Encounter Data Filtering Logic Updates

As you probably know, CMS has provided guidance regarding the filtering of encounter data for risk adjustment purposes.  This doesn't mean that either Medical Groups or Health Plans should not submit certain encounters- CMS requires that ALL encounter data must be submitted to them.

Currently, encounter data represents 25% of the calculation of risk scores.  CMS plans to increase the weighting of encounter data-based risk scores over the next couple of years by moving to a risk score incorporating 50% of the encounter data/FFS-based risk score in 2018, a risk score incorporating 75% of the encounter data/FFS-based risk score for 2019, and a risk score of 100% encounter data/FFS-based risk score in 2020,

The logic that they use to determine what encounters are included is laid out in this 2015 memo from CMS to health plans.  At the same time, CMS released a list of procedure codes that would be used for filtering professional and outpatient hospital encounters.  

Recently, CMS released the list of 2015 codes and preliminary 2016 codes to be used for encounter data filtering.

When determining which encounters may be used in calculating risk scores, health plans and provider groups should refer to these documents, as well as reports received from CMS and health plans.  As CMS moves forward with using only encounter data for risk score calculation it will become more important than ever that your encounter data be accepted by the health plan and ultimately by CMS.  We will continue to provide you as much information as possible on our Encounter Data/ICD-10 Page.  CMS is currently hosting teleconferences with health plans, to keep them informed about changes to encounter data processing.  We'll post webinar slides like these, on duplicate record and demographic data fields processing, so you can stay up to date as well.

What other tools would be helpful to you?  Remember, if you have suggestions for HCC University, or the blog, you can contact us at coding@scanhealthplan.com.

Coding Clinic Clarifies Diabetes and Complications, Ketoacidosis, and Anti-MAG Polyneuropathy

Apparently the Q1 2016 "clarification" of diabetes with associated conditions confused many people.  In Q2, 2016, Coding Clinic furthers their clarification by stating:

"The subterm "with" in the Index should be interpreted as a link between diabetes and any of those conditions indented under the word "with." The physician documentation does not need to provide a link ..... These conditions should be coded as related even in the absence of provider documentation explicitly linking them, unless the documentation clearly states the conditions are unrelated.... For conditions not specifically linked by these relational terms in the classification, provider documentation must link the conditions in order to code them as related."

Coders will have to look to the Index and/or the code description for the term "with" in order to make the determination whether or not the physician must specifically link the diabetes to the complication.


Coding Clinic also addressed Ketoacidosis in Diabetes.  They noted that physicians should be queried if they do not specify the type (i.e. Type 1 or Type 2) of diabetes.  In most cases, when a physician does not state the type of diabetes, the default is Type 2, due to coding rules.  However, ketoacidosis occurs most frequently in Type 1 diabetes. Therefore, when the physician fails to state what type of diabetes the patient has, the physician is to be queried.   This presents problems when coders are reviewing a chart note that is months old, since addenda or late entries should generally be made within a 'reasonable' time frame.  It's especially important to inform physicians that they must state the type of diabetes when documenting ketoacidosis, to avoid coding problems later.

Finally, Coding Clinic was asked what the correct code assignment for Anti-MAG (anti-myelin-associated glycoprotein) polyneuropathy is.   Coding Clinic instructed that code G62.89, Other specified polyneuropathies, should be used.

Most of the other Coding Clinic entries for Q2 were related to procedural coding.

Given the ongoing confusion about diabetic complications, I think that we can expect more Coding Clinic comments on diabetes in the future.

Although Coding Clinic has provided a lot of instruction about the documentation requirements for diabetic complications, physicians don't usually access the Index when documenting in a medical record.  Short descriptions in EMRs don't always provide enough information for physicians to know whether or not linkage exists in the description or index.  Given these limitations, it cannot hurt for physicians to include the causal relationship in their documentation when present.