Partners

Guest Blog Posting By Marc Carren, Encounter Data Manager

As you know,  on Friday, October 29,  2010, CMS held a Medicare Advantage industry-wide national meeting and formally announced their decision to transition from the current Risk Adjustment Processing System (RAPS) to a Full Encounter Data Collection model and a new CMS Encounter Data Processing System (EDPS).  This EDPS encounter data will be used to feed into CMS’ existing Risk Adjustment Processing System.  We sent an announcement to all of our provider partners, and asked that the announcement be shared with individuals within their organizations charged with:
¨       Supervision/management of claims and encounter data 
¨       The hands-on tasks of collecting the  encounter data from your service providers or sub-contracted providers ,
¨       The hands-on tasks of upgrading systems, operations, and work flow, and
¨       The responsibility for working with SCAN to ensure your organization can be in compliance with these high-impact CMS requirements by 1/2/2012.

On Wednesday, March 23, from 10a.m. to 11 a.m., SCAN will hold a Kickoff webinar conference to formally announce this initiative, our plan, and discuss any issues you expect with this transition.  If you know of anyone within your organization that needs to be involved in this webinar, and did not receive an invitation, please send an email to, and we'll  have someone contact you with Webinar information.

Following the kickoff webinar, SCAN will begin an assessment and survey effort via conference calls with all our Provider Partners.  The results of this assessment will inform our project plan and alert us to any possible assistance, guidance, or consultation various partners may require.  This initiative will be covered in more detail in the Kickoff webinar.
We thank you in advance for your attention, participation, and effort.
Marc Carren
Encounter Data Manager
SCAN Health Plan

Wednesday, March 2, 2011

Next CMS Fee-for-Service 5010 Conference Call: March 30, 2011

On March 30, 2011, CMS will host the next conference call in their series on the transition to the ANSI 837 5010 transactions.  The topic of this call is Provider Testing and Readiness.

CMS will be posting additional information regarding the call on the CMS Website at:

You should check the CMS website two to three weeks before the call for Webinar and call in information.

Monday, February 28, 2011

New Documents Posted to the

We have posted a number of new documents to the Full Encounter Data/ICD 10 page of  Scroll down to CMS Encounter Work-Groups and you'll see the documents listed below.

All of the documents are related to the January 2012 implementation of full encounter data, and the CMS workgroups that are ongoing.  Most of the questions are unanswered as of this time, but we hope as new documents become available, CMS will make more decisions.

Capitated and Staff Model Plans Summary Notes
Chart Review Work Group
Encounter Data Newsletter - Quarter 1
Encounter Data Newsletter –Quarter 2
Encounter Data Work Group Summary Notes for Editing and Reporting: Key Findings and Recommendations
Third Party Submitters Work Group

Friday, February 18, 2011

2012 Combined Advance Notice and Call Letter Posted to the CMS Website

The 2012 Advance Notice of Methodological Changes for Calendar Year (CY) 2012 for Medicare Advantage (MA) Capitation Rates, Part C and Part D Payment Policies and 2012 Call Letter has been posted to the CMS website at: 2012 Advance Notice and Call Letter.  

Although we have not had time to analyze the notice in detail, CMS is proposing not to implement the new model that was proposed for Part C for 2012 in order to minimize changes during 2012.

Based on the proposal released on Friday, there will be no changes to the CMS-HCC Model for 2012.  CMS will not implement previously proposed changes (e.g. addition of dementia and morbid obesity) until 2013 at the earliest, unless they change what is in the Advance Notice.  We will know with certainty on April 4, 2011 when the Announcement is published, but at this time, it is extremely unlikely that the model will change in 2012.

We will have more information for you at a later date.

Common ICD-9-CM Coding Errors

Usually, it’s a misunderstanding the rules of ICD-9 –but no matter the reason, many codes are found to be unsupported in a Risk Adjustment Data Validation or other audit.  The most common reasons for this seem to be that the ICD-9 doesn’t “talk” the way doctors do, or the person choosing the code doesn’t know that there’s a special rule related to it.  In an audit situation, the cause isn’t relevant—an error is an error.  The best way to avoid these errors is to make physicians aware of these common problems, and help them understand the ICD-9 rules.  Remember that those rules include Coding Clinic, which is officially tasked with clarifying coding rules for ICD-9.  So, what are the most common errors we see?

