ICD-10 Basics MLN Connects Video

Hi all.   Did you know that CMS has a You tube channel?  I didn't either.  But they do, and have a number of ICD-10 training videos.  I'll be posting them over the next few weeks, to help you with your ICD-10 training needs. 

Health Risk Adjustment Flags

 

Health Risk Assessments (HRAs) in the Risk Adjustment Processing System Transactions

 

 

 

In the 2013  In the November 2013 Software Release, CMS acted on their stated intention to gather information on enrollee health assessments or "health risk assessments" or HRAs.  

 

The Software release provided little information, and most health plans held off publishing information until we had additional information and clarification.  On December 5, 2013, we received some clarification during a Risk Adjustment User Group Call with CMS, where no questions were taken.

 

According to the initial explanation:

 

The Risk Assessment field must contain one of the following values:

A. Diagnosis code comes from a clinical setting.

B. Diagnosis code comes from a non-clinical setting and originates in a visit where all requirements specified at 42 CFR 410.15(a) for a First Annual Wellness Visit or Subsequent Annual Wellness Visit were met.

C. Diagnosis code comes from a non-clinical setting and originates in a visit where all requirements specified at 42 CFR 410.15(a) for a First Annual Wellness Visit or Subsequent Annual Wellness Visit were not met.

 

Health Plans requested clarification from CMS on the following:

 

1)    What is a "non-clinical setting"?

2)    Are Annual Wellness Visits the only services covered by Flags/Values 'B' and 'C'?

3)     Does the providers' credential have anything to do with use of the flags?

4)     Does use of any of these flags indicate that the service will not be risk adjusted?

 

To the best of our understanding at this time, the answers to these questions are as follows:

 

1)     The patients home is the only non-clinical setting they are referring to

2)     based on 42 CFR 410.15 (a), Initial Preventive Physical Exams, the "welcome to Medicare     physical is also included.

3)      The providers' credential has nothing to do with assignment of the flags.

4)       At the present time, the use of any flag will not affect risk adjustment.  A final policy will be published in the 2015 Advance Notice in February, 2014.

 

So, to answer what falls under 'A', 'B' and 'C'?  Very simply, this:

 

A--Any risk adjustable service not done in a patients' home.

B--Any risk adjustable service which is procedure code G0402, G0438 or G0439 and is not performed in the patients' home.

C--Any risk adjustable service which is not procedure code G0402, G0438 or G0439 and is performed in the patient's home.

 

In order for health plans to accurately assign the correct indicator, it is critical that you submit the accurate place of service and procedure code on all encounters, including abbreviated format encounters.

 

We hope this helps answer some questions about the Health Risk Assessment Flags.

Remember, if you have questions about ICD-9 Coding, or have suggestions for future blog postings, contact us at coding@scanhealthplan.com.

 

 

 

 



MedLearn (CMS) Web Based Training Programs -- Free CEUs, CMEs (2 Courses) From Multiple Organizations

CMS offers a number of Web Based Training (WBT) programs which offer CEUs which should be of interest to Coders and others.  Of special interest to everyone involved in risk adjustment is a CBT on Part C and Part D Risk Adjustment.   Two of the WBTs even offer CMEs approved by the AMA:

• Safeguarding Your Medical Identity
• Avoiding Medicare Fraud and Abuse: A Roadmap for Physicians

The following organizations offer continuting education credits:

·         American Association of Medical Audit Specialists
·         American Medical Billing Association
·         California Certifying Board for Medical Assistants
·         Healthcare Billing & Management Association
·         Medical Association of Billers
·         National Academy of Ambulance Coding
·       American Association of Medical Assistants
·       AAPC

And don't forget, SCAN Health Plan also offers free Continuing Medical Education on www.SCANCME.com!

