What's New on HCC University?

We've continued to add a number of documents to HCC University to make your documentation and coding go more smoothly!

We've updated our Annual Wellness Visit (AWV) with Health Risk Assessment (HRA) package to incorporate information on 5Star coding.  Since physicians are already capturing the data, we want to help make it easy to remember to submit it on the Superbill.  You can also review a presentation on completing the AWV with HRA.

We'll be posting more documents on HCC University in the near future. 

Medical Record Guidance

We often get questions about what constitutes a complete medical record.  To date, there is no all-encompassing official definition, although CMS provides their requirements during a Risk Adjustment Data Validation.

For offices, groups and health plans trying to develop coding compliance policies, there hasn't been a lot of information available.  Recently, the American Health Information Management Association (AHIMA) has tackled the issue head on in Defining the Core Clinical Documentation Set for Coding Compliance.  This useful article will help anyone tasked with creating a coding compliance policy.  You can find a copy of this paper here.

Coding versus Interpreting

As coders, we're required to code based upon the physician's documentation, and not to read into what the physician has actually written. 

Recently, we received the following question and follow up questions in the Coding@scanhealthplan.com inbox. 

Original Question: 

I would like to know some opinions regarding to coding the following documentation by Physician:  “ Vascular Dementia”.   

Our Answer: 

Vascular dementia NOS is indexed to 290.40.  I don’t see any alternative code.

Then, we received a follow up:

Follow up Question: 

In my opinion I’ll use 290.40 plus 437.0.   Please see instructional notes “ Use additional code to identify cerebral atherosclerosis”.  I need your opinion.

Our Answer:

You only use an additional code if it’s documented. It’s not something you automatically do.  Based on your email, the physician only documented vascular dementia.  If he had said vascular dementia due to cerebral atherosclerosis, then you would code it.

 The instructional notes for 250.40 say:

Use additional code, to identify manifestation, as: 
        chronic kidney disease  (585.1-585.9) 
             diabetic: 
             nephropathy NOS  (583.81) 
             nephrosis  (581.81) 
             intercapillary glomerulosclerosis  (581.81) 
             Kimmelstiel-Wilson syndrome  (581.81) 
 But you don’t code all those things unless they are documented.
I hope that clarifies.

In response, the questioner indicated that they planned on coding cerebral atherosclerosis  (437.0) because:

"Vascular dementia, Arteriosclerotic Dementia, Multi-infarct Dementia and Atherosclerotic disease are synonyms.   In my opinion the documentation of Vascular Dementia is the same as  Atherosclerotic Dementia or multi-infarct Dementia.    

Please look Dementia
                                       Multi-infarct(cerebrovascular) ( see also Dementia, arteriosclerotic)"

 
I don't believe I did a good enough job explaining why you wouldn't code something not documented.  But the reality is that cerebral arteriosclerosis is not the only cause of vascular dementia, although it may be the most common cause.  Multi-infarct dementia (MID), due to multiple strokes or TIAs,  or mixed type due to MID and Alzheimers, or many other

 conditions that reduce blood flow to the brain, including certain autoimmune diseases (e.g., lupus eythematosus, temporal arteritis), certain inherited (genetic) diseases, infections of the heart (endocarditis), brain hemorrhage, profoundly low blood pressure can also cause vascular .   Since arteriosclerosis is not the sole cause, coding 437.0 without documentation of cerebral arteriosclerosis is not appropriate.  As coders, we must code what's documented, without inserting our knowledge of disease states or opinions into the process.

SCAN CME Course -Dementia - Depression, Acute Behavioral Change, and Decision Making Capacity

As you know, dementia prevalence increases with age.   This free CME course will help ensure that you're able to:

 •Provide structured assessments with focus on problems that are prevalent amongst patients with dementia

 •Determine decision making capacity

 •Play an important role in providing education, psychosocial support, and referrals for these identified problems, among others, for patients and caregivers

 The target audience for this free CME program is physicians; nurses; social workers; and other healthcare professionals.

 

Click here to take this free CME program today!

What's New on HCC University?

We've done a little re-arranging on HCCUniversity.com.  While all of the old ICD-9 files are still there, we've put everything prior to 2012 in an archive that you can reach from the Tools page.   This will make navigating the Tools page easier, with less scrolling.

In addition, we've put a new widget on the Tools page.  Need to find an ICD-10 code?  Need to crosswalk an ICD-10 back to the equivalent ICD-9 code?  You can do it here on the ICD-10 widget.

What new documentation or coding tools would help you?  Send us your suggestions to coding@scanhealthplan.com.

Free CMEs for Physicians

For physicians looking for CMEs, check out http://www.scancme.com/!  Not only can you receive free CMEs, but you can find content geared toward care of your senior patients.

In addition to free CMEs, you can find practice tools, such as office forms, patient education, and clinical guidelines.

Check out the newly designed SCAN CME site today!

AHIMA Posts New Paper on Coding Compliance

The American Health Information Management Association (AHIMA) has posted a new paper in its Thought Leadership series that has implications for coding compliance in Risk Adjustment.

The paper, Defining the Core Designated Clinical Documentation Set for Coding Compliance, seeks to define what core pieces of documentation are required for coding of medical records in various settings. 

While it doesn't represent official coding guidance, it may be useful to medical groups, hospitals and oters seeking to develop Policies and Procedures related coding, internal Risk Adjustment Data Validations, encounter data submissions, and encounter data corrections. 

The paper may be downloaded from the AHIMA website, at: http://www.ahima.org/downloads/pdfs/advocacy/DefiningCoreClinicalDocumentation_TL.pdf