“Wound care” coding – Every time I drive by a wound care clinic, or see wound care written in a chart, I cringe.   I know that there’s a coding error ahead.  When you search the alphabetic index of the ICD-9 for the term wound, you won’t find any decubitus or vascular ulcers. You’ll see operative wounds (incisions) or lacerations (cuts).  I *know* what the provider means – he/she is treating an ulcer.  But if the doctor doesn’t call it an ulcer, choosing an ulcer code is wrong.  Physicians need to be instructed in the proper documentation for ulcers—location and type of ulcer must be described for vascular ulcers. For decubitus ulcers, the location, type (decubitus/pressure) and stage of ulcer must be documented.  For decubitus ulcers, two codes must be selected—one for the location and one for the stage.

Coronary Artery Disease (CAD) coding—Almost always, when I see a diagnostic statement of “CAD”, the code 414.00 (coronary artery disease, of unspecified type of vessel, native or graft) is attached.  Isn’t that correct? It sounds correct. No one mentioned whether it was a native or graft vessel, so it has to be correct! Except that it’s not. If there is no record of prior coronary artery bypass grafting, the correct code is 414.01 (coronary artery disease, of native coronary artery), because there’s a Coding Clinic that says so.  In Q2 1995, the following Coding Clinic ruling was issued:
Is it appropriate to assign code 414.01, Coronary atherosclerosis, of native coronary artery, if the medical record documentation does not indicate that the patient has a history of prior coronary artery bypass surgery?

"Assign code 414.01, Coronary atherosclerosis, of native coronary artery, if medical record documentation shows no history of prior coronary artery bypass. If the documentation is unclear concerning prior bypass surgery, query the physician."

Aortic Atherosclerosis coding – Documentation that indicates “aortic atherosclerosis” or “atherosclerosis of the aorta” without further clarification cannot be coded according to Coding Clinic, Q4, 1988.  If the physician can be queried (i.e., the note is new, and can be amended within approximately 72 hours of the visit) then the physician can clarify whether it is the aorta (vessel) or the aortic valve.  If it is the vessel, then the correct coding is 440.0.  Atherosclerosis of the aortic valve is coded 424.1.  Going forward, the physician should be sure to clarify whether it is valve or vessel.  For example, noting that there is atherosclerosis of the abdominal aorta makes it clear that it is the vessel.

Hemiparesis vs. Weakness -  We often see documentation that states “history of CVA with R. sided weakness”, and the physician has selected 438.20 –late effect of CVA, hemiparesis/hemiplegia of unspecified side.  While paresis does mean weakness, the issue is a little more complicated.  The term hemiparesis means more than weakness, it means weakness affecting an entire side of the body. And, in this case, it’s not just about the definition—but coding rules.   In Q1 2005, Coding Clinic was asked the following question:

Please provide clarification on the correct code assignment for a residual deficit of muscle weakness secondary to late effect of cerebrovascular accident. We have a difference of opinion on whether this should be coded to code 438.2x, Late effects of cerebrovascular disease, hemiplegia/ hemiparesis. What is the appropriate code assignment for residual weakness that is a late of effect of CVA?
Assign code 438.89, Other late effects of cerebrovascular disease and code 728.87, Muscle weakness, for residual muscle weakness secondary to late effect of cerebrovascular accident.
Therefore, when the physician documents weakness secondary to an old CVA, you cannot code 438.20.  Physicians must be educated regarding this rule, so that they can adjust their documentation going forward.

Finally, there’s a whole group of diagnoses that are coded when the physician really means that the patient had them in the recent past.  We see this most often when a patient is seen for the first time in the office after a hospitalization for:

      Acute MI (except in 1st 8 weeks)
Acute Coronary Syndrome
Non-ST Elevation MI (NSTEMI)
Unstable Angina
Acute Respiratory Failure

Once the patient has been discharged from the hospital, these conditions should no longer be coded. In some cases, it’s appropriate to code the “history of” code, or the underlying condition.  But coding these conditions in the office setting is only appropriate if the patient presents in the office and is (generally) transported by ambulance to the hospital.

There are other common errors that we see, but these are among the most common.  Understanding coding rules can help you avoid these pitfalls.

Do you have questions about coding rules?  Leave us a comment or email your question to