New Presentation on HCC University

There is a new presentation and quiz on HCCUniversity.com, with a corresponding quiz that you may be interested in.  The presentation covers changes to the CMS-HCC model, including things like the addition of Morbid obesity, and fibrotic lung diseases.  It also covers the deletion of previously included codes, like CKD stages I-III and polyneuropathy.  There are documentation tips for some of the new procedure codes, as well as some lessons learned from the last CMS Risk Adjustment Data Validation Study.  Finally,  there is a quiz, to help you test your knowledge of the new model and the common documentation errors that physicians encounter.  We urge you to share this  presentation and quiz with everyone involved in risk adjustment in your organization, especially physicians and physician extenders who may benefit from the documentation tips.  You can review the presentation at: http://www.hccuniversity.com/hcc-university/training-presentations/2014-cms-hcc-model/

 

If you are interested in having a webinar training session to cover the presentation, please feel free to contact us at coding@scanhealthplan.com.

 

Coding BMI

We've gotten several questions lately about the requirements for coding BMI, asking why BMI can't be coded if documented, but there is no documentation by the physician regarding obesity/morbid obesity, etc.

The Official ICD-9 instructions have been revised to indicate that the BMI may be documented by someone who cannot make a diagnosis, such as a dietitian.  However, they go on to state that the BMI is always a secondary diagnosis, and the physician must document the related diagnosis, such as overweight, obesity, etc.

This is further supported by Coding Clinic, Q2, 2010 which confirms that the BMI may be recorded by non-physician clinicians, like nurses or dieticians, but it cannot be reported (coded) unless there is also documentation by the physician of the related condition, such as overweight or obesity.

Therefore, it is not appropriate to assign the code for BMI unless the related diagnosis is also documented and reported.

We hope this helps understand the Official ICD-9 Guidelines for reporting BMI.

New ICD-10 Resources Available!

CMS has published the new version of the ICD-10 CM and GEMs (the General Equivalence Mappings).  In addition, they have posted some new ICD-10 tools, for providers to use:

• General Equivalence Mappings Frequently Asked Questions
• ICD-10 CM Clinical Enhancements
• ICD-10 CM/PCS The Next Generation of Coding

These three new CMS publications should help you in developing new superbills and coding sheets for your office.

More Full Encounter Data Tips

Issues in Encounter Submission

Remember that Full Encounter Data (FED) submission closely mirrors Fee-for-Service (FFS) claims submission.  Therefore, you should run reports against encounters submitted under FED that were rejected by CMS:

·        While the Companion Guides help with creating and submitting an EDI transaction, there are a number of billing guides produced by Medicare Administrative Contractors that give advice on claim submission.

·        In addition, the cms.gov website also has instructions for claim submissions as well.  Check the Claims Processing Manual chapter(s) that relates to your type of service.

·        The focus of the guidelines on the CMS website is more on claims submission and payer processing of claims/encounters for adjudication.  Following the instructions on both of these websites will help you produce encounters which can be processed successfully.

The following websites have billing information to help you file correctly:

 

Claim Submission

DMEPOS and PEN Submission                                                  

Billing guides by specialty

Modifier Billing Guide

Completing the 1500 Claim Form

 

Possible Systemic Issues to Identify and Correct

·        Incorrect modifier for HCPCS/CPT code (e.g. surgical modifier on an E/M code).

·        Incorrect dates of service - Many DMEPOS services require a span of dates of service—for example, rentals and a month’s worth of supplies.  The dates of service should be the 30 day span that represents the rental or supply period.

o   Note that the number of services should reflect the number of days for a rental, or the number of units for supplies.  Do not default to “1” in these situations.

·        Use the correct place of service.  The place of service for DME must be the patient’s home  (POS 12).  Rarely, a Skilled Nursing Facility or Nursing Facility is appropriate (POS 31 or 32)

·        Some services have specific diagnosis requirements—“CPAP” or “BiPAP” machines require specific diagnoses.   All services except the few screening services allowed require a specific diagnosis related to the service.

·        Incorrect number of services (e.g., 1 service for 30 day span). Number of services should be evenly divisible by the date span.

·        Missing critical information—e.g. ordering provider, rendering provider on a medical group or DME claim/encounter.

·        Incompatible place of service (i.e.  Outpatient service like 99214 billed with Place of service 21, 31 or 32).

·        Incorrect or missing origin/destination for ambulance claims.

 

We hope that this information helps you in your goal of submitting clean FED claims/encounters.

 

 

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