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.